Supratarsal Fold Research Articles

Transconjunctival Levator Aponeurosis-Müller Muscle Complex Plication to Correct the Acquired Ptosis Following Double-Eyelid Surgery.

One of the most common adverse outcomes of an upper blepharoplasty involving double-eyelid surgery is asymmetric upper eyelids due to unbalanced supratarsal folds or a difference in the palpebral fissure height. This study aimed to evaluate the efficacy and safety of transconjunctival levator aponeurosis-Müller muscle complex plication for correcting acquired ptosis following double-eyelid surgery. This retrospective study evaluated 18 patients who underwent transconjunctival levator aponeurosis-Müller muscle complex plication between June 2016 and June 2019 to correct acquired ptosis. On the basis of the main area of eyelid drooping, ptosis was categorized as central (mid-pupillary), medial (medial limbus), or lateral (lateral limbus). Preoperative and postoperative palpebral fissure heights were measured and compared. Three months postsurgery, the mean difference in palpebral fissure height between bilateral eyes decreased from 0.96 to 0.04mm in the medial ( P <0.001), from 0.93 to 0.00mm in central ( P =0.003), and from 1.30 to -0.03mm in lateral ptosis ( P =0.079). In 13 patients who underwent unilateral correction, the amount of plication was significantly associated with increased palpebral fissure height at the medial limbus ( P =0.043) and mid-pupillary line ( P =0.035). All patients reported a significant improvement in satisfaction. Five patients experienced acute postoperative complications, including chemosis, conjunctival injection, and foreign body sensation, all of which were resolved after a month of observation. No asymmetries or recurrences were observed. Transconjunctival levator aponeurosis-Müller muscle complex plication is a minimally invasive, safe, and effective technique for correcting acquired ptosis following upper eyelid surgery.

Sunken Upper Eyelid Deformity Correction by Orbital Fat Pad Repositioning and Orbicularis Oculi Muscle Folding in Blepharoplasty.

Sunken upper eyelid deformity results in an aged and unnatural appearance and is common among Asians along with the single eyelid. The upper eyelid volume restoration is as important as the creation of a supratarsal fold for patients with sunken eyelids. In the present study, the combination of orbital fat pad repositioning and orbicularis oculi muscle flap folding was established to correct the upper eyelid depression during blepharoplasty. A retrospective study was conducted on patients who underwent the orbital fat pad repositioning and orbicularis oculi muscle flap folding to correct the upper eyelid depression between July 2020 and October 2021. The preoperative and postoperative sunken depths were calculated and compared, and overall patient satisfaction was performed to evaluate the operation efficiency. There were 40 patients, including 39 females and 1 male, who underwent surgery with an average age of 25.4 years. During the mean follow-up period of 12.7 months, the sunken depth improved from 3.2mm preoperatively to 1.5mm postoperatively with a statistical significance. Satisfactory results were achieved without major complication. For patients with mild to moderate sunken upper eyelids, the combination of orbital fat pad repositioning and orbicularis oculi muscle folding has been proved efficient and consistent to restore the upper eyelid volume and helpful to build esthetic double eyelids.

Combined Sub-Brow Lift and Upper Blepharoplasty to Minimize the Supratarsal Fold Thickness and Lateral Hooding: A Concept and Review of Cases

Despite upper blepharoplasty being the most popular periorbital rejuvenation surgical procedure, in Asians with moderate to severe blepharochalasis, the occurrence of postoperative puffy supratarsal fold (double eyelid) and residual lateral hooding is not uncommon. A qualitative retrospective analysis of before and after photos of 268 cases of combined sub-brow lift and upper blepharoplasty was done. A substantial number of cases had satisfying supratarsal fold thickness and improvement in lateral hooding. A combined sub-brow lift and upper blepharoplasty is an effective method to reduce the supratarsal fold thickness and lateral hooding in Asians with moderate to severe blepharochalasis.

Simultaneous Double Eyelid Blepharoplasty and Blepharoptosis Correction With Levator Aponeurosis Plication Technique: Clinical Experience of 108 Cases.

