Re: A Modified Procedure for Single-Eyelid Asian Females with Lacrimal Gland Prolapse: Lacrimal Gland Reposition Combined with Fat Transposition in Double-Eyelid Operation

Abstract

To the Editor, We eagerly read the interesting article by Changsheng Yang et al. [1] on the results of a modified procedure for lacrimal gland reposition combined with fat transposition in 167 patients with Single-eyelid or inconspicuous doublefold eyelid females with lacrimal gland prolapse (LGP) from 2009 to 2019. They could preoperatively diagnose the LGP in 79% of their cases and had to open the septum to find out the LGP in 21% [1]. Inspection and palpation of the lateral upper eyelid bulging was used for the preoperative diagnosis [1]. While there was no any other sign and test but lateral eyelid bulging for such a preoperative diagnosis of LGP during their study period (2009-2019), the Supine test has been introduced in 2019 and proved to be having 100% positive predictive value for the preoperative diagnosis of the LGP before upper blepharoplasty [2]. Supine test makes the preoperative diagnosis of LGP very easy, comfortable, and convenient [2]. especially in Asian eyelid where the preoperative diagnosis is challenging [1]. Positive supine test means a LGP of 3 mm and more which requires fixation and negative supine test obviates the need for septal opening which could be leading to unnecessary complications [2]. Lateral eyelid bulging, on the other hand, showed a high negative (96.2%) but low positive (30.6%) predictive value meaning that its absence is more informative than its presence [2]. They performed a preaponeurotic fat flap transfer to the site of the LGP fixation in order to fill the hollowness and closed the Asian blepharoplasty incision with separate sutures [1]. While we observed such a hollowness intraoperatively, none of our 142 non-Asian patients with LGP fixation had such a fat transfer and experienced any upper eyelid hollowness postoperatively [1]. It seems that such an intraoperative hollowness will be spontaneously improved with no additional procedure. We, however, routinely put 2-3 tension relieving absorbable sutures [3] before closing the lateral skin incision in all of our upper blepharoplasty procedure in order to prevent lateral wound dehiscence, secure a subtle LGP, and make a second barrier to prevent recurrence of the LGP in cases with LGP fixation. In conclusion, we believe that the Supine test should be preoperatively performed in all the patients seeking for upper blepharoplasty and recommend tension relieving sutures before the lateral upper eyelid skin closure.