Background For the patients seeking secondary upper blepharoplasty, a static double-eyelid fold featuring an immobile lower flap and depression of the fold is common. Objectives In this study, the authors propose a novel technique of reconstructing pretarsal tissue defects (PTDs) to converting static folds to dynamic folds. Methods Two hundred three patients with static folds underwent revision surgery. After complete adhesion release of the lower flap, a PTD was identified, which was defined as an area deficient of orbicularis oculi muscle in front of the tarsal plate. If the width of the PTD was over 2 mm tissue transfer was performed to reconstruct the PTD, usually with a free retro-orbicularis oculus fat (ROOF) graft or a pretarsal orbicularis oculi flap. Results Among the 105 patients with severe static folds, 67 received ROOF grafts, and 38 received orbicularis oculi muscle flaps. This technique converted a static fold into a dynamic fold. The surgery had a satisfaction rate of 86.7%. Complications included partial fold loss (n=7, 3.4%), complete fold loss (n=3, 1.5%), sunken upper eyelids (n=5, 2.5%), multiple folds (n=3, 1.5%), an unnatural curve of the double fold (n=5, 2.5%), and asymmetric folds (n=4, 2.0%). Conclusions To convert a static fold to a dynamic fold, we devised a technique that releases adhesion of the lower flap and reconstructs the PTD with ROOF graft or an orbicularis oculi muscle flap. Our study achieved a high patient satisfaction rate, and the resulting fold mimicked the dynamics of the congenital double-eyelid fold.
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