Brief Clinical Studies The Journal of Craniofacial Surgery
7. Böckmann R, Schön P, Frotscher M, et al. Pilot study of
modification of the bilateral sagittal split osteotomy (BSSO) in pig
mandibles. J Craniomaxillofac Surg 2011;39:169–172
A Novel Strategy to Achieve
Stable and Lasting Double
Eyelids in Upper Blepharoplasty
Shenzhen Gao, BS, Baixue Lu, BS, and Weicheng Gao, MD
Background: Incision blepharoplasty is very common among
aesthetic surgery, but the effect of it varies considerably. The
quality of incision blepharoplasty is mainly defined by oper-
ator’s ability, which will result in the uncertainty of operation
result. We are committed to seeking a principle to guide every
operator to achieve optimum success.
Materials and Methods: A retrospective study of 150 patients
experienced the new method from January 2020 to May 2022.
This method was mainly divided into 4 steps. Firstly, released
adhesion between the orbital septum and the levator aponeu-
rosis and the connection between the orbital septum and the
pretarsal fascia. Then, dealt with the epicanthus to reduce the
resistance. Third, improve the lifting force of opening eyes or
decrease the resistance of opening eyes to keep the balance of
biomechanics in the upper eyelid. Last, sutured and closed the
incision. The postoperative outcomes were assessed by “Global
Aesthetic Improvement Scale.”
Result: The follow-up period at last for 3 months.-The results
showed that the rate of “Very much improve” was 88% (132
patients); that of “Much improve” was 9.3% (14 patients); that
of “Not change” was 0.6% (1 patient); and that of “Worse” was
2% (3 patients). The recovery time of patients varied from 2
weeks to 1 month. And the complications of the narrowing and
lightening of the double-eyelid line decreased.
Conclusion: Applying the biomechanical balance principle to
incision blepharoplasty can generate a more beautiful double-
eyelid line and is less likely to trigger off complications.
From the Department of Plastic and Cosmetic Surgery, The Affiliated
Friendship Plastic Surgery Hospital of Nanjing Medical University,
No.146, Han-zhong Road, Nanjing, Jiangsu, China.
Received October 11, 2022.
Accepted for publication November 23, 2022.
S.G. and B.L. have the equal contribution to this article, and they
should be considered as co-first authors.
Address correspondence and reprint requests to Weicheng Gao, MD,
Department of Plastic and Cosmetic Surgery, The Affiliated
Friendship Plastic Surgery Hospital of Nanjing Medical University,
No.146, Han-zhong Road, Nanjing 210029, Jiangsu, China;
E-mail: gaoweicheng9@163.com
The authors report no conflicts of interest.
Supplemental Digital Content is available for this article. Direct URL
citations are provided in the HTML and PDF versions of this article
on the journal’s website, www.jcraniofacialsurgery.com.
Copyright © 2023 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000009252
e308
Copyright © 2023 Mutaz B. Habal, MD. All rights reserved.
 Volume 34, Number 3, May 2023
Key Words: Balance, biomechanics, complication, incision ble-
pharoplasty
A s we all know, the upper eyelid blepharoplasty is increas-
ingly becoming one of the most popular aesthetic surgeries
in Asia.1 To obtain aesthetic appearance of blepharoplasty,
previous studies tried to combine blepharoplasty and epi-
canthoplasty, because the epicanthus can weaken the effect of
blepharoplasty.2,3 Although the double-eyelid surgery has been
developing, plastic surgeons still have a hard time dealing with
the bad effects of complications double-eyelid surgery triggers,
including deep fold or ectropion, shallow fold, low crease, or
high crease, etc. On the basis of current clinical operation
techniques, certain shortages include relatively rigid folded and
distinct scars might still be left. Moreover, some people may
experience the narrowing and lightening of the double-eyelid
line over time. Therefore, how to decrease the incidence of
complications becomes the problem most plastic surgeons have
to think.4,5 By studying previous researches, we found many
scholars believed that epicathal folds would limit the opening of
eyes and influence the blepharoplasty.6,7
To overcome the above problems, we came up with an
original concept that to reasonably apply biomechanics in
double-eyelid surgery can be expected to solve some clinical
problems. In our practice, the epicanthoplasty would be per-
formed to reduce the influences of blepharoplasty, and then the
double-eyelid fold was obtained without suture fixation after
removing the appropriate tissue during the operation. After
fully releasing the tissue, the resistance force of upper eyelid
tissue can be reduced. At the same time, the lifting force of
opening eyes should be enhanced to form a natural, beautiful,
and smooth double-eyelid line. The aim of this study was to
describe the novel strategy to achieve stable and lasting double
eyelids.
