Different Suture Techniques for Double Eyelid Surgery

I shall be giving a public talk in March, 2011 about eyelid surgery and so have to cover double eyelid surgery (in addition to eyelid tumours, ptosis, eyebags and recontruction). Going through several review articles I downloaded, there is a plethora of information about different suture techniques for double eyelid surgery. At the last count, there are more than 20 techniquess described and these technique frequently bear the names of the surgeon described (I suppose this is not a bad thing if you want to increase your private patients load: "Hello, my name is Dr. Mikamo and I have a double eyelid technique named after me." and very likely the patients' confidence in the doctor will escalate). However, the majority are only slightly different from the Mikamo's technique who was the first to describe suture technique for double eyelid surger in 1896. Below are some of the methods described. Personally, I prefer the Maruo's method as there are more contact between the subcutaneous tissue and the underlying structure (tarsal plate or levator) and further more it is not necessary to pass the needle through the underlying surface of the eyelid and thereby prevent the risk of exposed suture irriating the eyes.

MIKAMO's technique.

MARUO's technique.

BAEK's method.

MUTOU's technique

JUNG's technique.

The Must Have Book for Ophthalmology Trainees in Malaysia.

The Chinese New Year is round the corner (from 3rd Feb 2011), I would like to take this opportunity to wish everybody a Happy Chinese New Year of the Rabbit. As for me, I shall take a week off from the clinic and concentrate on finishing my book on Common Short Cases for Master Students in Ophthalmology. The book is written specially for Malaysian Master Students in Ophthalmology, however, the standard is purposedly set higher and should be useful for people taking FRCS and FRCOphth. Below is the preliminary cover of the book and samples of the contents. The book would be sponsored by the AMO and published by my company Marudi Publishing.

How to approach short cases in master examination

The Short Cases represent the biggest hurdle for the master students because the candidates are expected to show their depth of knowledge and be able to shift their examinations from one part of the eye to another and sometimes extra-ocular region (for example in pupil examination, the candidates would be expected to examine the eye movement for any third nerve palsy if the pupil is fixed and dilated or neck and chest examination for signs of sympathetic damage in Horner’s syndrome).

Preparation is essential and the best way to do this would be to learn all the common examination techniques and apply them religiously in the day-to-day practice until they become second nature. Remember that the actual examination is not the place to practice your examination techniques for the first time. Otherwise, the examinations will appear hesitant and likely to miss most of the signs or fail to extend your examination to other parts of the eye or body for further clues. Your examination should appear naturally, sleek and thorough. If you could do these, the signs should be elicited easily and allows you to concentrate on the signs and formulate the differential diagnosis and management.

How to approach the patient

Examiners do not like rude candidates and you are unlikely to leave a good impression if you are discourteous to the patients or cause them pain during examination through rough handling. The only way to learn this would be to treat all your patients in your daily practice politely and avoid causing discomfort.

During the examination:

 Always introduce yourself to the patient and ask permission to perform the examinations asked of you by the examiners.

 Show concern for the patient’s comfort for example in patient’s with a red eye ask patient if it is hurting before lifting the eyelid

 Proper positioning of the patient especially when using the slit-lamp making sure the patient does not have to stretch his/her neck or bend in an awkward position.

 On completion of the examination, thank the patients and replace any items you may have to remove during the examination (such as removal of clothing for signs of chest scar in patients with myasthenia gravis or Horner’s syndrome).

What the Examiners Look for in the Candidates

a. the ability to observe/elicit all the relevant signs and piece them together.

For example, if the candidate were asked to examine the anterior segment of the right eye above, the following signs should be observed: surgical iridectomy, flat trabeculectomy, tube in the anterior chamber, pseudophakia and a corneal stitch at the temporal cornea. The examiner would expect the candidate to tie all these signs together, a good candidate would come out with :"This patient has had trabeculectomy which failed needing tubing to control the intraocular pressure. The patient later developed cataract which was removed via a temporal approach phacoemulsification to avoid disturbing the tube."

b. the ability to connect the signs seen to relevant system.

For example, the examiner may ask you to look at the patient's above and "What examinations would you like to perform on this gentleman?". Any master student should recognize the port-wine staining and this condition is associated with open angle glaucoma and sometimes brain involvement resulting in visual field defect. "I would like to examine the right eye of this patient on the slit-lamp for signs related to glaucoma and also perform a visual field examination for any evidence of left homonymous field defect."

c. the ability to elicit underlying cause(s) related to the signs observed.

