In Asian patients born with or without a naturally-occurring eyelid crease, the upper eyelids may appear baggy on either an inherited or age-related basis. Bagginess is generally due to the presence of excess skin and fat.

Some patients may desire reduction of upper eyelid fullness while preserving the current creaseless (or nearly creaseless) state of their lids. Because of certain anatomical features in the Asian eyelid, however, use of "standard" Asian double-eyelid or Occidental surgical incisions run a definite risk of altering the current state of the crease, leaving a visible scar, and yielding a disappointing result.

There is, unfortunately, some irony in such an outcome. Overly conservative techniques undertaken specifically to create a crease may, at times, yield only a minimal or fleeting result, while surgery undertaken specifically to thin the eyelid and NOT create a crease may, if not well planned, not only unintentionally establish or disturb the crease but also do so in a way that looks unnatural and is resistant to revision.

We have developed our own technique for use in such cases:

Cross-section of eyelid
showing multi-level approach

Legend
Orbital Septum	Orbicularis Muscle
Levator Aponeurosis	Eyebrow Fat Pad
Orbital Fat	Tarsal Plate

• The skin is incised low, usually only a few millimeters above the lashes. The incision is superficial and does not go through the underlying orbicularis muscle. A plane extending upward between the skin and orbicularis muscle is then established. In this way, a flap consisting of skin alone is elevated without disturbing the underlying eyelid structure.

• If excess bulging fat needs to be thinned to decrease a pronounced convexity in the eyelid, the orbicularis muscle in entered at a higher level (that is, not immediately below the first skin incision but slightly higher). The orbital septum is next opened at yet a higher level , A tiny amount of fat is teased out and removed. The orbital septum and orbicularis muscle are allowed to close naturally without suturing. Unless bulging fat is objectionable, however, this step may be omitted.

• If the fat pocket closest to the nose is bulging noticeably, this area may be approached from the back side of the eyelid (transconjunctival), a small incision created, and any excess fat removed. No visible external scar is created.

• Finally, the skin flap is draped over the original incision and extra skin is trimmed conservatively. The skin edges are closed with sutures without employing any sort of deep fixation.

By not removing orbicularis muscle or orbital septum and by staggering the various incisions so that any normal scarring is not allowed to concentrate in a single area, formation of a visible crease is averted and the healing external scar is reasonably well camouflaged by the eyelashes.