3
WILLIAM A. CIES, M.D.,
ER EYELID FOLD
AND HENRY I. BAYLIS,
M.D.
Los Angeles, California
The integrity and symmetry of the upper eyelid fold contribute to the normal ap pearance of the eye. Any abnormality of the eyelid fold constitutes a cosmetic blemish. A variety of situations may result in eyelid fold deformities, but this problem is most commonly encountered as a complication of blepharoptosis surgery. An acceptable eye lid level may be marred by eyelid fold ab normalities or lash blepharoptosis (Fig. 1). Surgical revision of eyelid fold abnormali ties may be necessary to achieve a completely satisfactory appearance of the upper eyelid. The eyelid fold results from the insertion of fibers from tne apon^"™^ nf tfag Watnr palpebrae superions ( L P S ) rn"«flp intn the skin.^l'his insertion exerts an upward and posterior traction on the skin. The skin above the insertion is under no tension and, therefore, hangs down forming an eyelid fold. If the levator muscle is paretic, it will exert less traction on the upper eyelid skin and result in an absent or diminished eyelid fold. An abnormal eyelid fold results from disruption of the normal levator muscle-skin relationship. By comparison, thfcjevator muscle in the Oriental eyelid may not insert on fhp skin or only on the skin near the eyelid margin. The scarcity of cutaneous in sertions may result in the absence of the eyelid fold. The more anterior insertion of the orbital septum on the L P S aponeurosis permits a downward displacement of postseptal fat that further obscures an eyelid fold. In either case, surgical revision of the upper eyelid fold creates an adhesion of the levator muscle and tarsus to the skin to From the Department of Ophthalmology, Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles, California. This study was supported in part by National Institutes of Health grants EY00021 and EY00331, from the National Eye In stitute. Reprint requests to William A. Cies, M.D., Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles, CA 90024.
simulate the effect of the normal levator mus cle insertion into the skin. Most eyelid fold techniques have been described for revision of the Oriental eye lid.1"8 Beard,9 de Blaskovics,10-11 Smith and Gunderson,12 and Putterman and Urist" have described situations in which an eyelid fold procedure is used in the occidental eye lid. Holz14 described an operation for entropion and trichiasis in 1879 that is similar to some eyelid fold procedures. Our technique has been applied primarily for the correction of eyelid fold abnormalities after blepharoptosis surgery. There are small variations in the technique, depending on the type of blepharoptosis operation that re sulted in the abnormal eyelid fold. METHOD
Anesthesia may be local or general. Even in general anesthesia, a subcutaneous injec tion of 1% lidocaine (Xylocaine) with 1:100,000 epinephrine is used to minimize bleeding. The incision was made at the site of the proposed eyelid fold. An ellipse of skin (Fig. 2, A ) , with the lower margin along the proposed eyelid fold, was excised in cases involving the Fasanella or frontalis suspension procedures or in Oriental eyelid revisions. Lash blepharoptosis may be cor rected by excising the skin closer to the eye lid margin so the closure will rotate the lash follicles upward. The skin was undermined to the eyelid
Fig. 1 (Cies and Baylis). Severe eyelid fold abnormality with lash blepharoptosis. 1019
1020
AMERICAN JOURNAL OF OPHTHALMOLOGY
DECEMBER, 1975
TABLE 1 PROCEDURES FOR 89 CASES
No. of Cases
Fig. 2 (Cies and Baylis). A, Skin excision; B, Undermining of skin to eyelid margin; C, Excision of pretarsal orbicularis and oculi muscles; D, Fullthickness vertical mattress sutures.