Fifty percent of Asians are born without a supratarsal fold (also called single eyelid), and double eyelid blepharoplasty is one of the most commonly performed and most popular facial cosmetic surgeries in the Asian population. However, patients with single eyelid frequently present with concomitant mild blepharoptosis (degree of ptosis, ≤2 mm), which often fails to cause the attention of surgeons and misses correction. A retrospective study of all patients who underwent double eyelid blepharoplasty and blepharoptosis correction simultaneously with the modified levator aponeurosis plication technique was performed from June of 2017 to June of 2020. A total of 108 patients (155 eyelids) underwent double eyelid blepharoplasty and blepharoptosis correction simultaneously with the modified levator aponeurosis plication technique and were enrolled in the study. The average follow-up period was 11.8 ± 4.5 months. There was a statistically significant difference between the preoperative margin reflex distance 1 (MRD1) and postoperative MRD1 (2.93 ± 0.37 vs 4.21 ± 0.39 mm, P = 0.000), and the mean MRD1 improvement was 1.28 ± 0.50 mm. Sufficient correction was obtained in 148 eyelids (95.5%), whereas undercorrection was observed in 5 eyelids (3.2%) and overcorrection was observed in 2 eyelids (1.3%). One hundred two patients (94.4%) were completely satisfied with the final result.All patients had smooth and elegant upper eyelid margin curve, and no patients complained of distortion of the eyelid margin contour and foreign body sensation.There were no cases of hematoma, infection, suture exposure, corneal abrasion, and keratitis in any patient. This modified levator aponeurosis plication introduced in this study is a simple and effective method for creating double-eyelid crease and correcting mild blepharoptosis simultaneously, and provides a satisfactory outcome. As such, we recommend this method in treating patients with both single eyelid and mild blepharoptosis.

Blepharoplasty Combined With Mini-incision and Interrupted Buried Suture Techniques.

Blepharoplasty has become one of the most popular plastic surgery techniques for generating double-eyelid folds. The mini-incision blepharoplasty technique results in minimal trauma and the formation of supratarsal folds. In this study, the authors combined mini-incisions with interrupted buried sutures. To perform the blepharoplasty procedure, the authors marked the supratarsal folds and divided them into 5 line segments: 3 cutting lines and 2 noncutting lines. For the cutting lines, the authors used orbicularis-tarsus fixation to form double eyelids and only removed a small strip of muscle under the incision to maintain the physiological structure of the pretarsal tissue. For the noncutting lines, the authors used the interrupted buried suture technique to add 2 fixed points. A total of 42 patients (mean age 25.25 years) underwent this minimally invasive blepharoplasty. Among these patients, 42 underwent bilateral surgery. The average follow-up period was 35.91 months (range: 13-47 months). Only one patient underwent a second operation to address a shallow, unilateral supratarsal crease. Nonetheless, all patients were satisfied with their results. Our minimally invasive blepharoplasty approach resulted in minimal damage to the pretarsal tissues and robust supratarsal folds and is relatively easy to perform for the novice surgeon. Level IV.

The hinge effect of the posterior septum and levator muscle fixation technique in Asian double-eyelid operation

In Korea, upper eyelid puffiness with the mild ptosis is frequently reported and the levator muscle advancement is needed in double-eyelid operation. After levator muscle advancement in ptosis, continuous discomfort of upper eyelid may be noted. So we paid attention to the elasticity of the posterior septum. We advanced the levator muscle and sutured the connected posterior septum to the lower incisional margin of the upper eyelid skin as a hinge. The posterior septum effectively controls the pulling power of the levator muscle to create the natural supratarsal fold. Herein, we aimed to present our levator muscle fixation technique using posterior septum in double-eyelid operation of the mild ptosis. We performed double-eyelid operation in 30 patients with mild ptosis aged 18–55 years since 2017 to create a supratarsal fold. We opened the anterior septum, and the posterior septum and the connected levator muscle are dissected from the Muller’s muscle. The levator muscle is advanced for ~ 2 mm. Then, the advanced levator muscle was fixed, and the posterior septum connected to the lower incisional margin of the upper eyelid skin was sutured. No depressed scar formation and no complete loss of the supratarsal fold occurred. Postsurgical discomfort on upper eyelid resolved in 2 months. The suprafold was not loosened 12 months postoperatively. All patients were satisfied with the outcome. Our levator muscle fixation technique produces lesser discomfort and creates more naturally appearing supratarsal folds than any other technique for double-eyelid operation of East Asians. Level of Evidence: Level IV, therapeutic study.