MATERIALS AND METHODS
Patients
From January of 2020 to May of 2022, a total of 150 pa-
tients (146 women and 4 men; age range 18–40 y; mean age 24y)
were scheduled for eyelid cosmetic surgery at our department,
who did not have diabetes, hypertension or cardiac disease and
other diseases. All of these patients both had epicanthus and
accepted blepharoplasty and epicanthoplasty operated by the
corresponding author. All patients gave written informed con-
sent before surgery.
Surgical Technique
The palpebral folds are designed 7.0 to 8.0 mm above the
ciliary margin on each side in accordance with the simulation
and all the surgical procedures were conducted under local
anesthesia. An incision was made by the preoperation design. If
the patient’s epicanthus is obvious, the epicanthus must be dealt
with firstly to reduce the influence of blepharoplasty, which is
corrected by Prak’s modified epicanthoplasty.8 The excess or-
bital septum fat needed to be removed appropriately after or-
bital septum was opened, and the orbital septum near the nasal
side was fused with the pretarsal fascia. We separated the
connection between the orbital septum and the pretarsal fascia
(Fig. 1). In the same way, the lateral connection between the
orbital septum and the pretarsal fascia should also be separated.
Meanwhile, paid attention to stripping the fibrous structure
between orbital septum fat and aponeurosis. After releasing
carefully the adhesion tissue(such as adhesion fibers around the
Copyright © 2023 by Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 34, Number 3, May 2023
FIGURE 1. The major surgical procedures of keeping biomechanics balance
principle in double-eyelid surgery. (A) The left side dashed line indicates that
the orbital septum near the nasal side is connected with the pretarsal fascia.
(B) Similarly, the right side dashed line indicates that the orbital septum which
is not released in the outside. (C) An asterisk indicates the fibrous structure
which is not released between orbital septum fat and aponeurosis. (D) The
picture shows the release of the above adhesion, the removal of part orbital
septum fat, and the pruning of some redundant orbicularis oculi muscle and
orbital septum tissue. (E and D) The right eye achieved biomechanical balance
to obtain an aesthetic double-eyelid line without suture after releasing
adhesion and pruning redundant tissue compared with the untreated left eye
when the patient opened (E) or closed eyes (F).
orbital septum, fibrous web bands between the levator
aponeurosis and orbital fat), patients were asked to open their
eyes to evaluate the morphology of the double-eyelid fold line
without suture. Then, trimmed properly the tissue included
partial superfluous orbicularis oculi muscle, retro-orbicularis
oculus fat and orbital fat to reduce the resistance of opening
eyes. In the condition without suture fixation, a stable double-
eyelid line can be formed after achieving mechanical balance.
Finally, suture was performed. Three buried stitches connected
the pretarsal fascia tissue to subdermal tissue with 7-0 nylon
sutures and the incision was closed interruptedly with 8-0 nylon
sutures.
Postoperative Care and Evaluation
We used sterile gauze for slight pressure dressing and 3M
bandage for shape. The bandage and fixture not only helped to
protect the incisions clean but also helped to staunch bleeding.
The dressing was removed after 24 hours and the sutures were
removed on the 7th day after operation. The evaluation of
clinical efficacy was detailed by the patients at the 3th months
after surgery on the basis of the Supplemental Table 1, Sup-
plemental Digital Content 1, http://links.lww.com/SCS/E853.
And the evaluation needed to be done by patients themselves
and doctors who didn’t take part in the surgery.
RESULTS
All patients were followed up for at least 3 months. The longest
follow-up time was 18 months, and the mean follow-up time
was 10 months. Different patients had diverse recovery time
varying from 2 weeks to 1 month. The data were incorporated
Copyright © 2023 by Mutaz B. Habal, MD
Copyright © 2023 Mutaz B. Habal, MD. All rights reserved.