margin, exposing pretarsal orbicularis oculi muscle and the L P S aponeurosis (Fig. 2, B). The anterior surface of the tarsus was exposed by excising all pretarsal tissue (Fig. 2, C) ; in patients who had a previous anterior levator muscle resection, this was usually unnecessary. In Oriental eyelids, the orbital septum was incised and excess fat was excised, if thinning of the eyelid was desired. In frontalis suspension cases, the sling was usually at the upper edge of the tarsus and was avoided. If additional blepharoptosis correction was desired, we advanced the sling on the tarsus. Three vertical mattress sutures (6-0 Dexon or silk) were introduced from the upper cul-de-sac through the conjunctiva above the tarsus, with one arm emerging through the L P S aponeurosis and out the upper edge of the skin incision. The lower arm came out the lower edge of the skin incision (Fig. 2, D ) . When the sutures were tied firmly, they caused an upward and posterior traction on the skin (Fig. 3 ) . They were removed in five to seven days. For two years, we performed surgery on 107 patients who had primarily blepharoptosis and eyelid fold abnormalities. Eighty-
Anterior levator muscle resections with eyelid fold sutures Eyelid fold revision
43 (1)
Fasanella procedures With eyelid fold technique Without eyelid fold technique Eyelid fold revision
38 (24) (14) (2)
Frontalis suspension procedures Eyelid fold revision
8 (4)
nine patients had primary blepharoptosis procedures, including 43 anterior levator muscle resections with eyelid fold sutures, 38 Fasanella procedures (24 with the eye lid fold technique, 14 without), and eight frontalis suspensions (Table 1). Addi tionally, there were 18 eyelid fold pro cedures, including five after Fasanella pro cedures (two from our larger blepharoptosis series), five after anterior resections (one from the series), four after frontalis suspensions (all from the series), two as sociated with congenital anophthalmia, and one each from trauma and Oriental eyelid fold revision (Table 2 ) . CASE REPORTS
Case 1—This 13-year-old girl had a prior an terior levator muscle resection (but no eyelid fold sutures) performed on the right upper eyelid (Fig.
Fig. 3 (Cies and Baylis). Left, Sutures tied firmly with distinct fold and upward lash rotation. Right, Cross-section view showing suture origin above the tarsus, pulling skin edges posteriorly and vertically.
VOL. 80, NO. 6
UPPER EYELID FOLD SURGERY
1021
TABLE 2 PROCEDURES FOR 18 EYELID FOLDS
No. of Cases Fasanella procedure Anterior levator muscle resection Frontalis suspension Congenital anophthalmos Posttraumatic Oriental
5 5 4 2 1 1
4, top). The eyelid level was good, but there was a poor, hooded eyelid fold with mild lateral lash blepharoptosis. An eyelid fold revision on April 4, 1971 resulted in an excellent eyelid fold (Fig. 4, bottom). Case 2—This 16-year-old girl had severe con genital blepharoptosis of the left upper eyelid (Fig. 5, top). An anterior levator muscle resection was performed with eyelid fold sutures on April IS, 1971.
Fig. 6 (Cies and Baylis). Case 3. Top, Preoperative severe blepharoptosis in the right eye and mild blepharoptosis in the left eye. Center, Three weeks after Fasanella procedure on left upper eyelid and anterior resection on right upper eyelid. Sym metric eyelid levels marred by abnormal eyelid fold in left upper eyelid. Bottom, Left upper eyelid, 1.5 years after eyelid fold revision. Fig. 4 (Cies and Baylis). Case 1. Top, After anterior levator muscle resection. A poor eyelid fold is present with redundant skin on each side of the fold. Bottom, 2.S months after eyelid fold revision with definite eyelid fold.
Fig. 5 (Cies and Baylis). Case 2. Top, Preoperative blepharoptosis, faint eyelid fold, and lash blepharoptosis. Bottom, Five months after anterior levator muscle resection and eyelid fold technique.
