Eyelid Crease Examination

    The examiner can find the upper eyelid crease by lifting the eyebrow and asking the patient to look downward first, then slightly upward, and then downward again. The distance from the central upper eyelid margin to the central crease as the patient looks down and as the eyelid fold is elevated with the examiner's finger determines the margin crease distance (MCD) measurement described by Urist and me (Fig. 3-4). Normally, this is 9—11 mm. If the distance is much less, reconstruction of the eyelid crease and excision of the skin fat should be considered. If the MCD is much greater than normal, a disinsertion of the levator aponeurosis should be suspected. As the levator aponeurosis recesses into the orbit, it frequently elevates the eyelid crease upward.


    The surgeon must discuss reconstruction of an upper eyelid crease with the patient preoperatively. Although most patients find a high upper eyelid crease to be cosmetically appealing, some, especially Asians, may strongly dislike its appearance. It is therefore advantageous to be able to demonstrate to patients preoperatively how they will look with crease reconstruction and to predetermine the desired level at which to reconstruct the upper eyelid crease.

    To predetermine the position at which to reconstruct an upper eyelid crease, the surgeon will need a curved instrument for compression of the upper eyelid skin. I formerly used an unwound, slightly curved paper clip and pressed it at various positions of the upper eyelid. Many of my patients reacted negatively to the use of a paper clip to determine the eyelid crease, saying how crude an instrument it was. This negative reaction led to my development of a more sophisticated instrument, the upper eyelid creaser (Bausch 8c Lomb Storz* Instruments).

    This creaser consists of a 4-cm, curved, thin meta wire attached to a handle (Fig. 3-5). The wire has i curvature similar to the normal upper eyelid crease but it is flexible and can be bent by the examiner if the curve needs to be flattened or extended. The examiner holds the handle and presses the wire into the uppci eyelid at various positions until the surgeon and patient agree on a desirable level at which the reconstruction is to be performed (Fig. 3-6). A measurement is made between the upper eyelid margin and the chosen position and is used intraoperativcly to determine the position for reconstructing the crease.

    The eyelid creaser is also useful in demonstrating to patients the need for forehead and brow elevation. Reducing the upper eyelid fold with the creaser will show patients the residual skin under their brows and if they find that unacceptable they are usually more willing to undergo a forehead and brow lift with an upper blepharoplasty.