This article discusses in detail the cultural aesthetic issues that confront the surgeon interested in performing Asian blepharoplasty in terms of defining an aesthetic Asian ideal and the subject of natural and ethnic preservation of identity. The surgical methodology of how to perform a full-incision–based Asian blepharoplasty is outlined in a stepwise fashion along with the perioperative concerns (preoperative planning and counseling, nature of recovery, and complications and revision surgery).
Key points
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Maintaining a low crease height is important for a natural, ethnically sensitive outcome.
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Always work in an alternating fashion during surgery to increase the chances for a symmetric result.
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The full-incision method has a higher likelihood of a long-term, tenacious crease result than more abbreviated incision approaches.
Introduction
Asian blepharoplasty is defined as the surgical creation of a supratarsal crease in an individual who has either a partial presence of a fold or an entire absence of it. There are many methods and variations to create a supratarsal crease in someone who was born without one, including the full-incision, partial-incision, and no-incision methods. Having studied and performed all three major methods, I have found that the full-incision method offers the most durable crease fixation, wider surgical exposure, precise ability to attain a defined crease shape, and can favorably modulate dermatochalasis associated with aging. However, the principal trade off is a significantly more protracted recovery period associated with the longer incision. Interestingly, scarring is less obvious in my opinion with the full-incision method compared with the partial-incision technique because the abrupt ends of the partial incision terminate in the middle of the eyelid and can be relatively more conspicuous.
This article details the full-incision method that has served me well over the past decade in practice so that the reader grasps the requisite preoperative, intraoperative, and postoperative considerations for the Asian patient desiring an upper-eyelid crease. The focus of this article centers on the younger Asian patient (<40 years old) who simply would like to create a supratarsal crease. Management of the aging Asian eyelid is a more complicated subject, and I have written about my strategy elsewhere in the literature.
Introduction
Asian blepharoplasty is defined as the surgical creation of a supratarsal crease in an individual who has either a partial presence of a fold or an entire absence of it. There are many methods and variations to create a supratarsal crease in someone who was born without one, including the full-incision, partial-incision, and no-incision methods. Having studied and performed all three major methods, I have found that the full-incision method offers the most durable crease fixation, wider surgical exposure, precise ability to attain a defined crease shape, and can favorably modulate dermatochalasis associated with aging. However, the principal trade off is a significantly more protracted recovery period associated with the longer incision. Interestingly, scarring is less obvious in my opinion with the full-incision method compared with the partial-incision technique because the abrupt ends of the partial incision terminate in the middle of the eyelid and can be relatively more conspicuous.
This article details the full-incision method that has served me well over the past decade in practice so that the reader grasps the requisite preoperative, intraoperative, and postoperative considerations for the Asian patient desiring an upper-eyelid crease. The focus of this article centers on the younger Asian patient (<40 years old) who simply would like to create a supratarsal crease. Management of the aging Asian eyelid is a more complicated subject, and I have written about my strategy elsewhere in the literature.
Treatment goals and planned outcome
First, it is worth reviewing some fundamental and relevant anatomy that pertains to the Asian eyelid. In the Occidental eyelid (and in some Asians), the levator aponeurosis inserts into the dermis to create the natural supratarsal crease ( Fig. 1 ). In the Asian there is a partial adhesion or an entire absence of the adhesion leading to variable degrees of crease presence. In addition, what leads to the narrower palpebral fissure (eye opening) and fuller, puffy eyelid appearance is the presence of orbital fat that descends lower toward the ciliary margin because the levator muscle does not prohibit its descent. Accordingly, in many cases I do not remove much fat (unless the fat is excessive and prohibits a strong levator-to-skin adhesion). Also, I have a proclivity to preserve fat because I am a proponent of fat grafting to restore lost volume related to aging, so I would not want to accelerate perceived aging through overzealous fat removal.
Culturally, it is worth discussing the evolution of an aesthetic over the past 30 plus years. In the 1980s, the term “Westernization” was highly popular, because many Asians truly wanted to look white, but this surgery involved excessive fat and skin removal along with a very high crease fixation. This technique led to extremely artificial-looking results that did not appear white or Asian but simply alien in nature. Today, the watchword is cultural and ethnic preservation, which can subtly but dramatically enhance the appearance of an individual. Creases are low and eyelids have a much fuller configuration; those are the only types of creases that I make, because it is outside of my desire to produce results that do not live up to a high aesthetic standard of naturalness and beauty.
Besides aesthetic enhancement, other motivating factors for Asian patients may include better assimilation into a Western society, ease with applying makeup (because there is now a fold into which the eye shadow can reside), improved vision afforded by a wider palpebral aperture, and more rarely a superstition of improved good fortune based on ancient Asian folkloric beliefs. The surgeon should obviously be well informed, sensitive, and exploratory during the preoperative counseling phase to ensure a mutually satisfactory outcome for patient and surgeon alike. During the consultation, the surgeon should discuss the desired aesthetic shape and height of the supratarasal crease (discussed in the next section) along with the protracted nature of the recovery period and what can be done to ameliorate the convalescent experience (discussed in the subsequent, relevant section).
A thorough anatomic evaluation of the patient’s eyelids should be undertaken and reviewed with the prospective patient. Asymmetry is perhaps one of the most commonly encountered attributes in the preoperative eyelid, and this condition most often stems from one side having a greater degree of partial fixation than the other side. The reason for this asymmetry is that the side with a greater degree of fixation typically has less of the fat descending toward the ciliary margin (as explained previously) and thereby a wider eye opening. Fortunately, this asymmetry can be greatly improved by simply making two equal surgical crease fixations. Accordingly, in most cases it is inadvisable to perform a unilateral eyelid crease because the other side will most likely not match the newly formed side.
Procedural approach
Designing the Proposed Eyelid Crease
The first order of business is to confirm and elaborate on the shape and height of the eyelid crease again with the patient. There are two principles shapes, oval and round, and two principal crease configurations, open and closed ( Fig. 2 ). The oval shape refers to a flared configuration in which the lateral terminus of the crease is higher than the medial side. The round shape refers to a crease height that is parallel to the ciliary margin throughout its entire extent. The inside fold refers to a crease that terminates inside (lateral) to the epicanthus, whereas an outside fold runs parallel and medial to the epicanthus. As one can imagine, typically an inside fold naturally pairs with an oval eyelid shape, and an outside fold works well with a round-shaped design. Personally, if the patient does not have a preference, I recommend the inside fold, oval configuration combination, because I believe it has the greatest aesthetic appeal. The methods of epicanthoplasty design, strategy, and execution lie beyond the scope of this article but suffice it to say that I prefer the Z-plasty method of Dr Jung Park, which has been widely published in the literature and which can be easily combined with the double-eyelid method elaborated herein.
Operative Steps
Anesthesia begins with a topical anesthesia that is applied to the thin eyelid surface for 1 hour preoperatively. Twenty-three percent lidocaine with 7% tetracaine is the preferred topical anesthetic that tends to provide profound anesthesia so that the pain associated with local-anesthetic infiltration is significantly minimized. After an hour has transpired, the patient’s eyelids are cleaned of the topical anesthetic, and a fine-tipped gentian violet pen is used to draw the proposed incision line. Typically the incision is made about 7 to 9 mm above the ciliary margin for a skin removal of about 3 to 4 mm. The incision lines are designed with the skin under tension so that the eyelashes are everted to 90 degrees and with the aid of Castroviejo calipers ( Fig. 3 ). The incision line can stop lateral to the medial canthus for an inside fold design (or medial to the medial canthus for an outside fold) and can be flared laterally to form an oval configuration ( Figs. 4 and 5 ).