The result was an excellent eyelid level, eyelid fold, and lash rotation (Fig. S, bottom). Case 3—This 4-year-old girl had severe blepha roptosis in her right upper eyelid, with mild blepha roptosis in her left upper eyelid (Fig. 6, top). An anterior levator muscle procedure with eyelid fold sutures was performed on the right eyelid, and a Fasanella procedure without eyelid fold sutures on the left on Aug. 27, 1973. Symmetrical eyelid levels were marred by the poor eyelid fold in the left eye lid (Fig. 6, center). The revision of the left eyelid fold on Oct. 1 symmetrized the results (Fig. 6, bottom). Case 4—This 8-year-old boy had mild blepharop tosis of the right upper eyelid (Fig. 7, top). A Fasanella procedure on Aug. 9 resulted in good eyelid levels, but an absent eyelid fold and poor lash rotation (Fig. 7, center). The eyelid fold procedure on Oct. 18 corrected these problems (Fig. 7, bot tom). Case 5—This S-year-old girl had a fascia lata suspension procedure after a levator muscle tenotomy on Feb. 28, 1974 for right upper eyelid bleph aroptosis associated with jaw winking. The absent eyelid fold and redundant skin obscured the raised
1022
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 7 (Cies and Baylis). Case 4. Top, Preoperative blepharoptosis, right upper eyelid. Center, Postoperative Fasanella procedure with poor eyelid fold and lash blepharoptosis. Bottom, 2.5 months after eyelid fold revision. eyelid margin (Fig. 8, top). An eyelid fold pro cedure and an advancement of the previously placed sling on the tarsus resulted in an additional bleph aroptosis correction and the eyelid fold (Fig. 8, bottom). DISCUSSION
I n addition to the proper pyoHH level, a nnrmal upper pyplid phniild have a distinct
symmetrical fold. The distal eyelid should be thin with no redundant skin, and no lash blepharoptosis should be present. In the normal eyelid, the LPS aponeurosis inser tions accomplish this; to correct an abnor mal eyelid fold, a procedure must produce a union of tarsus and levator muscle to the
DECEMBER, 1975
skin and deeper structures. Generally, it is difficult to obliterate fully the abnormal ad hesions between the skin and levator muscle in patients with distorted or abnormally located eyelid folds. Excision of pretarsal orbicularis oculi muscle results in a thinner eye lid and permits adhesions between the skin and tarsus. The sutures attach the skin edges to the levator muscle, and this adhesion causes upward and posterior traction of the skin by the levator muscle. We found that a simple suture placed anteriorly through skin and levator muscle, as described in several eyelid fold techniques,1'3'6'7'10 often resulted in a less distinct eyelid fold than those obtained from the full-thickness vertical mattress sutures. In congenital blepharoptosis. the eyelid fold is frequently diminished or absent. The eyelid told is usually produced or accentu ated as part of most anterior levator muscle resections. Levator surgery that does not reconstitute the insertion of the levator muscle into the skin may result in an ab normal eyelid fold (Case 1). Therefore, we routinely finish an anterior resection with eyelid fold sutures to insure a distinct fold (Cases 2 and 3). The Fasanella procedure resulted oc casionally in an absent or a diminished eyelid fold and lash blepharoptosis. The eye-
S k i n t o SJmillaff fh
WILLIAM A. CIES, M.D.,
ER EYELID FOLD
AND HENRY I. BAYLIS,
M.D.
Los Angeles, California
The integrity and symmetry of the upper eyelid fold contribute to the normal ap pearance of the eye. Any abnormality of the eyelid fold constitutes a cosmetic blemish. A variety of situations may result in eyelid fold deformities, but this problem is most commonly encountered as a complication of blepharoptosis surgery. An acceptable eye lid level may be marred by eyelid fold ab normalities or lash blepharoptosis (Fig. 1). Surgical revision of eyelid fold abnormali ties may be necessary to achieve a completely satisfactory appearance of the upper eyelid. The eyelid fold results from the insertion of fibers from tne apon^"™^ nf tfag Watnr palpebrae superions ( L P S ) rn"«flp intn the skin.^l'his insertion exerts an upward and posterior traction on the skin. The skin above the insertion is under no tension and, therefore, hangs down forming an eyelid fold. If the levator muscle is paretic, it will exert less traction on the upper eyelid skin and result in an absent or diminished eyelid fold. An abnormal eyelid fold results from disruption of the normal levator muscle-skin relationship. By comparison, thfcjevator muscle in the Oriental eyelid may not insert on fhp skin or only on the skin near the eyelid margin. The scarcity of cutaneous in sertions may result in the absence of the eyelid fold. The more anterior insertion of the orbital septum on the L P S aponeurosis permits a downward displacement of postseptal fat that further obscures an eyelid fold. In either case, surgical revision of the upper eyelid fold creates an adhesion of the levator muscle and tarsus to the skin to From the Department of Ophthalmology, Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles, California. This study was supported in part by National Institutes of Health grants EY00021 and EY00331, from the National Eye In stitute. Reprint requests to William A. Cies, M.D., Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles, CA 90024.