Brief Clinical Studies
FIGURE 2. A 23-year-old woman obtained a natural double-eyelid line with
this method. (A and B) The morphology of eyes closed (A) and eyes opened (B)
after applying biomechanical balance principle in surgery. (C) The incision was
closed by using interrupted 8-0 suture. (D) The morphology of the double-
eyelid crease after suture was basically the same as that of the unstitched one
(B) due to the application of biomechanical balance principle and the sutures
were only used for closing incision. (E) Before operation. (F) 9 months after
operation.
into our statistics only if the doctor and patient had the same
degree of satisfaction. The results showed that the rate of “Very
much improve” was 88% (132 patients); that of “Much im-
prove” was 9.3% (14 patients); that of “Not change ” was 0.6%
(1 patient); and that of “Worse” was 2% (3 patients). The pa-
tient who was assessed as “not change” wanted to have an
inconspicuous appearance of double eyelid based on his own
original one. The reason why the patients were assessed as
“Worse” consisted in their having some complications, includ-
ing the narrowing and lightening of the double-eyelid line. And
they underwent the double-eyelid surgery again. The compli-
cations of upper blepharoplasty were observed at 3, 6, and
12 months postoperatively, we especially focused on the nar-
rowing and lightening of the double-eyelid line after surgery. To
our delight, the complications of the narrowing and lightening
of the double-eyelid line did not appear until the ninth month
after surgery. And the probabilities were 2% (3 patients), one
patient had complications of lightening of the double-eyelid line
at 12th month after surgery, one patient had complications of
high fold crease at 10th month after operation, another one
appeared narrow double-eyelid crease at 18th month after sur-
gery. The typical case was shown in Figure 2.
DISCUSSION
The complication of the narrowing and lightening of the dou-
ble-eyelid line in the incision blepharoplasty is the most com-
mon and often bothers plastic surgeons.4,5 The inaesthetic
appearance complications cause marks the failure of the sur-
gery. To resolve this problem, we explored the principles of
double-eyelid surgery and tried to apply a new method to
achieve the goal. One of the most widely used surgical methods
of aesthetic blepharoplasty is the incision method which means
making an incision on some tissue. The principles of incision
method have following features includes9,10: (1) multiple fix-
ations, it means that the surgeon sutures the tarsus to the fascia
which locates in the front of the tarsus and then sutures the
incision; (2) the reduction in the volume of upper eyelid tissue, it
means that the surgeon excises a part of orbicularis oculi muscle
and the connective fascia on tarsus in order that no extra
tissue between the tarsus and skin is left. The two methods
utilize either the force of suture or the force of scars to form the
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Brief Clinical Studies The Journal of Craniofacial Surgery
crease line. There are various theories which explain the
mechanism of double-eyelid configuration11,12 Two of the most
convincing theories are the following: (1) The levator aponeurosis
extends forward and attaches itself to the skin, forming a fibrous
junction. Reviewing the formation mechanism of double-eyelid,13
we believe that the essence of double-eyelid formation is the
balance of forces. And the double-eyelid is a folded thin layer
structure which is formed on a curved surface.14
We assume that for people who have inborn double-eyelid,
the forces of the tissue within the upper eyelid and those on the
tissue’s plane are balanced when the crease line is formed at
the time of opening eyes. In the same way, the forces should be
statically balanced while eyes are kept closed. Because the
people born with double-eyelid, the forces are balanced, they
can have the symmetric and unartificial crease line.15 We believe
that the changes in anatomical structures will reduce the re-
sistance that accompanies the eye-opening process. Releasing
the adhesion fibers, and removing superfluous, hypertrophic
partial orbicularis oculi muscle and retro-orbicularis oculus fat,
and removing redundant orbital septum fat. By these changes,
we think the force would have some variations. If we can bal-
ance the lifting force and the resisting force of the upper eyelid,
the natural and aesthetic double-eyelid will be achieved. On the
basis of this speculation, we bravely presume that there would
be a suppositional tangent plane located in the double-eyelid
line, so the resultant resistance and driving force on the tangent
plane should be zero. In the mechanical event of double-eyelid
formation, the lifting force of the upper eyelid and its resistance
is mainly embodied. In contrast, the lifting force of the upper
eyelid mainly refers to the upward levator force provided by the
levator palpebrae superioris and Müller’s muscle. Besides, the
aponeurosis of levator palpebrae superioris and Müller’s muscle
also produce some fatal active forces when the double-eyelid
folded line is formed.14 In contrast, the resistance of upper
eyelid incorporates the gravity of upper eyelid, the friction force
which derives from the levator palpebrae superioris aponeurosis
sliding upward, and the shear stress which is demanded in the
formation of the double-eyelid fold. With the application of
biomechanical balance principle in the process of eye opening,
natural and lasting double eyelids can be obtained.