Free Orbital Fat Grafting During Upper Blepharoplasty in Asians to Prevent Multiple Upper Eyelid Folds and Sunken Upper Eyelids.

Nowadays, a sharp, well-defined supratarsal fold and appropriate fullness of the upper eyelid tissue are considered important features of beautiful and youthful eyes. Individuals with thin upper eyelid tissue are at high risk of developing multiple upper eyelid folds and/or sunken appearance after upper blepharoplasty. Innovatively, the authors propose the application of free orbital fat grafting to the postorbicularis oculi space during upper blepharoplasty in order to achieve better aesthetic results. Fifty Chinese patients with congenital single eyelids combined with mildly sunken upper eyelid tissue were operated on between June 2017 and October 2018. During blepharoplasty, the lateral portion of the orbital septum was dissected, and appropriate lateral orbital fat was harvested. When the double-eyelid fold was formed and skin was interruptedly sutured, the harvested fat was divided into several pieces each side according to the sunken depth, and they were used to replace a layer on two-thirds of the central region of the supraseptal skin-muscle flap through the zipping gaps. Forty-five patients underwent the follow-up interview for 6 to 18 months with a mean period of 10 months. The satisfaction rate was 82%. No significant asymmetry, irregularities, and sunken upper eyelid and multiple upper eyelid folds occurred. The lateral orbital fat grafting to the central region of the supraseptal skin-muscle flap during upper blepharoplasty is an effective and simple method to correct or prevent multiple upper eyelid folds and/or sunken upper eyelid in Asians.

Clinical efficacy and strategy of complications of blepharoplasty for double eyelids

Objective To investigate the causes, the prevention and the treatment of the complications of blepharoplasty for double eyelids. Methods The clinical data, the surgery methods and the causes were analyzed in 100 cases of blepharoplasty from July 2011 to December 2017. Results All of these patients underwent these perfect procedures with satisfied anesthesia. Incisions were all healed in one stage with no infection. Double eyelid width was (7.0±1.2) mm with natural and smooth lines after 3 months operation, 86 patients (86%) had double eyelid with natural and smooth lines, slight scars and good bilateral symmetry. 14 patients (14%) required surgical revision for complications, as asymmetry of supratarsal folds (7%), over narrow of supratarsal folds (4%), over width of supratarsal folds (2%), disappearance of supratarsal folds (2%), multiple eyelid (3%) and ptosis (1%), and the effects were satisfactory. Conclusions In order to achieve the natural and smooth double eyelids, it is important for plastic surgeons to have the comprehensive grasp of overall outline and operational details in blepharoplasty for double eyelids. Preoperative design should be accurate, intraoperative procedures should be careful, and postoperative care should be standardized. Key words: Blepharoplasty; Postoperative complications; Treatment outcome; Retrospective studies; Double eyelids

Value of levator shortening for correction of high supratarsal fold after cosmetic upper blepharoplasty

