In Asia, an upper eyelid without a crease is called a single eyelid, and an eyelid with a crease a double eyelid. The double-eyelid operation, which is the creation of an upper-eyelid crease, has been the most popular cosmetic surgical procedure in Asia. In this chapter, three major surgical techniques to create an upper-lid crease are described.

The characteristic features of the Asian eyelid are a low or absent eyelid crease; an obliquely slanted, smaller palpebral fissure; fullness of the superior sulcus; short, inferiorly directed eyelashes; and the presence of an epicanthal fold. Appreciation of the differences of the upper-eyelid anatomy between Asians and Caucasians is important for the surgeon who performs eyelid procedures on Asian patients. In the Asian eyelid, the orbital septum fuses with the levator aponeurosis below the superior tarsal border, and there are no subcutaneous attachments of the levator aponeurosis.^1,2,3,4,5 This allows the preaponeurotic fat pad to descend anteriorly. The subcutaneous, suborbicularis, and pretarsal fat pads are more prominent^2,3 (Fig. 24-1). These differences create the fullness of the Asian upper lid as well as a low or absent lid crease.

Besides the anatomic differences, the surgeon must take into consideration that many Asian patients may have different standards of beauty and cultural backgrounds that will influence their definition of a successful procedure. The surgeon should try to assess what the Asian patient desires (Fig. 24-2). When performing blepharoplasty in Asian patients, it is important to be aware that most Asians do not want to look Caucasian. Most patients do not want other people to notice that they have undergone blepharoplasty.

Most Asian patients want the double-eyelid operation to create the appearance of a bigger, beautiful eye, not to create a Westernized appearance. In Western eyes, the eyelid crease usually measures 9 to 10 mm from the ciliary margin. However, a low eyelid crease appears more natural in Asian eyes. Thus, for Asian eyes, an eyelid crease of 6 or 7 mm from the ciliary margin in women and 5 or 6 mm from the ciliary margin in men and children is preferable.

There are three approaches in performing the double-eyelid operation: the suture ligation method, the small incision method, and the external incision method.