Invited Discussion on: Orbicularis–White Line Fixation in Asian Blepharoplasty—Kiss Technique

Abstract

This is an interesting article on a surgical technique for Asian upper eyelid blepharoplasty. The authors’ technique leaves the orbital septum intact, mobilizing the inferior flap in the retro-orbicularis oculi plane, lifting the pretarsal orbicularis oculi off the anterior tarsus and fixating the pretarsal orbicularis oculi to the lower edge of the levator aponeurosis at the fusion point of the levator with the orbital septum. This conjoined area has a distinct whitish appearance and accordingly is called the ‘white line.’ The key difference with the incision Asian upper blepharoplasty used by most surgeons is that the orbital septum was left intact. The authors reasoned that because the technique involves lesser extent of dissection by sparing the orbital septum, recovery is quicker, and the incision faded well and yet fixation provided is robust enough to have no incidences of crease loss in the long term in their patients. As the authors noted, the non-incision method is advantageous for its simplicity and quicker recovery. Its limitations are that rate of loss of the crease or recurrence in the short term is relatively higher and the longevity of the crease thus created may be shorter as the excess skin and loosening of the fixation around the suture develops over time. Perhaps as importantly as well, non-incisional methods have very limited versatility in managing skin excess and to more precisely contour the upper eyelid crease. This technique is also unable to address the puffiness of the upper eyelids common in Asian eyelids. The alternative approach, the open method has the advantage of greater versatility in contouring the crease that was desired, in addressing skin excess and elimination of puffiness of the upper eyelids. The recurrence rate is much lower and the longevity is also much better. The disadvantage is the significantly more prolonged swelling and edema that the incision method would involve. Furthermore, in Asian upper eyelids, swelling tends to be more significant and more prolonged compared to Caucasian upper eyelids. The swelling associated with upper eyelid surgery is associated with the extent of the dissection. The more aggressive the dissection, the greater the surgical trauma associated with the surgery and perhaps the more extensive the disruption in the upper eyelid lymphatics, the greater and more prolonged the swelling [1, 2]. Conceptually then, if the same effect may be achieved with less extent of surgical dissection, the technique with the lesser dissection is the preferred and indeed the superior technique. With the incision upper blepharoplasty approach, opening the orbital septum is a key step with many surgical techniques that have been described. Opening the orbital septum as a surgical step was performed for a few notable reasons. First is to remove the excess upper eyelid & Chin-Ho Wong [email protected]