Upper Blepharoplasty in the Asian Patient

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CHAPTER 9 Upper Blepharoplasty in the Asian Patient

William P. Chen

Because the anatomy of the Asian eyelid differs from that of the Caucasian eyelid, I believe that a separate chapter emphasizing the difference is important. In the first edition, I showed how to westernize, or occidentalize, the Asian appearance by constructing an eyelid crease similar to the technique used in Caucasians. It later became apparent that most Asians would like to enhance their appearance by having a crease that conforms with Asian features, and this chapter was added.

William Chen describes the many variations in upper eyelid creases. He emphasizes that many Asians have what he refers to as a nasal tapering type of crease, in which the crease converges and tapers to the eyelid margin nasally, while other Asians possess a crease that is parallel to the eyelid margin. With a nasally tapered crease, it is important that the reconstructed upper eyelid crease extends to this inside nasal fold. Forming a parallel crease nasally in such a patient leads to a duplicated nasal crease and, frequently, to an unhappy patient.

Dr Chen also emphasizes removing a small amount of preaponeurotic fat and pretarsal tissue. He creates an eyelid crease by suturing skin to the levator aponeurosis along the superior tarsal border, at 6.5–7.5 mm above the eyelid margin (10–11 mm in a Caucasian). I vary my technique slightly by excising the superior pretarsal tissues and by passing sutures through tarsus and then the levator aponeurosis and skin. I also have the patient sit up on the operating table to make sure that the creases are forming in the desired positions.

Allen M. Putterman

A review of the medical literature published in English reveals more than 50 major articles describing upper eyelid surgery in Asians. Most of the articles describe the technique of construction of an upper eyelid crease in a patient without the crease. Authors of some of the earlier reports aimed to westernize the patient’s appearance, whereas other authors insisted on creating a crease alone and preserving the Asian features.

In this chapter, before I review the steps of upper eyelid blepharoplasty in Asians, I explain the basic difference between Asians and Caucasians with respect to ethnic differences in eyelid creases, the anatomy of the face and upper eyelids, and the psychological and aesthetic needs of the patient.

Ethnic differences

Depending on the study and the population sampled, approximately 50 percent of the Asian population have upper eyelid creases (including Chinese, Koreans, and Japanese – all descendants of the Han race). The remaining 50 percent are not born with an eyelid crease or may have only rudiments of a crease. Asians who do not have an eyelid crease have been described as having ‘single eyelids.’ Those with a distinctive crease (‘double eyelids’) appear to have two segments of eyelid skin between the eyebrow and the eyelashes. The upper eyelid crease seems to be present in most Caucasians. A person with an eyelid crease appears to have a wider palpebral fissure or a bigger eye than a person without an eyelid crease, even though the physical dimensions of the palpebral fissures are the same.

Psychological and aesthetic needs

The desire of some Asian women to have an eyelid crease surgically formed as a way to beautify themselves (i.e. to have ‘bigger’ eyes) is sometimes perceived as an attempt to westernize (occidentalize) their appearance. In my opinion, most of the individuals who want to have an eyelid crease placed do not wish to appear Caucasian, although they are well aware that western surgical techniques make this cosmetic change possible. Some people argue that because very few of these operations were performed until after World War II, it must be the influence of westerners that catalyzed this enthusiasm for placement of an upper eyelid crease in Asians. From my extensive travels in Asia, it is my perception that this concept of beauty reaches even the most remote area and that the desire for ‘double eyelids’ did not start just in the last 60 years. These patients need only to be aware that such surgical procedures are available without necessarily wanting to resemble Caucasians or even knowing what westernized means. Furthermore, I do not believe that Asian patients who live in the Western Hemisphere want to have the procedure to blend in with Caucasians.

Anatomy

Upper eyelids

The difference between the Asian and Caucasian eyelid lies at the lower point of fusion of the orbital septum with the levator aponeurosis.1 In Caucasians (Fig. 9-1), the orbital septum fuses with the levator aponeurosis at approximately 8–10 mm above the superior tarsal border, limiting the downward extent of the preapo-neurotic fat pads while allowing the terminal inter-digitations of the aponeurosis to insert toward the subdermal surface of the pretarsal upper eyelid skin, starting along the superior tarsal border and heading inferiorly. As a result, when the levator muscle contracts and pulls the upper eyelid up, the skin forms a crease above the superior tarsal border and the skin above the crease forms the fold.

image

Figure 9-1 Schematic drawing showing a cross-section of Caucasian upper eyelid.

In Asians who do not have this crease (Fig. 9-2), as suggested by the anatomic studies of Doxanas and Anderson,1 the point of attachment of the orbital septum to the levator aponeurosis is lower, frequently as low as the superior tarsal border. This position allows the preaponeurotic fat pads to be present at a lower point on the upper eyelid, giving it a fuller appearance, and is found conjointly with a lack of attachment of the terminal strands of the levator aponeurosis from attaching to the subdermal surface of the pretarsal upper eyelid skin. The result is an apparently puffier ‘single eyelid’ without a crease (Fig. 9-3A).

image

Figure 9-2 A midsagittal section through an Asian upper eyelid without a crease. The orbital septum is usually seen fused to the levator aponeurosis along the superior tarsal border in an Asian without an upper eyelid crease.

image

Figure 9-3 Schematic diagrams (A–G) showing the different configurations of creases in the Asian upper eyelid. A, Absence of a lid crease and fullness of upper eyelid. B, Continuous crease. C, Discontinuous crease. D, Incomplete crease. E, Multiple creases. F, Inside fold with tapering of the eyelid crease toward the medial canthal angle and gentle lateral flare of the crease. G, Parallel crease. H, Typical Caucasian eyelid crease.

In terms of fat distribution and compartments, Uchida2 first described the presence of four areas of fat pads in Asian eyelids:

• Subcutaneous fat.
• Pretarsal fat.
• Central fat pads, which are more appropriately termed submuscular or preseptal fat pads.
• Preaponeurotic fat pads, which he termed ‘orbital fat pads’.

Face

Onizuka and Iwanami3 note that Asians, particularly the Japanese, have a flat face and a head shape that is mesocephalic. The eyes tend not to be recessed deep in the orbit. These authors also find the lateral canthus to be 10 degrees superior to the medial canthus. They believe that creating an upper eyelid crease and removing any upper lid hooding would make the palpebral fissure appear wider and more open, which is aesthetically pleasing. I do not believe that all Asians have a lateral canthus 10 degrees above the medial canthus; however, certainly some of the other observations by these authors may be true.

Eyelid crease

The configuration of the crease in the upper eyelids of Asians varies greatly. As I describe in other publications,4–6 the crease may be absent in one eye (see Fig. 9-3A) and present in the other. It may be continuous (see Fig. 9-3B) or discontinuous (see Fig. 9-3C). The crease may be partial or incomplete (usually present from the medial canthal angle and then fading laterally) (see Fig. 9-3D), and there may be multiple creases on an eyelid (see Fig. 9-3E).

Individuals who have a continuously formed eyelid crease may have either the inside-fold (nasal tapering) type of crease (see Fig. 9-3F) or a crease that is more parallel to the ciliary margin from the medial canthus to the lateral canthus (see Fig. 9-3G). With the inside-fold type, the crease may start from the medial canthal angle and gently flare away from the eyelid margin as it reaches the lateral canthal region (lateral flare) (see Fig. 9-3F

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