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.

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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).

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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.

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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); more often, it may start in the medial canthal angle and run fairly parallel to the ciliary margin from the middle of the eyelid onward. Asians rarely have an eyelid crease with a semilunar shape, as in Caucasians, in whom either end of the crease is closer to the respective canthal angle than the central portion of the crease (see Fig. 9-3H).

Preoperative counseling

The shape of the crease is clearly an important factor for the surgeon to discuss with the patient before surgery. The patient will need to be informed of the desirability of either a nasally tapered crease or a parallel crease and the undesirability of a semilunar crease, which is truly a Caucasian crease and appears incongruous on the face of an Asian. The ultimate decision, of course, rests with the patient. Nevertheless, none of my Asian patients chose the semilunar crease after I explained to them the different crease configurations and their prevalence in Asians.

Most of the patients I encounter know what they want in terms of the crease configuration and its degree of prominence. They may be unaware, however, that swelling accompanies the procedure or that sutures are used. These are important points that need to be addressed with the patient preoperatively.7

Surgical techniques

There are two approaches to the creation of an upper eyelid crease: (1) conjunctival suturing and (2) exter-nal incision. The early champions of the conjunctival suturing technique include Mutou and Mutou,8 Boo-Chai9 who practices external incision as well, and some of the surgeons in Japan. The advantage is that it is a relatively non-invasive technique. The major drawback is that the crease may disappear with time.

Early proponents of the external incision approach include Sayoc10–15 and Fernandez.16 This technique is preferred in the Western Hemisphere and is also practiced in Taiwan and Hong Kong.

Conjunctival suturing

In the conjunctival suturing technique, the eyelid is first anesthetized with local infiltration of lidocaine (Xylocaine). The upper eyelid is everted, and three double-armed sutures are placed from the conjunctival side in a subconjunctival fashion above the superior tarsal border. Then either of the two following techniques is performed:

Alternative 1: Both ends of the suture pass through to the skin side; then one end is again passed subcutaneously to exit through the second needle’s exit site on the skin. The two ends are tied and buried subcutaneously. (Or one end of the suture goes through the eyelid and exits through a stab skin incision; the other end goes through skin next to the stab incision and is repassed subcutaneously to join the first suture that exited through the stab incision. The two suture ends are tied in the stab incision and buried.) The suture knot encompasses Müller’s muscle, levator aponeurosis, and some pretarsal orbicularis muscle, creating a scarring process between the subdermal tissue along the superior tarsal border and the levator aponeurosis-Müller’s muscle complex.
Alternative 2: Without piercing the skin, one end of the double-armed suture is passed through Müller’s muscle and levator aponeurosis to the subcutaneous plane along the superior tarsal border. With the needle staying subcutaneously, the suture arm is passed back through the same tissue and exits conjunctivally. The two ends of the suture are knotted and buried within the conjunctiva above the superior tarsal border. The effect is the same as that of the first alternative.

I have seen quite a few Asian patients who underwent these procedures overseas and complained of corneal irritation.

External incision

I favor the external incision technique and perform it as follows.

Premedication and anesthetic agents

The patient usually receives 10 mg of diazepam (Valium) and 5 mg of hydrocodone (Vicodin) by mouth 1 hour before the procedure. One drop of topical anesthetic, 0.5 percent proparacaine (Ophthaine), is instilled on each cornea for comfort during surgical preparation. The upper eyelid receives a subcutaneous injection along the superior tarsal border, consisting of 0.25–0.5 ml of a mixture of 1 ml 2 percent lidocaine with a 1 : 100,000 dilution of epinephrine diluted with 9 ml of injectable normal saline. During the next 5 minutes, one can see the vasoconstrictive effect of the mixture even though the epinephrine was diluted ten times (1 : 1,000,000). The purpose of this preinfiltration is to allow for a relatively painless injection because the pH of acidic 2 percent lidocaine is restored closer to neutrality when it is diluted with the buffering action of injectable normal saline.

