A well-defined double eyelid crease is typically formed through secure attachment between the levator aponeurosis and the pretarsal skin, supported by appropriate management of soft tissue layers [1]. In revisional blepharoplasty—particularly after ptosis correction—surgical scarring frequently distorts normal anatomy, obscuring landmarks. This makes safe and precise identification of the levator aponeurosis difficult and can result in functional deficits such as ptosis or lagophthalmos, as well as aesthetic problems including asymmetry or triple folds [2].

Conventional dissection methods usually proceed bottom-up, beginning near the tarsus. However, in revision cases this approach increases the risk of damaging the levator–Müller complex. To address these risks, we propose a top-down adhesiolysis method, which enables earlier recognition of the intact levator aponeurosis at a less-scarred and safer level. We also describe an orbicularis muscle strap interposition, elevated without detachment, that preserves muscle volume, minimizes adhesion, and prevents triple fold formation. Furthermore, we stress the importance of splitting the orbicularis muscle 3 mm below the incision line to maintain subincisional tissue and reduce the risk of aberrant adhesions.

A 50-year-old man presented with residual ptosis and upper eyelid hollowness following two prior upper blepharoplasties. Preoperative evaluation revealed deep scarring and poorly defined eyelid folds. The crease height was 11 mm on the right side and 6 mm on the left. Levator function measured 2 mm on the right and 11 mm on the left, while marginal reflex distance-1 (MRD1) was –1 mm and 3 mm, respectively (Fig. 1). Under local anesthesia (2% lidocaine with 1:100,000 epinephrine), the incision line was marked 6 mm above the lash line, adjusted according to skin redundancy. After excision of redundant skin, the orbicularis muscle was approached not at the intended crease level but 3 mm inferior to the incision, thereby preserving the subincisional soft tissue layer. At this level, the orbicularis muscle was grasped with two forceps to provide controlled vertical traction and then split horizontally, exposing the shiny white levator aponeurosis beneath (Fig. 2A). The orbital septum was opened, and dissection extended superiorly toward Whitnall’s ligament and inferiorly to the upper tarsal border, carefully following the intact levator aponeurosis under protruding fat. This top-down approach reduced the risk of tissue injury (Fig. 2B). To preserve upper eyelid volume and prevent adhesions, an orbicularis muscle strap was elevated in continuity without severing medial and lateral attachments (Fig. 2C). This strap was interposed between the skin and deeper layers to act as a buffer and provide structural support. Levator aponeurosis advancement was then performed for ptosis correction, with moderate overcorrection of MRD1 to 4 mm. The lower skin flap was anchored to the superior tarsal border, creating a 6 mm crease height. Immediate postoperative results showed stable crease formation without triple folds and restoration of periorbital volume (Fig. 3). No complications such as exposure keratopathy, entropion, suture abscess, or conjunctival prolapse were observed. At the 2-month follow-up, the crease height remained at 6 mm, levator function had improved to 12 mm, and MRD1 was 3 mm, symmetric with the opposite eyelid. No postoperative volume loss or hollowness was evident, and the patient expressed satisfaction with the outcome (Fig. 4).

Traditional upper blepharoplasty involves excision of skin, underlying orbicularis muscle, and often a portion of orbital fat to expose the levator aponeurosis. A well-defined crease is then created by securing the aponeurosis, orbicularis, and septum to the upper tarsal border [1,3]. In relatively straightforward primary cases, exposure of the levator aponeurosis is easily achieved by removing pretarsal tissues. However, this process becomes unreliable in revision settings, where fibrosis and anatomical distortion compromise the original layered structure. Scarred pretarsal tissue and a damaged levator aponeurosis may result in iatrogenic ptosis and make identification of key landmarks challenging. In addition, upward dissection from the tarsus—commonly used in traditional revision techniques—may inadvertently disrupt the levator–Müller complex, increasing the risk of hematoma, prolonged edema, or conjunctival prolapse. Because Müller’s muscle is vulnerable to denervation and has limited sympathetic responsiveness, such trauma may also cause inconsistent ptosis correction [4].

In these circumstances, we found that a top-down dissection beginning at the upper, less-scarred region of the eyelid enabled earlier and safer identification of intact levator aponeurosis. This approach avoids injury to the levator–Müller complex, which is particularly vulnerable during bottom-up dissection from the tarsal plate. Moreover, superior-to-inferior dissection provides controlled entry into clearer anatomical planes, allowing safe downward progression to the tarsus while minimizing unnecessary trauma.

One limitation of the top-down technique is that the identifiable aponeurosis lies superior to the desired crease level, particularly in the lateral upper eyelid. If all tissue between this plane and the target crease is excised, considerable volume loss may occur, producing a high or unstable crease, or even formation of a triple fold above the surgical line. Previous attempts to address this with limited slit incisions from the top carried the same risks when extended along the entire incision length [5]. To overcome this, we introduce an orbicularis muscle strap dissected and elevated in continuity while preserving medial and lateral attachments. This strap preserves soft tissue volume above the target fold, prevents adhesion, reinforces natural contour without requiring filler or autologous fat grafts, and reduces the risk of a hollow upper periorbital appearance [6]. Unlike muscle-sparing blepharoplasty, which merely minimizes resection, our method combines secure exposure of the desired plane with preservation and repositioning of pretarsal tissue, achieving both free determination of incision height and maintenance of volume.

This technique also addresses the longstanding debate over orbicularis muscle resection in upper blepharoplasty. Some advocate muscle excision for improved crease definition and septum exposure, whereas others emphasize that volume preservation produces a more youthful, natural appearance [3]. Our technique supports the latter perspective: by preserving the orbicularis as a strap, we maintain both crease definition and youthful fullness. Alternatives such as eyelid fat or dermal grafts are prone to clumping, and even small nodules can become conspicuous beneath thin eyelid skin. Although the orbicularis strap depends on a random circulation pattern, it remains viable and pliable due to the rich blood supply of the periorbital region.

We also stress the importance of the level at which the orbicularis is divided. Rather than cutting directly beneath the incision, we split the muscle 3 mm inferior to the upper skin incision. This spatial offset preserves the tissue layer beneath the incision and reduces the risk of adhesion between skin and deeper structures. When the incision and muscle split are too close, unwanted tethering of the skin may produce multiple folds or asymmetry. By functioning as an interpositional buffer, the muscle strap decreases this risk and improves crease predictability. A limitation of this study is that it describes only a single patient outcome. Furthermore, the technique requires dissection through relatively supple tissue, bypassing scarred areas; therefore, it is not applicable when scarring extends up to the superior border. Nonetheless, the surgical principles described here can be consistently applied in both primary and complex revision cases.

In summary, the combination of a top-down approach, orbicularis strap preservation, and deliberate 3 mm inferior muscle split provides anatomical, functional, and aesthetic advantages in challenging upper eyelid revisions. Together, these modifications help overcome the shortcomings of conventional dissection, reduce the risk of triple folds, and enhance postoperative stability.

In conclusion, the integration of top-down adhesiolysis, orbicularis muscle strap preservation, and muscle splitting 3 mm below the incision offers a safe and effective strategy for revisional blepharoplasty. This method facilitates reliable identification of the levator aponeurosis, preserves soft tissue volume, prevents triple fold formation, and supports favorable functional and aesthetic outcomes through deliberate tissue preservation and strategic plane separation.