Introduction

Few young Caucasians undergo cosmetic procedures for their upper eyelids. Most of these individuals have large eyes with crisp, tall upper lid creases. In contrast, Asians are described by westerners as having puffy, small eyes, epicanthal folds, and lack of supratarsal folds. However, this is not true of all Asians. About 50% of women in East Asia have these features.^1,2 Many Asian women wish to enhance their appearance but they do not want Caucasian eyelids.^1,2,7 Asian blepharoplasty or “double eyelid” surgery is the most common cosmetic operation in Asia, with some reports suggesting that 30–60% of Asians undergo this procedure.⁸ If these women have deep-set, large eyelids with high folds like Caucasians, they look unnatural, as such eyelids do not match the shape of their faces. Therefore, ethnic differences should be considered.

The first procedure to create a supratarsal fold or “double eyelid” was described by Mikamo in 1896.⁹ The procedure was performed on a patient who lacked a fold in one of her upper eyelids. Shirakabe et al. made a historical review of 32 surgical techniques reported in Japan.¹⁰ In the western countries, Sayoc reported anatomic differences of upper eyelids between Caucasians and East Asians. The anatomic differences and their implications regarding double eyelid surgery were discussed.¹¹ Fernadez and Flowers in Hawaii, where East meets West, published papers about double eyelid surgery for Asians.^4,12 Newer techniques seeking to be more refined and less invasive while imitating the natural fold are being reported.¹³

Anatomic considerations

Multiple theories exist regarding the formation of the supratarsal crease or fold (Fig. 10.1). First, Sayoc explained the presence of double fold based on anatomic differences between Caucasian and East Asian eyelids. Expansions of the levator palpebrae superioris muscle penetrating through the septum and orbicularis oculi muscle to the overlying dermis were thought to be present in Caucasian eyelids and less so in Asians (Fig. 10.2A).¹⁴ The presence of such attachments between the levator aponeurosis and skin was established by Cheng and Xu through scanning electron microscopy studies.¹⁵ Another concept is the role of fibrous septa between the tarsal plate and pretarsal skin. The adherence between the tarsal plate and pretarsal skin is loose in the single eyelid and tight in the double eyelid.^4,16 Therefore, both explanations focus on the connection between the levator mechanism and the pretarsal skin.

Fig. 10.1 Anatomy of upper eyelid in Caucasians and Asians.

Fig. 10.2 (A) The cross-sectional anatomy of the Caucasian upper eyelid. (B) The cross-sectional anatomy of the Asians with puffy eyelid.

An important factor contributing to supratarsal crease formation is the level of fusion of the orbital septum and the levator aponeurosis. The supratarsal crease is formed by the dermal insertion at the confluence of the septum and levator aponeurosis.¹³ The level of adhesion between the orbital septum and levator aponeurosis defines the superior palpebral crease in most Caucasian eyelids,¹⁷ whereas lower fusion of the orbital septum to levator aponeurosis results in a low lying or absent crease in the Asian eyelid (Fig. 10.2B). Asians with naturally occurring superior palpebral folds have a relatively higher fusion of the orbital septum and levator aponeurosis (Fig. 10.3).¹⁸ The preaponeurotic orbital fat present in the pretarsal space eliminates the formation of double fold in Asians. Among Asians, it is not unusual for the upper lids to vary, being double and single in the same individual, depending on such variables as fatigue, diurnal variations of eyelid swelling, and weight change.

Fig. 10.3 The cross-sectional anatomy of the Asians with thin eyelid.

The epicanthal fold is also a characteristic feature of Asian upper lid. It hides the medial part of eye, including the caruncle and lacrimal lake and increases the intercanthal distance. In East Asians, at least 50% of adults have epicanthal fold. If slight traces are included, almost all East Asians retain epicanthal folds, and a mild epicanthus is not an unusual feature for them.¹ There has been a recent trend to eliminate or loosen the epicanthal fold as part of the double eyelid operation. This medial epicanthoplasty will decrease the wide intercanthal distance and increase the horizontal width of the palpebral apertures. However, surgeons should be very cautious about total elimination of epicanthal folds, because this can leave a noticeable scar and result in loss of ethnic identity.