Then I inject 0.5–1 ml of the 2 percent lidocaine with a 1 : 100,000 dilution of epinephrine (5 ml mixed with 100 units of hyaluronidase) in the suborbicularis plane along the superior tarsal border. The hyaluronidase promotes dispersion of the anesthetic and greatly reduces any tissue distortion. Rarely, when confronted with a patient with low tolerance to pain, I supplement the local field infiltration with a frontal nerve block.

The eyelids and face are then prepared in the usual fashion for ophthalmic surgery. The eyes are again given a drop of tetracaine for enduring corneal anesthesia. Corneal protectors are applied over each eye.

Marking the eyelid crease

With the eyelid everted, the vertical height of the tarsal plate over the central portion is measured with a caliper. In Asians, the vertical height of the tarsus is usually 6.5–8.5 mm. This measurement is then transcribed on the external skin surface on the central part of the upper eyelid using methylene blue on a fine point. This marking directly overlies the superior tarsal border centrally. If a crease is to be nasally tapered, I mark the medial one-third of the incision line to taper toward the medial canthal angle or to merge with the medial canthal fold. The lateral one-third is marked in either a leveled or a flared configuration. For the parallel crease, the measured height of the superior tarsal border is drawn on the skin surface across the eyelids.

To create adequate adhesions, it is necessary to remove some subdermal tissue. A strip of skin measuring approximately 2 mm is then marked above and parallel to this lower line of incision. Again, in the patient who desires a nasally tapered configuration, I taper this upper line of incision toward the medial canthal angle or merge it with any medial canthal fold that may be present (Fig. 9-4A).

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Figure 9-4 A, The vertical height of the central portion of the upper tarsus is transcribed onto the skin surface centrally. This serves as the central point for the lower line of incision, with the overall line dictated by the shape of the crease desired. The upper line of incision usually includes 2 mm of skin.

B, After the incisions are made, a wet-field cautery is applied for hemostasis and a surgical cautery is used to incise through the orbicularis oculi muscle along the superior incision site.

C, The orbital septum is first opened with a monopolar cautery along the upper line of incision. It is then extended horizontally with Westcott spring scissors.

D, A small amount of the preaponeurotic fat pad is excised.

E, From 2–3 mm of the pretarsal orbicularis muscle is excised along the inferior edge of the skin wound.

F, Placement of an interrupted suture from the skin to the levator aponeurosis to the skin.

G, Skin closure using placement of five to six interrupted 6-0 sutures to form the crease and a continuous suture to approximate the edges of the wound.

Incision and excision

An incision is then carried out using a No. 15 (Bard-Parker) surgical blade along the upper and lower lines, and I cut just below the subcutaneous plane. Fine capillary oozing is stopped with a delicate bipolar (wet-field) cautery (see Fig. 9-4B). The strip of skin is excised with scissors. The superior tarsal border is still covered by pretarsal and preseptal orbicularis oculi muscle, the terminal portions of the septum orbitale, and the anteriorly directed terminal fibers of the levator aponeurosis behind the septum. Then I retract the incision wound superiorly and use a fine-tipped monopolar cautery in the cutting mode to incise through the orbicularis muscle and orbital septum along the upper skin incision.

In Asians, even though the orbital septum is now only 2–3 mm above the superior tarsal border, it is readily opened, and preaponeurotic fat pads can be seen bulging forward in most cases. The septum is opened horizontally (see Fig. 9-4C), and this strip of preseptal orbicularis muscle and orbital septum hinged along the superior tarsal border is then carefully excised. Depending on the degree of fullness of the upper eyelid, either none or a small amount of the preaponeurotic fat pad is excised with sharp scissors (see Fig. 9-4D). Any bleeding points in the fat pads are controlled with light application of the wet-field cautery. The fat excision often requires a small local supplement of lidocaine in the space beneath the preaponeurotic fat pads. The terminal portion of the levator aponeurosis is now seen along the superior tarsal border. To facilitate the infolding of the surgically created crease, I further excise a 2–3 mm strip of pretarsal orbicularis muscle along the lower skin incision (see Fig. 9-4E).

