Lower Eyelid Repositioning: Vertical Palpebral Aperture Enlargement for Asian Patients
The desire for larger, more defined eyes is prevalent among many Asian patients seeking cosmetic procedures. Traditionally, treatments such as double-eyelid surgery, levator aponeurotic surgery, and epicanthoplasty have been widely accepted. However, for some patients, these interventions fall short of their aesthetic goals, particularly those desiring vertical enlargement of the palpebral aperture. This gap in patient satisfaction led to the development of a novel approach by Dr. Toshitsugu Hirohi and Dr. Kotaro Yoshimura. Their research focuses on lower eyelid repositioning surgery, a technique aimed at increasing the vertical height of the eye by lowering the lower eyelid.
Surgical Approach
The lower eyelid repositioning procedure enhances the vertical dimension of the palpebral aperture by lowering the lower eyelid through the static shortening of both the anterior and posterior lamellae, while preserving the middle lamella. Specifically designed for Asian patients, this technique addresses the narrow palpebral aperture and up-slanting appearance common in Asian eyelids, creating a more oval and aesthetically pleasing shape. Performed on 125 Japanese patients over a four-year period, it has proven to be both effective and reliable in carefully selected cases.
Key aspects of the surgery include:
Subciliary Skin Excision:
This procedure involves making an incision just below the lower eyelid’s lash line (subciliary region) to remove a small amount of skin, typically between 4 to 6 mm. The goal is to reduce excess skin in the lower eyelid, which helps reposition the eyelid margin and improve its appearance. This excision focuses on the lateral third to two-thirds of the eyelid, preserving the orbicularis oculi muscle to maintain proper eyelid tone and function. The incision placement ensures minimal visible scarring and improves the cosmetic result.
Transconjunctival Posterior Lamella Shortening:
In this step, the lower eyelid retractors (muscles that help pull the eyelid downward) are shortened through a transconjunctival approach—meaning the incision is made inside the eyelid, through the conjunctiva, to avoid external scars. The surgeon sutures the retractors to the inferior edge of the tarsal plate (the dense connective tissue that gives the eyelid its shape). This pulls the lower eyelid margin downward, expanding the vertical height of the eye. This technique effectively repositions the eyelid, improving both form and function, while avoiding disruption of the middle lamella, which can minimize complications.
Precise Suture Placement:
This step involves placing fine sutures (typically 5-0 polydioxanone sutures) during the procedure to securely hold the repositioned eyelid tissues in place. Precision is key to ensure that the eyelid margin is properly aligned and symmetrical with the other eye. After the lamellae are shortened, the surgeon closes the incisions with 7-0 nylon sutures to ensure a smooth and seamless closure. Proper suture placement not only ensures stability and symmetry but also minimizes the risk of complications such as scarring, asymmetry, or undercorrection.
Surgical Techniques for Lower Eyelid Repositioning
1. Preoperative Planning and Design
Preoperative assessment is crucial for determining the amount of skin excision and the extent of retractor shortening required. The surgeon should evaluate:
Lower eyelid tone: This is done using a snap test, where the eyelid is pulled away from the globe and allowed to retract. A quick return to its original position indicates healthy tone, reducing the risk of postoperative malposition.
Eyeball and malar prominence: If the malar eminence is posterior to the cornea (a negative vector), the patient may have poor eyelid support, increasing the risk of complications. This assessment is critical for preventing lower eyelid retraction or ectropion postoperatively.
Preoperative marking is done while the patient is in a sitting position with their lower eyelids under tension. The amount of skin excised typically ranges from 4 to 6 mm, depending on the patient's specific anatomy and aesthetic goals.
2. Subciliary Skin Excision (Anterior Lamella Shortening)
The procedure begins with a subciliary incision, made approximately 2 mm below the lower eyelid ciliary margin, ensuring a cosmetically acceptable scar. The excision typically covers the lateral one-third to two-thirds of the lower eyelid, focusing on areas where the patient exhibits an up-slanting appearance or narrow palpebral aperture.
