BACKGROUND: Through process of aging or secondary to previous blepharoplasty, loss of orbital fat in preaponeurotic space results in the deepening of the superior sulcus. In asian population, this results in an abnormal demarcation just below the supraorbital rim leading to an appearance of a supratarsal fold. Wide pretarsal show in asian patients is quite unnatural and gives the upper lid a heavy appearance. Also with deep superior sulcus, in creating a supratarsal fold during standard asian blepharoplasty, there can be an appearance of two supratarsal fold. There has been many material and methods to address the correction of the deep sulcus. From filler injections to surgical procedures using autologous or alloplastic material, there are advantages and disadvantages to these approaches. The author presents his experience with alloderm as a filler to the superior sulcus in asian population.

Method: From January 2005 to December 2006 we have performed 61 primary and 29 secondary upper blepharoplasties in conjunction with the placement of the alloderm to the superior sulcus region. In the process of standard open upper blepharoplasty surgery, a pocket in the preseptal region is dissected. After adequate space between the orbicularis and orbital septum is made, appropriate size, shape, and thickness of alloderm is placed and secured. The surgery is performed under local anesthesia with light iv sedation so that the appearance of the supratarsal fold as well as the depth of the superior sulcus can be assessed.

Result: Most patients were happy with surgery, one patient required additional surgery to further augment the hollowness. There were no complications. No clinical evidence of irregularity. In the mean followup period, there was no significant decrease in the graft.

Conclusion: Hollowness of the superior sulcus in the upper lid is frequently seen either due to normal aging, or due to overzealous resection of the orbital fat in primary blepharoplasty. Especially in Asians, in whom at an early age, occidental blepharoplasty was performed, in mid-age, this seems to be quite frequent. Autologous fat graft alone or dermal fat grafts have been described and detailed. The author had earlier, utilized autologous dermal fat grafts. However, on occasions, two problems were occasionally seen. First, due to the bulkiness of the dermal/fat graft and the extreme thinness of the upper lid soft tissues, irregularities and palpabilities were noted on occasion. Secondary, when placed in the preaponeurotic space, cicatrial reactions can occur leading to restriction of the levator gliding movement. This can manifest as some degree of ptosis or irregular supratarsal fold. By placing a smooth surfaced alloderm, there were no incidence of irregularity or palpability. By placing the graft in the preseptal space, no cicatrial reaction occurs between the graft and smooth gliding levator aponeurosis. We believe this is a better option for addressing the superior sulcus hollowness.
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