During the surgery, surgeons would ask patients to open and
then close their eyes to evaluate biomechanical balance. As
patients opened their eyes, we observed the height and width of
the crease line. In addition, the static balance was measured
while patients closed their eyes. The objective and direct esti-
mation index includes the width or height of the double-eyelid
fold, and the degree of efforts to open eyes when patients are
given the instruction of opening eyes. Opening eyes will be
easier at that time than doing before the operation, because the
adhesion tissue between the orbital septum and levator apo-
neurosis is adequately slack. Likewise, due to the release of the
connection between the orbital septum and the anterior fascia of
the tarsus, the resistance of opening eyelid would be weakened.
Releasing adhesion tissue, just like adding oil to the gear set,
makes the resistance force decrease. That is why the patients
who underwent surgery feel more comfortable to open eyes.
From the mechanical point of view, the force produced by the
levator muscle, levator palpebrae superior aponeurosis, Mül-
ler’s muscle and its aponeurosis is dynamic as the eyes open.
However, the internal force produced by the upper eyelid can be
considered as static, when the action of keeping eyes open is
maintained. The rest acting force of the upper eyelid interacts
with that of the tissue, which may resist the movement of
opening eyes. To analyze the movement of opening eyes, it is
not difficult to find that the internal force produced by excessive
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Copyright © 2023 Mutaz B. Habal, MD. All rights reserved.
 Volume 34, Number 3, May 2023
tissue and adhesion is the resisting force. When eyes open, the
resisting force prevents eyes from keeping great open. Once the
force of keeping eyes open could not be in an appropriate
mechanical equilibrium condition, it must result in some un-
sightly and inaesthetic facial features, such as blepharoptosis
and eyes of different sizes that include one big eye and the other
small eye, or triangle eyes.5
Previous studies indicated that the epicanthus can limit the
opening of eyes and weaken the effect of blepharoplasty.7,16 We
think that the epicanthus not only affects aesthetic appearance
but also affects the balance of force in forming double eyelid
when the eyes open. Because excess skin tissue in the canthus has
a traction force to the skin, and pull the skin to the side of nose.17
The force which is created by the inner canthus would hamper
opening eyes. Once the resisting force produced by inner canthus
can be removed, the lifting force which is used to open eyes and
form smooth double eyelid would be enhanced.18 We observed
that the skin on the canthus would not contract when patients
opened their eyes, after releasing the force of the canthus.
We close the incision with 2-step sutures. The first step is to
suture pretarsal fascia to subdermal tissue with 7-0 nylon su-
tures, which makes the lower incision margin to be tightly at-
tached to the tarsus and eliminates the lacunae. And then the
incision was closed using interrupted 8-0 sutures. In the con-
dition of biomechanical balance, surgeons gently sutured the
front fascia of tarsus to orbicularis oculi muscle. It is worth
noting that the purpose of suture is not to depend on sutures to
create double-eyelid crease, but to reduce skin tension, eliminate
lacunae, match the skin, and close incisions.
The common incision blepharoplasty depends on the
strength of sutures, and it has some characteristics19: (1) the
upper margin of the tarsus was sutured to the orbicularis oculi
muscle; (2) or sutured the levator aponeurosis to the orbicularis
oculi muscle. In traditional double-eyelid surgery, the surgeons
make use of the force of the stitches to form a double eyelid in
the operation. Hence, the cause of formation the double-eyelid
line is the force of the stitches. And in a long term, traditional
operation method would make use of the force of the scar after
taking the stitches out to form the double-eyelid line. The su-
tures would be loose as time goes by, and therefore, some
complications would develop, such as the narrowing and
lightening of the double-eyelid line.20 Compared with the
common incision blepharoplasty, the method of applying the
principle of biomechanics balance rarely relies on the strength of
sutures. The formation of double-eyelid crease does not depend
on the force of suture in the early stage, and does not depend on
the force of scar after taking the stitches out. The core of sutures
is to fix the formed double-eyelid line instead of helping to form
the double-eyelid crease. It is a counterpoint suture, just making
tissue closed. Without using the strength of the sutures, the
natural double eyelid can be obtained by means of using the
strength of force balance in the upper eyelid. Only through
keeping the biomechanical balance can a relatively aesthetic and
effective surgical result be achieved. This advantage decreases
the incidence of complications caused by suture factors, such as
loose sutures and the shear force produced by sutures.
