People of North East India present with the absence, or a very soft, upper eyelid fold and are open to the surgery known as Asian blepharoplasty or double eyelid surgery. At our Centre, Divine Cosmetic Surgery in Delhi, India, we are doing five such cases every month, and now have an experience of over 200 such surgeries. All of the surgeries are performed under local anesthesia, and the procedural time is never more than 25 minutes.

Markings

In my view, one important aspect is the presence of a mild fold. This indicates the location of the lower edge of LPS. In some patients, that fold is also missing. I then mark a curvilinear line 7-8 mm from the lid margin. We need to assess the relative laxity of skin. If the skin appears to be in excess, I would look to excise some skin along with a strip of orbicularis oris. This is not the case in all patients, some of them have tight skin, and any removal would have disastrous results. Excess of fat can also be judged at this time.

Surgery

We apply local anesthesia cream 25 minutes prior to surgery. Subsequently local anesthesia in the form of lidocaine (+adrenaline) is infiltrated. The skin incision is made on the line as discussed. Most patients will have fat bulging into the field as soon as the orbicularis is opened. I like to remove all the fat that bulges into the field above the LPS. The next step is to demonstrate the LPS and expose the lower segment of the muscle. The LPS is clearly visible as a light brown layer, it is not very thick and is easy to cut through, so extreme caution is to be taken during dissection. I place 5 sutures of 5.0 nylon from the medial to lateral between the LPS and the dermis of the upper incised skin. Each suture is checked by asking the patient to open his/her eyes. The fold is clearly seen to develop if the suture is properly placed. The procedure is completed with continuous running 5.0 nylon layer. No dressing is needed.

Follow-up care

Patients are recalled at four days for suture removal. No further follow up is required till three months later.

Patients need to be counseled that the scar can take six months to settle down due to continuous traction of LPS. Use of nylon sutures virtually eliminates the chance of a recurrence.