simulate the effect of the normal levator mus cle insertion into the skin. Most eyelid fold techniques have been described for revision of the Oriental eye lid.1"8 Beard,9 de Blaskovics,10-11 Smith and Gunderson,12 and Putterman and Urist" have described situations in which an eyelid fold procedure is used in the occidental eye lid. Holz14 described an operation for entropion and trichiasis in 1879 that is similar to some eyelid fold procedures. Our technique has been applied primarily for the correction of eyelid fold abnormalities after blepharoptosis surgery. There are small variations in the technique, depending on the type of blepharoptosis operation that re sulted in the abnormal eyelid fold. METHOD
Anesthesia may be local or general. Even in general anesthesia, a subcutaneous injec tion of 1% lidocaine (Xylocaine) with 1:100,000 epinephrine is used to minimize bleeding. The incision was made at the site of the proposed eyelid fold. An ellipse of skin (Fig. 2, A ) , with the lower margin along the proposed eyelid fold, was excised in cases involving the Fasanella or frontalis suspension procedures or in Oriental eyelid revisions. Lash blepharoptosis may be cor rected by excising the skin closer to the eye lid margin so the closure will rotate the lash follicles upward. The skin was undermined to the eyelid
Fig. 1 (Cies and Baylis). Severe eyelid fold abnormality with lash blepharoptosis. 1019
1020
AMERICAN JOURNAL OF OPHTHALMOLOGY
DECEMBER, 1975
TABLE 1 PROCEDURES FOR 89 CASES
No. of Cases
Fig. 2 (Cies and Baylis). A, Skin excision; B, Undermining of skin to eyelid margin; C, Excision of pretarsal orbicularis and oculi muscles; D, Fullthickness vertical mattress sutures.
margin, exposing pretarsal orbicularis oculi muscle and the L P S aponeurosis (Fig. 2, B). The anterior surface of the tarsus was exposed by excising all pretarsal tissue (Fig. 2, C) ; in patients who had a previous anterior levator muscle resection, this was usually unnecessary. In Oriental eyelids, the orbital septum was incised and excess fat was excised, if thinning of the eyelid was desired. In frontalis suspension cases, the sling was usually at the upper edge of the tarsus and was avoided. If additional blepharoptosis correction was desired, we advanced the sling on the tarsus. Three vertical mattress sutures (6-0 Dexon or silk) were introduced from the upper cul-de-sac through the conjunctiva above the tarsus, with one arm emerging through the L P S aponeurosis and out the upper edge of the skin incision. The lower arm came out the lower edge of the skin incision (Fig. 2, D ) . When the sutures were tied firmly, they caused an upward and posterior traction on the skin (Fig. 3 ) . They were removed in five to seven days. For two years, we performed surgery on 107 patients who had primarily blepharoptosis and eyelid fold abnormalities. Eighty-
Anterior levator muscle resections with eyelid fold sutures Eyelid fold revision
43 (1)
Fasanella procedures With eyelid fold technique Without eyelid fold technique Eyelid fold revision
38 (24) (14) (2)
Frontalis suspension procedures Eyelid fold revision
8 (4)
nine patients had primary blepharoptosis procedures, including 43 anterior levator muscle resections with eyelid fold sutures, 38 Fasanella procedures (24 with the eye lid fold technique, 14 without), and eight frontalis suspensions (Table 1). Addi tionally, there were 18 eyelid fold pro cedures, including five after Fasanella pro cedures (two from our larger blepharoptosis series), five after anterior resections (one from the series), four after frontalis suspensions (all from the series), two as sociated with congenital anophthalmia, and one each from trauma and Oriental eyelid fold revision (Table 2 ) . CASE REPORTS
Case 1—This 13-year-old girl had a prior an terior levator muscle resection (but no eyelid fold sutures) performed on the right upper eyelid (Fig.
Fig. 3 (Cies and Baylis). Left, Sutures tied firmly with distinct fold and upward lash rotation. Right, Cross-section view showing suture origin above the tarsus, pulling skin edges posteriorly and vertically.
VOL. 80, NO. 6
UPPER EYELID FOLD SURGERY
1021
TABLE 2 PROCEDURES FOR 18 EYELID FOLDS
No. of Cases Fasanella procedure Anterior levator muscle resection Frontalis suspension Congenital anophthalmos Posttraumatic Oriental
5 5 4 2 1 1
4, top). The eyelid level was good, but there was a poor, hooded eyelid fold with mild lateral lash blepharoptosis. An eyelid fold revision on April 4, 1971 resulted in an excellent eyelid fold (Fig. 4, bottom). Case 2—This 16-year-old girl had severe con genital blepharoptosis of the left upper eyelid (Fig. 5, top). An anterior levator muscle resection was performed with eyelid fold sutures on April IS, 1971.