Preoperative considerations and diagnosis

Most Asian patients desiring double eyelids no longer want a westernized appearance, but rather an appearance more appropriate for Asians. Because the anatomy of the orbit differs greatly between Asians and Caucasians, Asian blepharoplasty should be performed in accordance with the orbital anatomy of Asians. Previously, most young Asians seeking upper blepharoplasty have done so only for double fold formation. More recently, Asians have undergone upper blepharoplasty to achieve a more attractive eyelid shape by reducing the puffiness in their eyelids, obtaining a double fold, and increasing the palpebral fissure length.¹⁸ These patients also prefer a flat upper eyelid which looks young and stylish, not sunken or deflated.⁴

The height of double eyelid is an important issue. In young Caucasians, the superior palpebral fold is small and the height of the pretarsal skin exposure is similar to te height of the superior palpebral crease.¹⁸ In contrast, the Asian lid crease is generally 2–3 mm lower, and a large superior palpebral fold hangs over the pretarsal skin.⁷ Thus, exposure of pretarsal skin is less than in Caucasians. The lower border of the fold is called the double eyelid line, and the distance between this line and the margin of the lid at primary gaze is pretarsal exposure (Fig. 10.4). After blepharoplasty, the pretarsal exposure is determined by several factors, such as the height of incision, the amount of pretarsal skin excision, the height of fixation, and levator function.¹⁸ Currently, the preference for most Asians is a pretarsal exposure <3 mm, and as little as 1 mm.⁷ These desires have geographical variation (Fig. 10.4).

Fig. 10.4 The mechanism of double eyelidplasty in North-East Asians. a, Double eyelid line, lower border of fold; b, upper lid margin; c. pretarsal exposure; d, lower lid margin.

Another preoperative consideration is the shape of the desired crease. Caucasians typically have a semilunar shaped crease where the central third of the crease lies farther from the lash line than the medial and lateral thirds.¹⁹ Most Asians are uncomfortable with this configuration, since it appears unnatural to them. They prefer a fold that for most part is parallel to the lid margin. Laterally, the crease may have a slight flare, in that the crease lies farther from the lash line than the central third. Medially, the crease may taper toward the medial canthus (“inside fold”) or run outside the epicanthus (“outside fold”) (Fig. 10.5).²⁰

Fig. 10.5 “Inside” vs “outside” fold in Asian blepharoplasty.

Treatment/surgical technique

Although procedures for blepharoplasty in Asians have a number of similarities to those in Caucasians, it is important to recognize that upper blepharoplasty in Asians is not a westernization procedure. Thus, surgical techniques should differ in some respects from a Caucasian blepharoplasty.

Incisional versus nonincisional methods

Generally, surgical techniques for double fold formation can be categorized as incisional and nonincisional methods, although some authors have advocated partial incisional methods.

Nonincisional methods

Numerous nonincisional methods have been described.^21–26 These methods are used primarily for young people who do not require skin excision and for patients with thin upper eyelid tissue who do not have an excess of fat. The advantages of these minimally invasive techniques must be balanced against the knowledge that the fixation may not be as durable over time when compared with the incisional methods. Non-incisional methods can be categorized as single stitch and multiple stitch methods, both of which have advantages and disadvantages.

Video 1

Video 2

In these techniques, stitches are simply inserted through the skin at the level of the preferred lid crease, traversing the full thickness of the lid tissues down to and including either the levator aponeurosis or the tarsal plate. The stitches are tied in such a way that the knots are buried.

• Single stitch nonincisional methods have many modifications.²¹ Figure 10.6 shows a nonincisional single stitch method. Fixation through the levator aponeurosis can result in a more natural appearance and minimal postoperative edema, but relapse can sometimes occur. Fixation through the upper portion of the tarsal plate can result in a more definite eyelid crease with minimal relapse, but postoperative edema can occur more frequently than in levator fixation methods.