Some authors routinely debulk the entire pretarsal tissue, believing that it is better to have only skin along the anterior surface of the tarsus. My experience has not been so, and I remove pretarsal tissue only if pre-tarsal fat is quite apparent and threatens the surgical formation of the desired upper eyelid crease. In the pretarsal plane of an Asian eyelid, there are very few, if any, terminal interdigitations of the levator aponeurosis to the dermis in a creaseless eyelid. I refrain from vigorous dissection along the pretarsal plane, as I believe that this creates long-term postoperative edema and increases the risk of the undesirable formation of more than one crease. Furthermore, Asians who have a natural eyelid crease often have some degree of pretarsal fullness along the area between the crease and the eyelashes.

Skin closure

To create adequate adhesion between the terminal portions of the levator aponeurosis above the superior tarsal border to the crease incision lines, I use 6-0 non-absorbable (silk or nylon) sutures to pick up the lower skin edge, the levator aponeurosis along the superior tarsal border, and the upper skin edge and then tie each of these as an interrupted suture (see Fig. 9-4F). Usually, besides the central stitch, two or three sutures are placed medially and two laterally. With these five or six crease-forming sutures in place, the rest of the incision may be closed with 6-0 or 7-0 nylon in a continuous or subcuticular fashion (see Fig. 9-4G).

Postoperative care

The wound is cleaned daily and covered with antibiotic ointment. Diuretics and steroids are not usually given. The sutures are removed in 5–7 days, depending on the suture material.

Patient psychology: postoperative expectations

Postoperatively, the eyelid crease invariably appears high; the patient should again be reminded after the operation that this seeming ‘overcorrection’ is from tissue swelling. I usually inform my patients to expect a certain degree of postoperative edema to last for at least two months and that the crease configuration may vary from month to month and from one eyelid to the other. When the patients are instructed not to expect a stable and satisfactory appearance for 6 months, I find that they are much more accepting of the normal wound-healing process (Fig. 9-5).

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Figure 9-5 A, Preoperative appearance. B, One month after upper blepharoplasty.

I also inform my patients to expect a 5 percent chance of needing touch-up revisions if the crease formation is inadequate. This is a realistic estimate in my practice, and most patients feel comfortable with it.

Complications

Complications are similar to those seen with any blepharoplasty operation and may include hemorrhage, grossly asymmetric creases, obliteration or fading of the crease, prolonged postoperative edema, hypertrophic scar formation, excessive fat removal with a hollowed eye appearance, and formation of multiple creases. The detailed description of correction of some of these problems is beyond the scope of this chapter. Interested readers may find helpful ideas in References 5 and 17.

I have seen other complications develop in two unusual cases. In one of my patients, the crease was obliterated after 6 months by proliferation of submuscular (preseptal) fat of the upper eyelid in conjunction with a 35 percent weight gain during recovery from anorexia nervosa. Another patient had a low tolerance to pain and hardly moved her upper eyelids for 1 week postoperatively; the crease formed poorly in this patient. Since then, I have encouraged my patients to practice upgaze and downgaze after the first 48 hours to facilitate the formation of subdermal-levator aponeurosis adhesions.

Epicanthal folds

Medial canthal folds, as found in Asians, should not be equated to pathologic epicanthal folds as found in congenital blepharophimosis syndrome. The literature includes many articles dealing with this topic.18–29 I tend to be conservative in my treatment and, with few exceptions, refrain from correcting epicanthal folds in Asians, for several reasons:

• First, many Asians appear to have epicanthus palpebralis (a fold equally divided between the upper and lower eyelid) when they are young but then appear to have epicanthus tarsalis when they reach adulthood; one possible explanation is development of the nasal bridge.
• Second, Asians tend to have more reactive skin and tend to have hypertrophic scarring in the thick medial canthal skin area.
• Third, a nasally tapered crease that merges with the origin or a mild epicanthus tarsalis provides an aesthetically natural eyelid crease, as observed in Asians who have a crease.

References

1 Doxanas MT, Anderson RL. Oriental eyelids: An anatomic study. Arch Ophthalmol. 1984;102:1232-1235.

2 Uchida J. A surgical procedure for blepharoptosis vera and for pseudo-blepharoptosis orientalis. Br J Plast Surg. 1962;15:271-276.