Objective To correct the high supratarsal fold after cosmetic upper blepharoplasty is a challenge because of the shortage of both upper eyelid skin and fat. Levator shortening has been a procedure of choice selected by the surgeons to correct this condition. Methods Under local anesthesia, the desired crease was marked according to the characteristics of eyelid anatomy and aesthetic consideration for Asian women. The incision was made through the marked new skin crease and the old incision with surrounding scar tissue was incised. The adhesion between the skin and the levator aponeurosis was completely released. The levator aponeurosis was then divided above the tarsal plate. It could be shortened and then reattached to the tarsal plate depending on the amount of the upper eyelid skin and the degree of the ptosis. The skin incision was then closed to form new but lowered fold. Results Between 2003 to 2015, a total of 34 Chinese women underwent bilateral levator shortening for correction of high supratarsal fold after previous unsatisfactory upper blepharoplasty by other surgeons. There were no surgical complications postoperatively in this series and 32 patients (94.1%) were satisfactory for the outcome of the proper height of the supratarsal fold with at least 1 month follow-up. Only one patient (2.9%) required surgical revision for asymmetry of supratarsal folds and one patient (2.9%) for correction of deepened supratarsal fold. Conclusions The levator shortening can be an effective procedure to correct high supratarsal fold after unsatisfactory upper blepharoplasty in Asian women. It is especially useful to correct such a condition where there is shortage of the eyelid skin combined with the eyelid ptosis. Key words: Upper blepharoplasty; Levator palpebrae shortening; High supratarsal fold

Three Mini-Incision Double-Eyelid Blepharoplasty

Although there are many procedures reported in the literature regarding the partial incision double-eyelid blepharoplasty, the current methods still have potential problems such as unstable and limitation of application. In this study, the authors developed a 3-mini-incision technique that minimizes tissue injury and provides a tough connection between the levator aponeurosis and skin. With this method, 3 minute incisions (3-4 mm) are made in the upper eyelid. Through these incisions, the whole strip of pretarsal orbicularis oculi muscle under the inferior incision line and the excessive fat can be removed. This technique gives a stable and natural-looking supratarsal fold, with invisible scar, minimal complications, and a short recovery period; and can be applied to patients with fatty eyelids. This method has the benefits of both nonincisional and full-incisional techniques, and avoids the disadvantages of the current partial incisional methods.

Do Upper and Lower Orbital Fat Have a Connection?

This study, using cadavers, was conducted to determine whether there is a true connection between upper and lower orbital fat. A total of 39 orbits of 20 fresh Korean adult cadavers were used. Colored gelatin was injected into the upper or lower peripheral fat (preaponeurotic fat) of each orbit. One week after injection, dissection was continued and connection of the upper and lower orbital fat was examined. No migration of gelatin injected into the upper or to the central fat (intermuscular cone fat) was observed. However, migration of gelatin injected into the upper or lower preaponeurotic fat into the entire episcleral space through the adipose orifice (AO) was observed. The 3 sides of the upper AO consisted of the superior oblique muscle before the trochlea, superior oblique tendon after the trochlea, and sclera. The 3 sides of the lower AO consisted of the inferior oblique muscle, lateral rectus muscle, and fascia between the inferior rectus muscle and lateral rectus muscle. The upper AO was located at the medial one third of the orbital width and superior one fifth of the orbital height. The lower AO was located at the lateral one third of the orbital width and inferior one fifth of the orbital height. The shape of the upper AO was a triangle with a base of 4.3 ± 2.0 mm and a height of 2.3 ± 1.2 mm. The shape of the lower AO was a triangle with a base of 4.5 ± 1.8 mm and a height of 2.7 ± 1.1 mm. We think that surgical obliteration of the AO might prevent migration of preaponeurotic fats. Prevention of migration of preaponeurotic fats will aid in avoidance of baggy lower eyelid or deepening of the supratarsal fold.