Fig. 6 (Cies and Baylis). Case 3. Top, Preoperative severe blepharoptosis in the right eye and mild blepharoptosis in the left eye. Center, Three weeks after Fasanella procedure on left upper eyelid and anterior resection on right upper eyelid. Sym metric eyelid levels marred by abnormal eyelid fold in left upper eyelid. Bottom, Left upper eyelid, 1.5 years after eyelid fold revision. Fig. 4 (Cies and Baylis). Case 1. Top, After anterior levator muscle resection. A poor eyelid fold is present with redundant skin on each side of the fold. Bottom, 2.S months after eyelid fold revision with definite eyelid fold.
Fig. 5 (Cies and Baylis). Case 2. Top, Preoperative blepharoptosis, faint eyelid fold, and lash blepharoptosis. Bottom, Five months after anterior levator muscle resection and eyelid fold technique.
The result was an excellent eyelid level, eyelid fold, and lash rotation (Fig. S, bottom). Case 3—This 4-year-old girl had severe blepha roptosis in her right upper eyelid, with mild blepha roptosis in her left upper eyelid (Fig. 6, top). An anterior levator muscle procedure with eyelid fold sutures was performed on the right eyelid, and a Fasanella procedure without eyelid fold sutures on the left on Aug. 27, 1973. Symmetrical eyelid levels were marred by the poor eyelid fold in the left eye lid (Fig. 6, center). The revision of the left eyelid fold on Oct. 1 symmetrized the results (Fig. 6, bottom). Case 4—This 8-year-old boy had mild blepharop tosis of the right upper eyelid (Fig. 7, top). A Fasanella procedure on Aug. 9 resulted in good eyelid levels, but an absent eyelid fold and poor lash rotation (Fig. 7, center). The eyelid fold procedure on Oct. 18 corrected these problems (Fig. 7, bot tom). Case 5—This S-year-old girl had a fascia lata suspension procedure after a levator muscle tenotomy on Feb. 28, 1974 for right upper eyelid bleph aroptosis associated with jaw winking. The absent eyelid fold and redundant skin obscured the raised
1022
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 7 (Cies and Baylis). Case 4. Top, Preoperative blepharoptosis, right upper eyelid. Center, Postoperative Fasanella procedure with poor eyelid fold and lash blepharoptosis. Bottom, 2.5 months after eyelid fold revision. eyelid margin (Fig. 8, top). An eyelid fold pro cedure and an advancement of the previously placed sling on the tarsus resulted in an additional bleph aroptosis correction and the eyelid fold (Fig. 8, bottom). DISCUSSION
I n addition to the proper pyoHH level, a nnrmal upper pyplid phniild have a distinct
symmetrical fold. The distal eyelid should be thin with no redundant skin, and no lash blepharoptosis should be present. In the normal eyelid, the LPS aponeurosis inser tions accomplish this; to correct an abnor mal eyelid fold, a procedure must produce a union of tarsus and levator muscle to the
DECEMBER, 1975
skin and deeper structures. Generally, it is difficult to obliterate fully the abnormal ad hesions between the skin and levator muscle in patients with distorted or abnormally located eyelid folds. Excision of pretarsal orbicularis oculi muscle results in a thinner eye lid and permits adhesions between the skin and tarsus. The sutures attach the skin edges to the levator muscle, and this adhesion causes upward and posterior traction of the skin by the levator muscle. We found that a simple suture placed anteriorly through skin and levator muscle, as described in several eyelid fold techniques,1'3'6'7'10 often resulted in a less distinct eyelid fold than those obtained from the full-thickness vertical mattress sutures. In congenital blepharoptosis. the eyelid fold is frequently diminished or absent. The eyelid told is usually produced or accentu ated as part of most anterior levator muscle resections. Levator surgery that does not reconstitute the insertion of the levator muscle into the skin may result in an ab normal eyelid fold (Case 1). Therefore, we routinely finish an anterior resection with eyelid fold sutures to insure a distinct fold (Cases 2 and 3). The Fasanella procedure resulted oc casionally in an absent or a diminished eyelid fold and lash blepharoptosis. The eye-
S k i n t o SJmillaff fh
