The Concept of a Glide Zone as It Relates to Upper Lid Crease, Lid Fold, and Application in Upper Blepharoplasty

Classically, the normal eyelid anatomy can be conceptualized as consisting of two layers: the anterior skin/orbicularis oculi muscle layer and the posterior layers of the levator muscle and aponeurosis, Müller’s muscle, and the tarsal plate. In general, Caucasians eyelids with a crease are thinner than their Asian counterparts. This is attributable to a combination of factors that include a higher point of fusion of the orbital septum onto the levator aponeurosis, the relatively higher position of preaponeurotic fat pads and resultant thinner lower segment of eyelid, less preseptal fat, and thinner orbicularis. Comparatively, Caucasians with an eyelid crease possess a greater number of distal fibers of the levator aponeurosis that terminate toward the skin along the superior tarsal border and the area above it to form the eyelid crease. When the levator contracts, the tarsal plate vectors upward and the eyelid crease invaginates easily. Caucasians may often have a deep-set supratarsal sulcus (Fig. 1). The upper eyelid anatomy of Asians is further divided into two groups—those with an upper eyelid crease and those without any crease. In Asians with a crease, although the eyelid may still be thicker than in Caucasians with an upper lid crease, there are distal fibers of the levator aponeurosis terminating toward the skin along the superior tarsal border.1 Despite the low point of fusion of the orbital septum, when the levator contracts, there is an invagination of skin along the superior tarsal margin to form a clinically apparent upper eyelid crease.2 When the lids are open and the subject is looking ahead, there is a greater degree of fullness in the preseptal region compared with Caucasians with a crease but less than that typically seen in Asians without an upper lid crease (Fig. 2). Asians who are without an eyelid crease typically have thicker eyelids because of the presence of a hypertrophied orbicularis and the presence of fat in the pretarsal, preseptal, and preaponeurotic areas. The orbital septum fuses with the levator aponeurosis at a lower point compared with those Caucasians with an upper eyelid crease. There are relatively few fibers or no attachment from the levator aponeurosis toward the skin along the superior tarsal border. Their pretarsal and preseptal zones are thicker compared with Caucasians or Asians who have an eyelid crease (Fig. 3). In aesthetic Asian blepharoplasty, where the goal has always been to create an ethnically appropriate crease, there are two categories of methods used to achieve this goal. The first consists of the suture ligation methods,3–6 which are often described as being less invasive and simpler to perform, and use several buried sutures to tighten the soft tissues along the superior tarsal border, which includes orbicularis, levator aponeurosis, and Müller’s muscle. The other category is the external incisional approach, whereby a skin incision is made along the designed crease and varying amounts of skin, muscle, and soft tissues may be removed; this is then coupled with various methods of crease construction by means of fixation or attachment of skin to the levator aponeurosis, skin to the tarsus, or orbicularis-to-aponeurosis fixation. The surgical results often depend on a complex interaction between the degree of excessive tissues overlying the pretarsal and preseptal areas, the presence of fat, the thickness of skin over each of the two areas mentioned above, the position of the globe, the brow position, levator function, and whether there is a firm adhesion From the Department of Ophthalmology, University of California, Los Angeles School of Medicine, Ophthalmic Plastic Surgery Service, Harbor-UCLA Medical Center, and Aesthetic Plastic Surgery Institute, University of California, Irvine. Received for publication July 12, 2005; accepted November 7, 2005. Copyright ©2006 by the American Society of Plastic Surgeons