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Topic 29 - 2
Six Causes of a "Rising Crease"
Long After Upper Blepharoplasty
treatment upper eyelid complications Risks & Revision eyelid skin graft for lagophthalmos

While seldom even mentioned, one of the most common (although minor) "complications" after upper blepharoplasty is the gradual migration of an eyelid crease that seems to rise higher and higher over time, thus becoming very visible. Causation of this long-term and cosmetically-annoying process is most often multi-factorial.

1. High Incision

The lower skin incision line in non-Asian upper blepharoplasty is almost always placed within the existing upper crease, which, in most patients of European ancestry is located at between 8-10 mm above the eyelashes. Neither lower nor higher is better in cosmetic blepharoplasty, and each misplacement can be associated with its own set of problems. When placed properly, the tiny scar that inevitably results with surgery will remain well-hidden within this natural indentation.

It is, unfortunately, not rare to encounter a patient with the incision placed at almost double this normal range, where it will remain forever on display.

2. Aggressive Tissue Removal

Even if the lower edge of the incision is placed at the correct level, removing too much skin above it will interfere or prevent "re-draping" of remaining skin back over the incision line after full healing. While the eyelid may still close sufficiently with even moderately aggressive skin excision, too much of the area below the crease ("the eyelid's platform" on which eye shadow would be applied) is exposed, making the eye look abnormally stark, over-attentive, and "surgical".

3. Very Aggressive Tissue Removal

If too much skin is removed to allow for effortless eyelid closure and the final result is too tight, the skin will gradually stretch to try to compensate. Such stretching will occur in the skin both above and below the scar, and the crease may rise upward quite noticeably over the years.

4. Ptosis

Inadvertent surgical damage to the levator muscle tendon ("aponeurosis") underlying the skin may cause it to later stretch and cause "ptosis." Since a normal crease is partially anchored at its natural location by the pull of the underlying levator muscle, weakening and elongation of the levator complex will allow the crease to rise gradually higher.

Corrective ptosis surgery can restore the integrity of the levator aponeurosis.

5. Inappropriate Brow Lift

If the brow and/or forehead are lifted inappropriately high along with upper blepharoplasty, the crease will be pulled upward and placed under high tension. Over time, the very thin upper eyelid skin will stretch and the crease migrate upward.

6. Progressive Fat Loss

Perhaps the most common but least appreciated cause of an overly high and deep crease appearing either immediately following or even years after eyelid surgery is a shortage of orbital fat in the upper socket. While such surgical loss may occur from over-zealous fat and muscle excision during blepharoplasty, it may also result from "traumatic fat atrophy" resulting from rough handling and then take years to make its full appearance.

Even without eyelid surgery, normal orbital fat may sometimes be slowly lost as part of the aging process (starting in the late twenties but picking up speed throughout the forties and fifties). Widely misunderstood by the majority of cosmetic surgeons, such deep fat loss responds only to orbital fat grafting, an advanced operation that is currently of extremely limited available.

What Can Be Done?

Presence of a "rising crease" either immediately after or even long after upper blepharoplasty is typically the result of surgeon inexperience and/or flawed technique. Overly aggressive surgery can result in multiple points of damage and tissue shortage and, with the exception of ptosis, is difficult and sometimes impossible to reverse.

Next: Sample Revision: Upper
Eyelid Skin Graft

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