• Multiple stitch nonincisional methods can be performed, usually with 3–5 stitches on each side (Fig. 10.7).²⁷

Fig. 10.6 Nonincisional double eyelidplasty (single stitch method).

Fig. 10.7 Nonincisional double eyelidplasty (multiple stitch method).

Several factors should be considered when performing nonincisional double fold formation. First, the conjunctival side of the stitches should not be exposed, since this exposure can result in corneal damage postoperatively and second, the possibility of relapse should be considered and mentioned preoperatively to all patients.

Partial incisional methods

Partial incisional methods (Fig. 10.8) are being used more frequently.^28,29 These procedures have evolved to overcome disadvantages of the above two methods. Partial incisional methods can result in moderate tissue adhesions, preventing the early relapse observed using nonincisional methods. Moreover, partial incision can result in a more natural appearance, minimizing scarring of the upper lid. Using the partial incisional approach, preaponeurotic fat can be easily removed to correct puffy eyelids.

Fig. 10.8 Partial incisional double eyelidplasty with fat removal.

In the partial incision method, one or more small stab incisions can be made in the planned upper eyelid crease, and after going through orbicularis, the preaponeurotic fat is removed. A permanent suture material is then placed between the skin edges and the underlying aponeurosis or superior edge of the tarsal plate. The lid should be inverted to confirm that the suture has been placed to catch the upper border of the tarsal plate, and to ensure that the suture has not pierced the conjunctiva.

Incisional methods

For double fold formation in the upper lid, traditional tarsodermal fixation through incisional methods (Fig. 10.9A,B) has been an effective standard method.³⁰ In patients with redundant eyelid skin, the incisional approach is unavoidable. There are as yet no definite standards for incisional blepharoplasty, but the common procedures will be described. The placement of the double fold on the upper lid should be decided preoperatively according to each patient’s appearance and preference utilizing forceps or a probe.

Fig. 10.9 (A) Incisional method: skin–aponeurosis. (B) Incisional method: skin–tarsus. (C) Double eyelidplasty: preoperative view. (D) Double eyelidplasty: postoperative view.

The skin incision marking tapers closer to the lash line as it progresses medially towards the epicanthal fold. Some patients may prefer that the medial portion of the crease lies outside the epicanthus. The superior incision is marked such that the skin to be excised will also taper, usually measuring 1 mm medially, 2 mm centrally, and 3 mm laterally. The skin incision is then made and the strip of skin excised. A strip of orbicularis oculi wider than the skin strip is then removed in order to create a sharp lid crease. Leaving excess orbicularis can result in a puffy appearance. The septum is then entered, and a variable amount of retroseptal fat may be either excised or released, allowing it to ride up superiorly. The levator aponeurosis is exposed as it approaches the tarsal plate. The Asian tarsal plate typically measures 6–7 mm in height. Fixation of the new upper lid crease is then done. Various methods of suture fixation involving internal buried sutures have been described. One method is to use 3–7 sutures passing through the aponeurosis and the dermis-muscle of the inferior skin edge. The skin is thus anchored to the levator mechanism, creating the new lid crease, which will be hidden by the overhanging tissue of the palpebral fold. Alternatively, fixation can be done to the superior edge of the tarsal plate, a procedure which is thought to create a more static and defined upper lid crease (Fig. 10.9B–D).