Estimation of skin removal in aging asian blepharoplasty

To describe a novel method for estimating the amount of skin to resect in upper blepharoplasty in the aging Asian eyelid and to report our experience with this technique. Retrospective review of patients in a single private practice. Resection of skin in upper blepharoplasty in an Asian eyelid can often be less forgiving than in other ethnicities due to the unique anatomy of the supratarsal fold. Excising a maximal amount of excess skin will result in an unfavorable appearance of the upper eyelid in an Asian patient. We applied a technique of pinching the skin while the patient is awake until the patient is satisfied with the appearance. The skin is then measured and the precise amount resected during blepharoplasty. The supratarsal crease is always recreated even in patients who have a preexisting crease. We conducted a retrospective review of 99 consecutive patients who underwent upper blepharoplasty using this technique. All patients were Asian and aged 40 years or older. The study group included 99 patients with a mean age of 55.7 years (range, 42-78 years). The mean follow-up time was 24 months (range, 12-30 months). The amount of desired skin overhang superior to the supratarsal crease varied considerably among patients. Complications included asymmetry in nine patients (9.1%), scarring in three patients (3.0%), and unfavorable cosmetic result in two patients (2.0%). No patients experienced infection, bleeding, or visual changes. In upper blepharoplasty in the aging Asian eyelid, it is necessary to resect less skin than in the Caucasian patient to achieve the desired appearance of the upper eyelid complex. Using a patient-assisted approach to estimate the amount of skin to remove, a favorable cosmetic result with a low incidence of complications was achieved in a consecutive series of patients.

Aesthetic Blepharoptosis Correction With Release of Fibrous Web Bands Between the Levator Aponeurosis and Orbital Fat

Blepharoplasty remains one of the most frequent operations in Asia. The most common complaint of Asian patients is a limitation of eye opening, and a substantial proportion of patients have puffy eyelids, supratarsal folds in the upper eyelid, and a narrow palpebral fissure, thus exhibiting a tired and sleepy appearance. To correct these features, an accurate understanding of upper eyelid anatomy is essential, especially concerning the levator aponeurosis, orbital fat, and orbital septum. After a strip of orbicularis oculi muscle was removed through usual transcutaneous blepharoplasty incision, we excised the submuscular soft tissue to expose the fusion line of the septum and the levator aponeurosis. Blunt dissection was carried out between the levator aponeurosis and the orbital fat. During dissection, a three-dimensional fibrous web connecting the orbital fat and levator aponeurosis, and continuing to just behind the Whitnall ligament, was observed in all patients. All of the connections with these fibrous bands were resected during the procedure using a Steven scissors while controlling bleeding. After this dissection, we reevaluated the degree of blepharoptosis in the upright position and checked the function of the levator palpebral muscle. We observed that mild and subclinical blepharoptosis was corrected without manipulation of the levator aponeurosis or the Müller muscle. Of the 32 patients evaluated, 22 were women and 10 were men. All of our patients had mild or subclinical blepharoptosis (<2 mm). The levator function was excellent or good in all patients. Most of these patients (29/32, 87.5%) were satisfied with the outcome after this operation. The authors found that fibrous web bands between levator aponeurosis and orbital fat limit movement of the levator aponeurosis, which is a cause of eye opening limitation. In the current study, subclinical and mild blepharoptoses were corrected by releasing these fibrous bands without manipulating the levator aponeurosis or the Müller muscle. This method has been shown to be highly effective in correcting mild ptosis and can be applied during most surgical blepharoptosis techniques.

Blepharoptosis Correction

Blepharoplasty remains one of the most popular surgical procedures in Asia. The most common patient complaint leading to a blepharoplasty is limited eye opening causing a narrowing of the palpebral fissure. The typical Asian eye is characterized by puffiness, lack of a supratarsal fold in the upper eyelid, and a narrow palpebral fissure, exhibiting a tired and sleepy appearance. Almost all such patients believe that a simple double-eyelid operation is able to make the eye look bigger with eversion of the eyelashes into a more charming configuration. Some of these patients actually have mild to moderate blepharoptosis, which can present both functional and aesthetic problems. Numerous surgical procedures have been developed to correct ptosis because proper correction can be difficult to achieve. The authors found abnormal lateral deviation of the levator aponeurosis in patients with blepharoptosis and suggest that this abnormality is a major cause of blepharoptosis, particularly in Asians. The authors assessed the effectiveness of a levator aponeurosis medial repositioning technique rather than levator resection or levator plication for mild or moderate ptosis. No disadvantage was attributed to this technique when it was used to correct 87 patients with mild ptosis. Eighty of the 87 patients achieved a good result with the first operation. Undercorrection was observed in 6 patients, and a hematoma was corrected in 1 patient. However, no other major complications related to the technique were encountered. Herein the authors describe their operative technique and present the long-term follow-up results. The authors propose that anatomic repositioning of a laterally deviated levator aponeurosis using the described repositioning technique is highly effective for correcting mild ptosis and can be applied during most surgical blepharoptosis procedures in Asian patients.