There are still some shortages to be overcome, for example,
how to keep the balance of biomechanics in the upper eyelid, how
to objectively measure the resistance in the adhesive tissue and
epicanthal fold, how to know the volume of orbital septum fat
need to be excised and so on. For patients who are not able to
form an aesthetic winkle after trying to keep the mechanical
balanced, we use the traditional method: the common incision
blepharoplasty. And the conditions that forming the crease and
hindering the formation of the double-eyelid line need to be
Copyright © 2023 by Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 34, Number 3, May 2023
explored. These uncertain factors may produce some un-
predictable consequences which could influence the effects of the
operation. For patients who still have complications, such as the
narrowing and lightening of the double-eyelid line after using this
technology, the following reasons should be taken into consid-
eration: (1) pretarsal tissue are removed insufficiently; (2) the
mechanical equilibrium might change as time goes by after op-
eration. Indeed, we think the most difficult problem in operation
is to maintain the balance of biomechanics on the upper eyelid. In
the following study, we expect to objectively and quantitatively
evaluate the biomechanics condition of the upper eyelid and hope
to find some ways to measure the resistance.
CONCLUSIONS
The new method for aesthetic upper blepharoplasty is described
above. The core of this technique is to keep the biomechanics
balance between enhancing the lifting force and reducing the
resisting force of the upper eyelid. The author makes sure that it
is easy for patients to open their eyes after surgery applying this
technique. Taking advantage of the biomechanics balance
principle in incision blepharoplasty can obtain long-term dy-
namic and vivid appearance with less adverse reactions. And the
complications of the narrowing and lightening of the double-
eyelid line are reduced.
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Brief Clinical Studies
16. Kitaguchi Y, Takahashi Y, Kakizaki H, et al. Impact of canthal
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Transillumination of an Anterior
Fontanelle Dermoid Cyst
Darshan Shastri, MD,* Wilson A.M. Fisher, MSc,*
Jeyhan Wood, MD,† and Carolyn Quinsey, MD*
Abstract: Dermoid cysts are slowly growing benign lesions of
ectodermal tissue that often occur in the anterior fontanelle.
Clinicians often rely on a negative transillumination test to
begin the process of correctly diagnosing a dermoid cyst.
However, here the authors present a case of a 7-month-old girl
who presents with a transilluminating dermoid cyst.
Key Words: Anterior fontanelle, congenital dermoid cyst,
dermoid cyst, skull lesion, transillumination
D ermoid cysts are rare congenital lesions that account for
<0.5% of all cranial tumors.1 They arise from the midline
within the subgaleal space, usually located within the anterior
fontanelle.2,3 They arise primarily from neuroectoderm en-
trapped during embryonic closure.4 These lesions are slow
growing, usually diagnosed between birth and the first 5 years of
life. Midline dermoid cysts can be associated with cranial and
spinal dysraphism as well as intracranial extension and as such
require early evaluation and treatment.4–6 Transillumination is
a feature very rarely seen within dermoid cysts and has been
utilized as a tool to not only characterize these lesions but dif-
ferentiate them from a meningocele or encephalocele, which
require a different surgical strategy.2–4,7–10 We present an
atypical case of an anterior fontanelle dermoid cyst with
transillumination.
From the *Department of Neurosurgery, University of North Carolina
School of Medicine; and †Department of Plastic Surgery, University
of North Carolina School of Medicine, Chapel Hill, NC.
Received June 16, 2022.
Accepted for publication November 27, 2022.
The authors report no conflicts of interest.
Address correspondence and reprint requests to Carolyn Quinsey, MD,
Department of Neurosurgery, University of North Carolina School of
Medicine, 170 Manning Drive, Physician Office Building, CB 7060,
Chapel Hill, NC 27599; E-mail: carolyn_quinsey@med.unc.edu
Copyright © 2023 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000009253
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