Medial epicanthoplasty

Medial epicanthoplasty (Figs 10.10–10.12) is a very important component of Asian eyelid surgery.³⁶ Various methods were originally introduced for the correction of blepharophimosis in Western countries. In Asia, however, these procedures have been used for the correction of average Asian medial epicanthal folds. Although traditional methods, including the Mustarde technique,^37,38 have been used, these procedures may result in bad scars on the medial canthal area. These problems may be overcome by the half Z-plasty technique.^37,39,40 Nevertheless, the amount of release is limited and a moderate scar remains. Many Asian patients have complained about these scars. New methods, including skin redraping methods, have therefore been developed to eliminate the possibility of scarring of the medial canthal area.^36,41 These skin redraping methods, which have become very popular in Asia, include a medial subciliary incision on the lower eyelid which makes a nonvisible scar and resection/releaser of medial epicanthal adhesions, procedures that can minimize medial epicanthal scars and correct medial epicanthus quite well (Figs 10.11 and 10.12).

Fig. 10.10 Various methods of medial epicanthoplasty.

Fig. 10.11 Medial epicanthoplasty with skin redraping method: planning.

Fig. 10.12 Medial epicanthoplasty with skin redraping method: completion.

These methods, however, can also have side-effects, including unnatural dimpling at the releasing points of medial epicanthal adhesions.

Lateral canthoplasty

Lateral canthoplasty (Figs 10.13, 10.14) may increase the horizontal length of the palpebral fissure and result in a more natural appearance around the lateral canthus.⁴² Although currently controversial, these procedures are being used for these purposes.

Fig. 10.13 Lateral canthoplasty technique.

Fig. 10.14 Lateral canthoplasty: other techniques.

Postoperative care

Postoperative care for Asian blepharoplasty patients is similar to that for Caucasians. Scarring is generally not a problem, although excessive swelling can result in a higher crease height than is desired. Postoperative instructions are as follows:

Outcomes, prognosis, and complications

Complications are similar to those observed during routine blepharoplasty procedures. These complications include asymmetry, prolonged swelling, multiple folds, infection and hematoma.

Asymmetry is the most common problem after Asian blepharoplasty, especially when combined with levator plication or advancement. Revision surgery may be required for patients with major and persistent asymmetry. Patients should be informed of this preoperatively.

Introduction

Augmentation rhinoplasty is one of the most common aesthetic plastic surgery procedures in Asian countries. Whereas most Western literature addresses issues related to rhinoplasty in Caucasians, such as reduction and corrective rhinoplasty procedures, augmentation of the nasal dorsum and tip remain key issues for Asian plastic surgeons.⁴³ In the past, most of these operations consisted of simple augmentation rhinoplasty. More recently, however, the needs of patients have become more complex, requiring more meticulous preoperative diagnosis and more involved surgical techniques. Ideally, rhinoplasty should enhance the harmony between the nose and face, thus requiring general evaluation of the entire face. For this purpose, the entire face must be evaluated. The general principles for rhinoplasty in Asians are quite similar to those in Caucasians. However, rhinoplasties in Asians and Caucasians have different characteristics. This section will describe various aspects of rhinoplasty in Asians, as well as commonly encountered problems and solutions.

History

Rhinoplasty in Asians was first reported in 1964 by Khoo Boo-Chai.⁵¹ He demonstrated augmentation rhinoplasty in Asians using autogenous materials and silicone implants. He proposed the “golden point”, midway between the orbital ridge and the intercanthal line, which is the optimal starting point for the end of a silicone implant on the nasal dorsum. He also proposed the importance of both dorsal and nasal tip augmentation in Asian rhinoplasty. In 1974, Furukawa summarized the important aspects of Asian rhinoplasty.¹⁶ He reported anthropometric data of Japanese, identified the ideal Asian profile and described unique techniques for the Asian nose. Moreover, diverse-shaped silicone dorsal implants were introduced. In 1986, McCurdy showed the aesthetic goals of rhinoplasty in the non-Caucasian nose are similar to those in the Caucasian nose.⁵² He also noted that technical modifications are needed when performing a non-Caucasian rhinoplasty. In 1990, Parsa’s report showed nasal augmentation with split calvarial grafts in Orientals.⁵³ Shin and Lee reported, in 1993, columella lengthening in nasal tip plasty of Orientals.⁵⁴

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