A New Technique of Upper Eyelid Blepharoplasty Using the Orbicularis Muscle Flap

Blepharoplasty of the upper eyelids is one of the most commonly performed procedures in aesthetic plastic surgery. The orbicularis muscle flap technique provides good results for patients with atonic skin and an atonic orbicularis muscle when there is excessive fullness in the lateral aspect of the upper lid. This flap also can be used to contain a prominent lacrimal gland or retro-orbicularis oculi fat (ROOF) without dangerous removal of the last one. A total of 30 patients underwent upper lid blepharoplasty through a supratarsal incision approach. Dissection of the orbicularis muscle flap was made 5-8mm above the supratarsal fold. Before the muscle flap suspension, the excess skin and fat pad were removed. The flap suspension was achieved with its rotation and motion of a tunnel in the suborbicularis plane, which anchored it on the periosteum of the orbital lateral rim of the frontal bone with a permanent suture. This technique restores the sharp and crisp tarsal folds and pretarsal show with deepening of the orbitopalpebral sulcus. The orbicularis muscle flap also can be proposed for cases with a ptosis of the lateral upper lid. The authors believe this technique reduces the risk for "rounding" of the eyelid and produces better contact of the lid with the ocular globe. The orbicularis muscle flap procedure is a feasible technique that can be used reliably to reshape the lateral upper lid. It would be a useful addition to the armamentarium of the plastic surgeon who is called on to perform upper blepharoplasty.

Mini-Incision Double Eyelidplasty

Blepharoplasty in Asia is almost synonymous with double-eyelid surgery, which refers to the creation of a palpebral fold by supratarsal fixation in patients with no visible or a low supratarsal crease. The best way to develop the supratarsal crease is to achieve a permanent attachment between the dermis and the levator aponeurosis/tarsal plate at an appropriate height. The authors describe the results of their mini-incision technique for developing a double eyelid. This method combines the benefits of both nonincisional and open techniques; two minute (2-3 mm) incisions are made together with debulking of the pretarsal soft tissues. The authors conducted a retrospective review of 526 consecutive patients who underwent the mini-incision upper blepharoplasty between March 1998 and December 2008. To evaluate the long-term results of the procedure, data were collected retrospectively on the number of patients who experienced disappearance of the double folds following surgery (and the point at which the folds were lost). Attempts were made to identify the likely reasons for the loss of folds by means of history and retrospective intraoperative assessment. Any complications encountered with this method were also identified. A total of 526 cases of mini-incision upper blepharoplasty were included in this study. There were 450 bilateral and 76 unilateral procedures. Of these, a total of 58 patients (11%) subsequently underwent further operations: 26 patients had height readjustment because of dissatisfaction with the initial height (ie, it was too low), 32 patients had subsequent surgeries to reestablish lost double folds. The overall disappearance rate of the folds with this technique was 6% (17 unilateral; 15 bilateral). The mean rate of fold disappearance was 14% (32/214) during the first four years in which the senior author was performing this technique, but only 3% (11/312) in the last six years of the study period. This is most likely due to the learning curve for this technique. The mini-incision technique offers a simple, safe, and reproducible approach to double eyelids in patients with no supratarsal folds, combining the best of both suture and open techniques.