For example, in the patient above. The examiner may ask: " Would you like to examine this patient and tell me what is the cause of the abnormalities seen?". A master student should be able to observe the right facial nerve palsy and lateral tarsorrhaphy and know the pathway of the lower facial nerve. The candidate should look for any signs of parotid gland tumour or operation, vesicle in the pinna (Ramsay-Hunt's syndrome), mastoidectomy scar or scalp scar for previous neurosurgery. In this patient, examination of the back of the head reveals a scar indicative of previous brain stem surgery for acoustic neuroma (see picture below).  



The Joys and Pitfalls of Suture Techniques for Double Eyelids - Patient Suitability

The suture techniques for double eyelid formation (Asian blepharoplasty) is one of the commonest and the simplest aesthetic eyelid operations in the Far East. While I mentioned simple, it does not mean that the procedure should be performed by any lay persons without medical knowledge, sterile environment or careful patient selection. Many persons underwent the procedures in beauty saloons by self-taught unlicensed personnels with unpredictable results. Those who had botched jobs do not where to turn and the persons who did the operation usually denied any responsiblities. However, in experienced hands with careful patient selection the procedure can be satisfactory for both the doctors and the patients.

Patient 4 years after successful suture technique.

 Patient 1 year after successful suture technique.

Patient 6 months after unsuccessful suture technique.

Patient 9 year after unsuccessful suture technique.

The purpose of the procedure is to obtain an aesthetically pleasing double eyelids. The advantages of the suture techniques over the incision techniques are:
a.  less postoperative swelling;
b. the double eyelid can be removed by cutting and remove the stitches (at least at the early post-operative stage) if the patient desires to return to the preoperative state
c. the scars are minimal.

However, the main disadvantage is that:
a. the failure is higher than that of the incisional technique
b. not possible to shape the double eyelids as easily as the incisional technique.

The double-eyelid creation depends on the mechanical strength of the suture between the subcutaneous tissue and the levator aponeurosis (the muscle that open the eye) or tarsal plate. Many factors are believed to play a part in the success of the suture technique which include the number of stitches, the methods of suturing (more on this in later blog), and more importantly the eyelid of the patients. Patients who had puffy upper eyelids are usually unsuitable for the suture technique because they usually have excess subcutaneous fat that prevent adequately adhesion between the subcutaneous tissue and the levator or tarsal plate.

Diagram showing suture technique in thin and thick eyelid.

The fat in thick eyelid will prevent adequate attachment of

the subcutaneous tissue to the levator or tarsal plate.

Thin eyelids suitable for suture technique.

Thin eyelids suitable for suture technique.

Thick eyelids not suitable for suture technique.

Thick eyelids not suitable for suture technique.



Doc, Can You Make Me Look Good for the Chinese New Year (CNY)?

It is amazing how desperate some patients can be just before some major events or occasions. Last year, it was a beauty finalist who wanted double eyelids 5 days before the grand final and this time it was a young patient who wanted to have swelling-free and bruising-free double eyelids for the Chinese New Year (10 days from now). If I were to use the incisional method, the patient is likely to develop some bruising and swelling which may take more than 10 days to get better. I advised her to have the procedure after the CNY but she said she would have gone oversea to study by then. Sensing the desperation of the patient and not wanting to lose a good businss, I opted to perform the suture technique. The suture technique involve the placement of non-absorbable sutures to create double eyelid without removing any eyelid tissue. There are many methods of suture techniques for doubel eyelid but I chose the continuous type which has a lower faillure rate. The technique involves making small incisions along the skin crease to be formed and use a 6/0 non-absorable suture to tie the subcutaneous (below the skin) tissue to the tarsal plate (see picture below).

The patient only consented to her right eye being shown so as to remain anonymous.

The right eye before the procedure.

Markings done to mark the sites for suture placements.

Suture was passed to tie the subcutaneous tissue to

the tarsal plate.

During the procedure.

End of the procedure. Some puffiness from the local

anaesthesia and tissue swelling.

15 hours after the surgery. There was still some swelling but

no bruising. The swellling will subside over the next 4 days.

Power of the Tapes - What to Do When the Waiting List is Long?