3 Onizuka T, Iwanami M. Blepharoplasty in Japan. Aesthetic Plast Surg. 1984;8:97-100.

4 Chen WP. Asian blepharoplasty. J Ophthalmic Plast Reconstr Surg. 1987;3:135-140.

5 Chen WPD. Asian Blepharoplasty and the Eyelid Crease, with DVD (second edition). Philadelphia: Butterworth Heinemann, 2006.

6 Chen WP. Concept of triangular, rectangular and trapezoidal debulking of eyelid tissues: Application in Asian blepharoplasty. Plast Reconstr Surg. 1996;97:212-218.

7 Chen WPD, Khan JA, McCord CDJr. Color Atlas of Cosmetic Oculofacial Surgery (Textbook). Edinburgh: Butterworth Heinemann, Elsevier Science, 2004.

8 Mutou Y, Mutou H. Intradermal double eyelid operation and its follow-up results. Br J Plast Surg. 1972;25:285-291.

9 Boo-Chai K. Aesthetic surgery for the oriental. In: Barron JN, Saed MN, editors. Operative Plastic and Reconstructive Surgery, vol 2. New York: Churchill Livingstone; 1980:761-773.

10 Sayoc BT. Plastic reconstruction of the superior palpebral fold. Am J Ophthalmol. 1954;38:556-559.

11 Sayoc BT. Simultaneous construction of the superior palpebral fold and ptosis operation. Am J Ophthalmol. 1956;41:1040-1043.

12 Sayoc BT. Absence of superior palpebral fold in slit eyes. Am J Ophthalmol. 1956;42:298-300.

13 Sayoc BT. Surgical management of unilateral almond eye. Am J Ophthalmol. 1961;52:122.

14 Sayoc BT. Anatomic considerations in the plastic construction of a palpebral fold in the full upper eyelid. Am J Ophthalmol. 1967;63:155-158.

15 Sayoc BT. Surgery of the oriental eyelid. Clin Plast Surg. 1974;1:157-171.

16 Fernandez LR. Double eyelid operation in the oriental in Hawaii. Plast Reconstr Surg. 1960;25:257-264.

17 Weng CJ, Nordhoff MS. Complication of oriental blepharoplasty. Plast Reconstr Surg. 1989;83:622-628.

18 Johnson CC. Epicanthus. Am J Ophthalmol. 1968;66:939-946.

19 Verwey A. Der Maskenhafte Antlitz und seine Behandlung. Z Augenheilkd. 1909;22:241.

20 Lessa S, Sebastia R. Epicanthoplasty. Aesthetic Plast Surg. 1984;8:159-163.

21 Von Ammon FA. Klinische Darstellungen der Krankheit des Auges und Augenlider. Leipzig: Wilhelm Engelmann, 1874;443.

22 Von Arlt CF. Erweiterung der Bidspalte Kantoplastik. In: Graef-Saemisch Handbuch des Augenheilkunde. Berlin: G Reimer; 1841.

23 Berger E, Loewy R. Nouveau procédé opératoire pour l’épicanthus. Arch Ophthalmol. 1889;18:453.

24 Mustarde JC. The treatment of ptosis in epicanthal folds. Br J Plast Surg. 1959;12:252.

25 Converse JM, Smith B. Naso-orbital fractures and traumatic deformities of the medial canthus. Plast Reconstr Surg. 1966;38:147.

26 Spaeth EB. Further considerations on the surgical corrections of blepharophimosis (epicanthus). Am J Ophthalmol. 1956;41:61.

27 Spaeth EB. Further considerations on the surgical correction of blepharophimosis and ptosis. Arch Ophthalmol. 1964;71:510.

28 Blair VP, Brown JP, Hamm WG. Correction of ptosis in epicanthus. Arch Ophthalmol. 1932;7:831.

29 Matsunaga RS. Westernization of the Asian eyelid. Arch Otolaryngol. 1985;111:149-153.

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