Skin excision width is customized per patient, but generally, 4 to 6 mm of skin is removed. Care is taken to preserve the orbicularis oculi muscle during this step to maintain eyelid tone.
3. Transconjunctival Posterior Lamella Shortening
The process is carried out through a transconjunctival approach to ensure minimal scarring and optimal aesthetic outcomes:
A conjunctival incision is made just below the inferior border of the tarsal plate, exposing the lower eyelid retractors.
The lower eyelid retractors are then sutured to the inferior edge of the tarsal plate using 5-0 polydioxanone sutures. This effectively shortens the posterior lamella, causing the lower eyelid margin to reposition downward. Three tucking sutures are typically used to ensure the adjustment is symmetrical and secure.
The goal of this technique is to lower the eyelid margin without interfering with the middle lamella, reducing the risk of scarring and ensuring a smooth, natural repositioning.
4. Ensuring Symmetry and Repositioning the Lower Eyelid Margin
Once the anterior and posterior lamellae are shortened, the surgeon reassesses the lower eyelid position with the patient in a sitting position:
The focus is on maintaining symmetry between both eyes, ensuring the eyelid is properly lowered without causing scleral show or ectropion.
If any undercorrection or overcorrection is noticed, the posterior lamella can be adjusted intraoperatively through the transconjunctival approach.
5. Skin Closure
After ensuring proper positioning, the skin excision area is closed with 7-0 black nylon sutures, carefully placed to prevent visible scarring and maintain the natural contours of the lower eyelid. The final check in the sitting position ensures that both eyelids are symmetrical and that the desired S-shaped eyelid margin has been achieved.
6. Postoperative Considerations
Intraoperative adjustments are crucial to minimizing postoperative complications, such as entropion (inward turning of the eyelid) or lagophthalmos (inability to close the eyelids fully). These complications occur in rare cases due to an imbalance between anterior lamella removal and posterior lamella shortening.
Indications and Patient Selection
The primary candidates for this procedure are patients with vertically narrow palpebral apertures and up-slanting eyelid margins. These anatomical features can give the eyes a harsh or tired appearance, which is often aesthetically undesirable for those seeking a more youthful, bright-eyed look. Preoperative evaluation is crucial to ensure successful outcomes. Surgeons must assess the lower eyelid tone, eyeball protrusion, and malar eminence to avoid postoperative complications like ectropion or scleral show.
Postoperative Outcomes and Complications
The aesthetic results of the procedure were overwhelmingly positive, with most patients expressing satisfaction with the vertical enlargement of their palpebral aperture. Objective morphometric measurements revealed a significant increase in both the height of the palpebral aperture and the area of the scleral triangle, contributing to a more open and youthful appearance.
While the complication rate was low, minor issues included:
Lagophthalmos (inability to close the eyelids fully) in 0.8% of patients
Entropion in 1.6% of cases
These complications were temporary, resolving within a month without additional surgical intervention. Additionally, 8 patients required revision surgery due to undercorrection, underscoring the importance of meticulous preoperative planning and intraoperative precision.
Conclusion
Lower eyelid repositioning offers a compelling solution for Asian patients seeking greater vertical eye aperture without altering the natural canthal tilt. This approach provides aesthetically pleasing results and has the potential to expand to non-Asian patients after careful consideration of anatomical differences. For surgeons specializing in oculoplastic or aesthetic procedures, mastering this technique can broaden their surgical repertoire and improve patient satisfaction in an often overlooked aspect of Asian eyelid aesthetics.
By integrating both anterior and posterior lamellae adjustments and emphasizing preoperative evaluation, this procedure emerges as a safe and effective option for enlarging the eyes vertically, helping patients achieve their desired appearance.
Reference:
Hirohi T, Yoshimura K. Vertical enlargement of the palpebral aperture by static shortening of the anterior and posterior lamellae of the lower eyelid: a cosmetic option for Asian eyelids. Plast Reconstr Surg. 2011 Jan;127(1):396-406. doi: 10.1097/PRS.0b013e3181f95b09. PMID: 21200235.
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