As the only oculoplastic surgeon in Sarawak, I have a long waiting list for patients who want their eyelid problems treated in Sarawak General Hospital, Kuching. I saw these 2 patients this morning who had malpositions of the lower eyelids. One had entropion and the other ectropion. In entropion, the lower eyelid rolls in causing the eyelashes to rub on the cornea. This condition is highly irritating to the eye and can cause scarring to the cornea resulting in reduced vision. In ectropion, the eyelid rolls out so that the eyelid is not apposed to the eyeball and this causes watering of the eyelid which also results in blurry vision.

Surgical treatment is the best option for both entropion and ectropion. However, because of the long waiting time I need to do something to reduce the patient's discomfort. The easiest way to do so is to use a clear sticking tape to either pull down the lower eyelid in entropion or to lift it up in ectropion as shown below.

The right lower eyelid has entropion ie. eyelid rolling in.

Transparent tape is used to pull down the eyelid.

 

This patient had a left lower eyelid ectropion

ie. the lid turning outward.

The clear tape is used to lift up the lower eyelid.



Here Goes the Strawberry

There are several ways of treating strawberry naevus and this include oral medication such as beta-blocker (propanolol) or steroid. However, the most effective and most commonly used method is with injection of steroid into the mass. I injected 2 ml of a combination of two different steroids (one long-acting and one short-acting) in equal amount for this baby girl. The mass shrank dramatically in just 2 weeks.

Before the treatment.

Steroids used for the injection.

The eye was examined and to ascertain its position

before injection.

2ml of steroid was injected into the mass.

2 weeks later.

Doc, Was it Because I Ate Strawberries While Pregnant?

This 6-month old baby girl was born with red birth marks above her right eyebrow and the mother became alarmed when a large red mass began to appear in the right eye which grew rapidly. She was told by her doctor this was a strawberry naevus and referred for urgent treatment. The mother thought it was caused by her eating strawberries duing pregnancy until we explained to her that this was a type of congenital eyelid anomalies caused by overgrowth of blood vessels (haemangioma) and not associated with any food intake at birth. Strawberry naevus is common in babies and most disappear spontaneously without leaving any serious problems. However, in some patients, the lesion can grow to a huge size and interfer with important structure such as the eye as in this patient. The right eye was completely covered by the red mass which grew from below the right upper eyelid. Because the eye was occluded there was a risk that the right eye may become lazy eye as it was not receiving proper visual stimulation during growth. Consequently, it was importat to treat the condition urgently (to be continued ............)

The right eye was competely covered by a red mass.

The mass arose from under the right uppe eyelid.

Cutis Laxa (elastolysis or dermatolysis) and the Curious Case of Benjamin Button

iIn the Curious Case of Benjamin Button, the main male character was born old and grew progressively younger. Unfortunately, some young people are affected by cutis lax(elastolysis or dermatolysis) which make them two or three times older than their actual age except that unlikes Jeremy Button they don't grow younger. Plastic surgery is the only way to restore some of their youthful appearance.

Cutis laxa is a rare disorder caused by defects or destruction of the collagen  in the skin. It may be hereditary or acquired.  Its typical dermatologic characteristics are loose skin with folds and premature aged appearance. In addition, some patients may also show premature ageing of their body organs like the hearts and lunds. Below are three sufferers from China. There are less than 10 cases in the whole of China.

This 21 year-old woman (left) appears as old as

her 70 year-old granny (right).

23 year-old man with the face of a 60 year-old. He underwent

a face lift to make him look younger but unfortunately

he is unable to regain the face of a 20ish.

A 29 year-with the face of a 70 year-old and after face lift.

Despite the extensive surgery, he still appears over 50.

Friday Presentation in UNIMAS

This Friday (14th Jan, 2011) is the turn of the Eye Department of UNIMAS to give a lecture to the faculty. After juggling with the topics (Double eyelid surgery, Eyelid Reconstruction, Sleepy Eyes, Recent Advances in Cataract Surgery etc), I decide to give a talk on eyebags and dark circles entitled: "All you need to know about eyebags and dark circles" in the Main Lecture Theatre, Ground Floor, UNIMAS Medical School. All are welcomed, the talk will review all the common procedures for eyebag surgery including transcutaneous, transconjunctival, fat repositioning, pinch blepharoplasty, fillers for tear trough and different treatment options for dark circles and how effective are there.  

