Aesthetic Rejuvenation in the Patient of Asian Ancestry

Abstract

1.

Aesthetic ideals differ between various Asian cultures. The preferred aesthetic enhancement is typically a highlighting of natural ethnic features rather than complete transformation.
2.

Fullness, sharp angles, and epicanthal folds uniquely characterize eyelids in persons of Asian ancestry.
3.

Anatomic differences in the orbital septum, levator palpebrae aponeurosis, and distribution of adipose tissues explain the varying configurations of creases that are seen in persons of Asian ancestry.
4.

The surgeon should have a detailed preoperative discussion to elicit the patient’s preference with regard to the height and configuration of the eyelid crease and any epicanthal fold or volume alterations.
5.

Both open and closed surgical techniques have been described for crease fixation, aimed at creating adhesions between the levator aponeurosis and the skin-orbicularis complex at the desired crease location.
6.

Our preferred surgical approach is the open technique, which typically yields a more physiologic and dynamic crease. The open technique also allows for more precise crease fixation and modification of the orbital fat, if desired.
7.

Most common postoperative concerns relate to eyelid crease asymmetry and poor longevity.

Introduction

Asia is the largest and most populous continent and encompasses a myriad of cultures and ethnicities. As such, “Asian aesthetics” also encompass diverse issues and vary significantly throughout the continent. For the purposes of this chapter, we will discuss aesthetics as it relates to people of East and Southeast Asian heritage.

Although certain aesthetic concerns are nearly universal across ethnicities, patients of Asian ancestry seeking cosmetic surgery often want enhancement of specific features rather than complete transformation. Frequent areas of focus on the face include the eyelids, the nose, the cheek, and jawline. A recent survey showed that the Asian country with the highest rate of surgical cosmetic surgery procedures per capita is South Korea, second only to Italy worldwide, followed in order by Taiwan, Japan, Thailand, and China .

The eyelids are a prominent and distinctive feature of an Asian face. The characteristic broad and arched brow, flatter supraorbital bridge, and fullness of the eyelid along with sharp canthal angles and accentuated almond shape confer uniqueness to the Asian eye as an aesthetic unit that is immediately recognizable and imparts its ethnic identity ( Fig. 15.1 ).

Of all surgical cosmetic procedures, blepharoplasty is the most common facial procedure performed among people of Asian ancestry . Aesthetic eyelid surgery often appeals to the younger Asian population that requests the formation of a supratarsal eyelid crease, or “double eyelid” . In lay terms, a “double eyelid” refers to an eyelid that has a visible eyelid crease, whereas a “single eyelid” does not. Procedures that create or accentuate an eyelid crease have been termed “double eyelid procedures.” It is important to recognize that most Asians do not seek a westernized look, but rather want to accentuate their natural ethnic features .

Anatomy

Face

The Asian face has inherent differences that distinguish it from those of other geographic regions. On average, many recognize the face to be wider with higher cheekbones. In one study, the bizygomatic and mandibular widths were found to be greater, along with wider intercanthal and interpupillary distances . The lower facial contour is also unique, with a prominent mandibular angle that is mostly attributed to the bony framework and masseter hypertrophy. The Asian brow rests higher than that of Caucasians and the brow fat pads tends to descend with age, further contributing to the fullness of the upper lids and the narrowed appearance of the eyelid fissures .

Skin

There are major differences between ethnic groups that translate into functional and aesthetic differences. Compared with Caucasians, Asian skin is typically thicker, has more melanin, and has more subcutaneous and submuscular fat. Consequently, Asian faces have less solar keratosis, fewer rhytids, and delayed age-related changes ( Fig. 15.2 ).

The same pigmentation that confers protection against ultraviolet-mediated photodamage also makes Asian skin more prone to solar lentigines and postinflammatory hyperpigmentation, which can follow surgery, chemical peels, laser procedures, or any form of cutaneous trauma. Skin in people of Asian ancestry is also more prone to developing hypertrophic scars as compared with Caucasian skin ( Fig. 15.3 ).

Eyelid

The eyelids in patients of Asian ancestry have a multitude of anatomical differences that contribute to their uniqueness. The presence of an epicanthal fold, lash ptosis due to anterior lamella redundancy, a higher lateral canthal position relative to medial canthal position, and an increased prominence of eyelid and orbital fat all characterize the Asian upper eyelid. Each of these will be addressed separately ( Fig. 15.4 ).

Eyelid Crease

Some studies have shown that up to half of the population of Chinese origin has an eyelid crease . The height of the crease varies, but typically is around 5 to 7 mm in females and 3 to 5 mm in males, whereas in Caucasians it is on average 2 mm higher.

Various configurations of the crease have been described. The crease can run parallel along the entire eyelid length, or can taper nasally to blend into the epicanthal fold ( Figs. 15.5 and 15.6 ). The eyelid crease is mostly determined by distal interdigitations of the levator palpebrae superioris (LPS) aponeurosis with pretarsal orbicularis and the skin. The average tarsal height is around 2 mm less in Asians than Caucasians, which may, in part, contribute to the lower lid crease .

Many believe that a lack of interdigitations from the LPS aponeurosis explains the absent crease in Asians with single eyelids . However, a recent cadaveric study demonstrated their presence in both single and double eyelids . An alternative explanation for lid crease formation may deal with anatomical differences in the orbital septum and configuration of the eyelid fibroadipose tissues. There may be a greater amount of preseptal, submuscular, and subcutaneous fat in the patients who lack a visible lid crease. The skin and orbicularis underlying the crease were also found to be thinner in patients with double rather than single eyelids .

Septum

The precise configuration of the orbital septum in Asians is controversial. Doxanas described the septum as fusing with the levator aponeurosis at a lower position in Asians compared with Caucasians, and suggested that this allowed anterior and inferior displacement of preaponeurotic fat, creating the classic full appearance of the Asian eyelid ( Fig. 15.7 ). The prolapsed fat may also prevent LPS aponeurosis fibers from directly interdigitating with the orbicularis and dermis, thus blunting formation of a crease . However, Kakizaki et al. later demonstrated that the LPS aponeurosis has a similar site of attachment with respect to the superior tarsal border in Asians and Caucasians, and believed that the supposed lower level of fusion of the LPS aponeurosis and septum was in fact explained by a shorter tarsal height in Asians.