Relating the rejuvenation of the eye in terms of the Asian face, this article covers the unique set of strategies for this population that include understanding cultural and aesthetic aspects of the Asian patient, anatomy of the Asian patient, and techniques that would be appropriate based on these cultural and anatomic considerations. Along with strategic planning, a detailed surgical technique is presented with graphic examples, in addition to a brief guide to postoperative care.
Surgical management of the Asian upper eyelid requires a thorough understanding of two essential concepts:
- 1.
Supratarsal crease creation
- 2.
Evaluation and treatment of the aging upper eyelid complex.
Successful treatment mandates a unique set of strategies that include understanding the cultural aspects of the Asian patient, the anatomy of the Asian patient, and the techniques that would be appropriate based on these cultural and anatomic considerations.
An essential element to success in these cases is a firm understanding of the cultural bias and aesthetic standards of the Asian patient. Without this, it is common for the Western surgeon to become easily frustrated and potentially fail to meet the expectations of the patient. These issues are explored in depth in this article, and it is hoped the reader will thereby gain better insight and sensitivity.
Cultural issues
Often, the Asian patient seeking cosmetic facial enhancement may have a separate layered agenda beyond simply desiring aesthetic improvement. Cultural and folkloric beliefs may not be overtly expressed but should be gently investigated to ensure patient satisfaction following a procedure. For example, the desire to obtain a larger nose through augmentation rhinoplasty may only be desired because of its association with greater wealth or the chance of obtaining it. Asian patients can be very obsessed with unblemished skin as a sign of beauty and also of good fortune.
Asians can also be much more secretive about undergoing plastic surgery than Caucasians, especially if the Asian has only recently immigrated to the West. Although HIPAA (Health Insurance Portability and Accountability Act) rules apply universally, the surgeon should be particularly circumspect when talking with any family member or friend regarding an Asian patient’s surgery. Asian patients can also tend to be more negative in opinion of each other following cosmetic surgery, and the surgeon should prepare the patient for this possibility. Certain negative remarks by family members or social peers may be made to the patient consequent to the less socially acceptable nature of plastic surgery as compared with its more recently accepted position in the reality-television dominated Western culture.
Another important trend to consider is the desire and expectation to preserve ethnicity following cosmetic surgery. Despite the global images of Western beauty that permeate Asia, and the once widely held belief that facial cosmetic enhancement should “westernize” the core Asian facial characteristics, it is clear today that maintenance of Asian anatomic features are essential to a successful outcome. With respect to management of the Asian eyes, it is essential to keep in mind that eyelid creases that appear too high may not only be unacceptable to the Asian patient but also to the surgeon striving to achieve ethnically appropriate and natural-appearing results. With respect to the aging Asian eyelid, maintaining a natural eyelid crease following rejuvenative blepharoplasty lies at the core of this article and is discussed in the following sections.
Despite some of these cultural similarities among Asians, there are also very distinct differences that exist between nationalities. For example, the Vietnamese and Koreans are more predisposed toward having cosmetic enhancement. The Chinese are only now becoming enamored with cosmetic surgery, given their recent newfound wealth in a surging Chinese economy (and given its illegal status before 1979 in China). Even Asians who have emigrated from the Far East carry these cultural biases for or against plastic surgery from their native country. Second- or third-generation Asian Americans may begin to shake off some of these long-standing cultural biases as they assume more of a Western perception toward plastic surgery and toward life in general.
Delving into the underlying motivation for cosmetic surgery beyond merely improving one’s aesthetic appearance can be a fundamental aspect to dealing with the Asian patient. Cultural biases may be overt or unspoken, but should be investigated as appropriate during cosmetic consultation with a prospective Asian patient.
Supratarsal crease formation
Asian upper eyelid blepharoplasty has a rich and varied history. The primary goal of this procedure is to create a supratarsal crease. The first reported case was performed and reported in the late nineteenth century. Since then, several innovative surgeons began to describe their strategies, which can be broadly categorized into suture-based, full-incision, and partial-incision techniques. It should be noted that the presence of a supratarsal crease is a naturally occurring anatomic finding in the Asian population. The desire to have a “double eyelid” is largely cultural, as this feature is considered attractive.