This Friday talk.

Previous Talk.

Another Double Eyelid Disaster from Beauty Salon

Insanity has been defined as doing the same thing over and over again and expecting different results. In the following case, the insane one is the patient and the beautician the unscrupulous one.

This 15 year-old girl presented with multiple swellings of both upper eyelids along the skin creases. She underwent four double eyelid surgeries over the past 12 months. The procedures were performed by the same beautician in a bauty/hair salon over a two year period. However, each time the double eyelids failed to form and after the last surgery which was 9 months ago, she was left with unsightly lumps in her upper eyelids. The beautician was unable to offer any remedial treatment for the swellings and as expected told her that she got "special" eyelids which were not suitable for double eyelid surgery.

The arrows in the top picture show the lumpy lesions. The bottom

picture show the prolene sutures excise (arrows).

She became depressed and afraid to go out for fear people would see the lumps. To get rid of the lumps and at the same time create stable double eyelids, I perform the incision technique . The lumpy lesions were found to be caused by prolene sutures wich were placed repeatedly by the beautician in the hopeless attempt to create double eyelids. These sutures were excised and skin creases were created with a height of 7 mm. She made an uneventful recovery.

The eyelids before and after revision with the lumpy

lesions removed.

The Hollywood Double Eyelids (blepharoplasty)

In my previous blog, I discussed the type of double eyelids (high skin creases with hollow upper eyelids) that some young Hollywood actresses used to aspire to but is not longer in fashion. However, when the new generation of Hollywood celebrities grow old and develop excess upper eyelid skin (dermatochalasis), they invariably go to Hollywood cosmetic surgeons who all seem to be taught by the same teacher. They without fail create hollow upper eyelid with exceedingly high double eyelids and elevate eyebrows (through brow lifts). Consequently, these ageing celebrities seem to have come out from the same factory. Unfortunately, these make them appear old as the loss of fat in the orbit (as evidenced by hollow orbit) is one of the sign of ageing.

Some victims of Hollywood blepharoplasty.

Do Caucasians Need Double Eyelid Surgery?

Almost all Caucasians are born with double eyelids so one may assume that they don't need double eyelids to make their eyes bigger. However, you may be surprised that some Caucasians undergo eyelid surgery to make their double eyelids even higher as these are thought to make them more glamorous. These so-called "Hollywood blepharoplasty" used to be popular amongst leading Hollywood actresses in th 50s and 60s and the most famous of which is Marilyn Monroe. To achieve these Hollywood double eyelids, the surgeons would remove orbital fat to make the eye sunken and suture the skin creases excessively high so that the patient would have some degrees of droopy eyelids. That may be why Marilyn Monroe always has a sleepy look.

Nowaday these looks are thankfully out of fashion, all the Hollywood movies would be full of sleepy beauties. Nonetheless, the height of the skin creases used to confer audience and director impression of the actress and got them tyecasted. A high skin creases gives the impression of a larger eye opening and accentuates the expression of the upper lid and much favored by leading actresses playing seductress. A low skin crease, in contrast, gives the eye a narrow and rather expressionless look. However, this can give mystery and intrigue to some actresses making them prime choice for mystery movies.

Marlene Dietrich (right) with her high double eyelids always played

seductress whereas Laura Bacall with her low double eyelids always 

casted as the woman of mystery.



Botched Dobble Eyelid Surgery by Phony Surgeon and How to Check the Validity of Your Doctor

This unfortunate woman came to see me a few months ago after a botched double eyelid surgery performed by a "doctor". Examination showed that she had unequal double eyelid heights and the double eyelids were too deep with unsightly scars. In addition, she had sunken orbit as a result of too much orbital fat being removed. She returned to the doctor but was told he did what she wanted and he could not see any problems.

When I asked her about the doctor, she produced a name card which showed the doctor had an oversea qualification. I began to smell a rat when she told me that he performed the procedure in his wife's beauty salon. I searched for the doctor name in the Malaysian Medical Council Register and could not locate his name. It is bad enough for ignorant people to have double eyelid surgery performed in beauty salon without proper sterilization and worse still for some crooks pretending to be doctors and peform invasive procedures.

If you want to find out if your doctor is genuine, you may visit the Malaysian Medical Council and enter his/her name to verify his qualification.