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spectively collected from the patients’ medical records. Written informed consent was obtained from all patients for use of their images for academic research purposes. The study protocol was approved by the ethical committee of Defense Service Medical Research Center (DSMRC) with the approval no. IRB/2020/B2, Nay Pyi Taw, Myanmar.Preoperative evaluation Levator function on each side of the eyelid was assessed by careful inspection on the eyeball move-ment followed by examination of the total upper eyelid and eyeball movement from down gaze to up gaze, while pressing over the patient’s eyebrow. During the consultation, the appearance desired by the patient was taken into consideration before surgical planning. Surgeon should aware the pref-erence of desired size of eyelid (i.e., small; 7-8 mm and large; 8-10 mm size of eyelid) that varies among each ethnic group. The height and shape of the desired double eyelid was demonstrated while the patient was in the sitting position. A probe was used to push the upper eyelid upward to form a crease in front of a mirror. When the patient was satisfied with the simulated crease, a point position was confirmed that was approximately 7-10 mm above the ciliary margin depending on the desired lid fold size of patients. A precise line for the inci-sion was then drawn on both sides of the eyelids symmetrically using a marker pen with the patient in the supine position. The marking for the incision varies depending on age, thickness of skin, extent of redundant skin, amount of excess orbital fat, desired size and appearance of the patients (Figure 2). Photographs were taken by the same surgeon at the same distance from the patient’s face in all cases using a Nikon COOLPIX B700 digital camera (Nikon, Tokyo, Japan). Photographs were obtained for all patients who could return to the clinic before surgery and 7 days to 6 months after surgery depending on whether or not the patient made a follow-up visit. All surgeries were performed by one surgeon (KCK).Surgical techniques A supratarsal fold was created by attaching the dermis to the levator aponeurosis (levator-dermal attachment) after exposing the orbital septum23, 24). Incisional technique with or without removing eyelid skin and orbital fat was performed. After the final markings had been drawn on both eyelids, 1-2 ml of 1% lidocaine with epinephrine 1:100,000 was injected for anesthesia on both sides of the marked area via a 29-gauge needle. The injected area was gently pressed manually for 5 minutes to minimize bleeding. The incision was made using a #11 blade to the skin and subcutaneous tissue. The orbital septum was incised and the preaponeurotic orbital fat was exposed. Excessive orbital fat was then removed and cauterized. Hemostasis was achieved with the aid of unipolar electrocoagulation. Once the levator aponeurosis was exposed, three 6/0 nylon sutures were placed and anchored through the levator aponeurosis to the dermis. The size of the lid fold on both eyelids was checked for symmetry by measuring the distance between the ciliary margin and the fold. To ensure the symmetry of the lid fold, the directions of eyelash lines were then confirmed to be inverting approximately 100° upwards on both sides while the patient was asked to open the eyes in the supine position (Figure 3). Skin closure was carried out by placement of inter-rupted 6/0 nylon sutures. Postoperative assessment Postoperatively, all patients were asked to attend for follow-up within 1 week to 6 months to eval-uate the esthetic outcome and functional improve-ment. The criteria used to define an esthetically successful outcome were as follows: an obvious crease without multiple eyelids; no disappearance of the fold; and a bilaterally symmetric eyelid. Functional improvement was assessed using the marginal reflex distance (MRD1)25), i.e., the distance between the center of the pupil and the upper eyelid margin (Figure 4). The real (white-to-white) corneal diameter was assumed to be 11.77 mm, which is the normal value in a healthy human26). The MRD1 was calculated using the following formula in Microsoft Excel 2018: Real MRD1 = Real corneal diameter (11.77 mm) x Measured MRD1 / Measured corneal diameterThe MRD1 was measured and calculated only in patients who attended a follow-up visit in the clinic 1 month after double eyelid surgery. Patient satisfaction was rated by telephone at months 1, 2, 3, and 6 using the following 4-point scale: 0, not satisfied; 1, acceptable; 2, moderately 453