Oriental Upper Blepharoplasty

Aesthetic surgery of the upper eyelids is a very common procedure performed in cosmetic practices around the world. The word blepharoplasty, however, has a different meaning in Asia than it does elsewhere. Orientals have different periorbital anatomic characteristics, their motivations for seeking eyelid treatment are different, and operative techniques have been adapted consequently. There are also many eyelid shapes among Orientals, mostly with regard to the presence and location of the supratarsal fold and/or presence of an epicanthal fold. The surgeon must therefore master a range of surgical procedures to treat these variations adequately. It is critical to know the indications for each blepharoplasty technique as well as their complications to select the right surgery and avoid unfavorable results. Epicanthoplasty performed on the right patient can greatly improve aesthetic results while retaining ethnic characteristics. This article will discuss Oriental eyelid characteristics, preoperative patient assessment, commonly used corrective techniques for the "double-eyelid" creation, and complications and how to avoid them.

Medial Epicanthoplasty Using the Skin Redraping Method

Background:The presence of epicanthal folds and the absence of supratarsal folds are unique features in the eyelids of Asians. The resulting appearance leads many to seek cosmetic improvement in the medial canthal area. Although many techniques have been described for the elimination of epicanthal f

Access to the frontal sinus and zygomatico frontal suture through the supratarsal fold

Precise repositioning of a fractured zygoma is difficult. The traditional approach is through an eyebrow incision, but it can produce a scar that causes aesthetic and psychological problems for the patient.We describe the supratarsal fold approach to expose the frontozygomatic suture and to reduce small displacements of frontal sinus anterior wall; it gives good access and excellent aesthetic results.

Simple Epicanthoplasty with Minimal Scar

This article makes for interesting reading about a technique that is easy to follow and perform. However, I am not sure that the concept is entirely original. I have performed a similar technique for the past 5 years, taught to me by a Japanese doctor, Dr Keizo Fukuta of Nagoya [1]. The sole difference is that with Dr. Fukuta s technique (Fig. 1a and b), the tiny triangular skin flap is taken from the terminal part of the epicanthic fold below the level of the horizontal limb and rotated 90 horizontally, whereas with the reported technique, the flap is derived from the skin above the level of the horizontal limb. This is a useful modification because it attempts to blend the vertical limb of the scar into the double-eyelid fold. However, judging from the photographs provided, it may not confer as powerful a correction of the epicanthic fold as the Fukuta technique. With the latter technique, the vertical limb may sometimes be visible as a scar over the medial aspect of the lower lid, but the correction is significant and lasting (Fig. 2a d). Whatever the case, both procedures are cosmetic improvements over the traditional techniques used for epicanthal correction, for which visible scarring has always been a problem. However, I believe the article perpetuates some stereotyping and conceptual misperceptions of the Asian eyelid that need to be corrected because westernization of the Asian eye is not a uniform goal of those seeking cosmetic improvement of the upper lid. Not all Asian eyelids are characterized by thick upper eyelid skin and orbicularis oculi muscle, excessive fat distributed between the orbicularis oculi muscle and the levator palpebrae muscle, laxity of the pretarsal fold and absence of supratarsal folds due to lack of levator palpebrae attachments to supratarsal skin, and the presence of a medial epicanthal fold (Fig. 3). Almost all Asians have some form of epicanthic fold whether there is an accompanying double-eyelid crease or not. When present, the double-eyelid crease or palpebral fold exists in two forms: an ‘‘innie’’ (in which the crease blends medially with the epicanthic fold; Fig. 4a and b) or an ‘‘outie’’ (in which the fold runs parallel with the lid margin; Fig. 5a and b). Some individuals may have an ‘‘innie’’ on one side and an ‘‘outie’’ on the other side (Fig. 6). This palpebral fold in the Asian upper eyelid is a true ‘‘double’’ eyelid because it is a pretarsal crease caused by folding of the pretarsal skin and not just a supraorbital hollow or sulcus (Fig. 7a), which characterizes many Caucasian lids. This latter Correspondence to W. Wu, M.D.; email: woffles@ woffleswu.com Fig. 1. (a) Fukuta technique, preoperative markings. (b) Fukuta technique, postoperative diagram of flap rotation. Aesth. Plast. Surg. 31:354 357, 2007 DOI: 10.1007/s00266-006-0205-6