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Asian Blepharoplasty
To perform a blepharoplasty successfully on Asian patients, the surgeon must take into consideration the following points: What does the patient perceive as beautiful? Does the patient desire a lid crease? If so, of what type should it be and where should it be located? The surgeon should avoid using terms such as “correction, revision, or westernization” of Asian eyelids, which may sound condescending.
To facilitate good communication, the surgeon should use terms familiar to the patient. In Asian countries, an eyelid without a crease is termed a single eyelid and an eyelid with a crease, a double eyelid. These terms are literal translations of the Chinese ideograms. They are widely used by both the lay public and the medical professions. There are four types of double eyelids: outer (or external, parallel), inner (or internal, unfolding fan), partial, and intermittent. The outer double eyelid, quite similar to a typical lid crease found in Caucasians, lies about 7 mm above the lash line. It is a well-defined lid crease, and the epicanthal fold associated with it is minimal. The inner double eyelid is located about 5 mm above the lash margin at the midpupillary line. It is the natural extension of an epicanthus tarsalis, and the epicanthal fold is fairly noticeable. Intermittent double eyelid can be unilateral or bilateral. It may be present depending upon the presence or absence of lid edema, up or down gaze. A partial double eyelid is present only in portions of the eyelid. A unilateral double eyelid can be of any type.
As a rule, we do not remove the epicanthal fold unless it is very prominent or specifically requested by the patient. Generally, the patient is not bothered by its presence. It should be noted that Asians tend to form more hypertrophic scar than do Caucasians, especially in the medial canthal area.
PREOPERATVE EVALUATION
A pertinent medical history should be taken to make sure that there are no thyroid, cardiac, or renal disorders. Most importantly, it should be ascertained that there is no psychiatric contraindication. An ocular examination should include recorded visual acuity, fundus examination, slit-lamp examination, and lacrimal function evaluation. The position and the curvature of the eyebrow should be noted. The position of the upper lid margin should be carefully measured and recorded. The presence or absence of an epicanthal fold and the degree of fullness in the superior sulcus should also be noted. A detailed discussion concerning sculpting this area with its possible outcome should be made with the patient. Sketches, printed illustrations, and computer-generated images are helpful aids in these discussions.
To an Asian patient, the particular type of upper eyelid crease with its height, shape, and curvature is the most important concern. To demonstrate what can be achieved, the surgeon may rely on illustrations or computer software. Clinically, the surgeon can use a small paper clip to gently press on the upper eyelid skin at the desired level to show the patient a more realistic result. All surgical candidates who are taking aspirin, Plavix, warfarin (Coumadin), or other blood thinners are instructed to discontinue taking these drugs for at least 2 weeks before the scheduled surgery. Since Asians tend to form hypertrophic scars, it is a good practice to forewarn the patient of a more intense inflammatory response and a prolonged recovery period.
INDICATIONS FOR SURGERY
As is true in any cosmetic procedure, the patient’s clear understanding and realistic expectation of what can be achieved is of utmost importance. Doing a blepharoplasty or creating an upper eyelid crease will offer a new and cosmetically pleasing appearance to the patient. In most cases, this will make the patient feel good, younger, and more confident and make him or her become more active. These procedures, however, will not help the patient find an ideal mate, restore a failing marriage, land a new job, or get a promotion. Underlying psychosocial factors or hidden desires must be carefully scrutinized. Very rarely, there are patients who would like to have their entire facial features “westernized.” They must be carefully evaluated and properly referred.
For a well-suited surgical candidate, there are two types of surgery that can be offered. The suture technique creates a new lid crease or enhances an existing one, but it does not change the contour of the periorbital region. It is simpler and less costly to perform and has fewer potential complications. The incisional technique, which recontours the periorbital area, is a more extensive and expensive procedure. It gives a more permanent result and has more potential problems.
Suture technique is preferred in younger patients with thin, taut skin and minimal submuscular or orbital fat whose only desire is to have a lid crease. Incisional technique is indicated in patients who desire a more extensive change in the periorbital contour and in patients with redundant skin, hypertrophic subcutaneous tissue, and prominent submuscular and orbital fat.
There are many variations on the theme in each of these techniques. We present a technique in each category that follows the general principles and yields consistently good result.
Figure 13-1A and B. The difference between a Caucasian (A) and an Asian (B) upper eyelid appearance is the result of a difference in the fascia layer of the eyelids. This layer consists of orbital septum, orbital fat, and the levator aponeurosis. In Caucasians, the aponeurosis layer fuses with the orbital septum a few millimeters above the superior tarsal border. The aponeurotic fibers extend anteroinferiorly beyond the fused complex and interdigitate in the fibrous septa of the orbicularis muscle. The eyelid crease is the result of the subcutaneous insertion of these most superior fibers. In Asians, the levator aponeurosis typically fuses with the orbital septum below the superior tarsal border, with the preaponeurotic fat extending closer to the eyelid margin. In addition, there is often a submuscular fat pad that extends inferiorly up to the superior tarsal border. These anatomic differences result in fullness in the upper eyelid, a less distinct, somewhat lower, or an absent eyelid crease in Asians. Generally, the Asian’s upper eyelid tarsal plate is slightly smaller than that of the Caucasian’s. The Asian’s eyelid skin also tends to be slightly thicker and forms hypertrophic scar more frequently.
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