The method advocated in this article is the full-incision technique. The rationale for this preference can be summarized by the following reasons:
- 1.
Relative permanence compared with other methods
- 2.
No need to rely on any buried permanent sutures to hold the fixation
- 3.
Ease in identifying postseptal tissues through a wider aperture
- 4.
Ability to modulate excessive skin (dermatochalasis) in the aging eyelid.
The major drawback of the full-incision method is the protracted recovery time during which the patient can look grossly abnormal for 1 to 2 weeks, and still not entirely natural for months if not a full year. Scarring has proven not to be an issue if the delicate tissue near the epicanthus is carefully avoided. Further, in the authors’ opinion the incision line is more difficult to observe with the full-incision method than with the partial-incision method because there is no abrupt ending that is apparent with the more limited incision technique.
Supratarsal crease formation
Asian upper eyelid blepharoplasty has a rich and varied history. The primary goal of this procedure is to create a supratarsal crease. The first reported case was performed and reported in the late nineteenth century. Since then, several innovative surgeons began to describe their strategies, which can be broadly categorized into suture-based, full-incision, and partial-incision techniques. It should be noted that the presence of a supratarsal crease is a naturally occurring anatomic finding in the Asian population. The desire to have a “double eyelid” is largely cultural, as this feature is considered attractive.
The method advocated in this article is the full-incision technique. The rationale for this preference can be summarized by the following reasons:
- 1.
Relative permanence compared with other methods
- 2.
No need to rely on any buried permanent sutures to hold the fixation
- 3.
Ease in identifying postseptal tissues through a wider aperture
- 4.
Ability to modulate excessive skin (dermatochalasis) in the aging eyelid.
The major drawback of the full-incision method is the protracted recovery time during which the patient can look grossly abnormal for 1 to 2 weeks, and still not entirely natural for months if not a full year. Scarring has proven not to be an issue if the delicate tissue near the epicanthus is carefully avoided. Further, in the authors’ opinion the incision line is more difficult to observe with the full-incision method than with the partial-incision method because there is no abrupt ending that is apparent with the more limited incision technique.
Operative technique
The first step is designing the proposed eyelid crease. There are several variations ranging from inside fold (the medial incision terminates lateral to the epicanthus) and outside fold (the medial incision extends medial to the epicanthus by 1 to 2 mm). There are 2 variations to the shape of the incision. The first is oval shape (slight flare of the crease height laterally above the ciliary margin), versus rounded in which the line runs parallel with the ciliary margin. The authors’ preference is the inside fold paired with an oval configuration ( Fig. 1 ).
Prior to marking, the patient should be placed in the supine position and the upper eyelid skin held relatively taut to the point that the eyelashes are just beginning to evert. To create a natural, low crease design (which constitutes the naturally occurring shape), the degree of skin excision to be performed should err on the side of conservatism, with about 3 mm (with the skin under stretch as mentioned above) between the upper and lower limbs and with a distance of about 7 mm from the ciliary margin in most young adults.
Once the incisions have been carefully inspected for symmetry, the patient can undergo infiltration of local anesthesia. Deep sedation should be avoided as patient cooperation is vital to ensure symmetry toward the end of the procedure. A mixture of 0.5 mL of 1% lidocaine with 1:100,000 epinephrine and 0.5 mL of 0.25% bupivicaine with 1:100,000 epinephrine attached to a 30-gauge needle is used to infiltrate the upper eyelid skin by raising 2 to 3 subcutaneous wheals, which are then manually distributed by pinching the skin along the entire length of the incision ( Fig. 2 ). This method, which avoids threading the needle, limits the chance of a hematoma that can lead to difficulty in gauging symmetry during the procedure. Of note, a total of only 1 mL of the aforementioned mixture of local anesthesia is infiltrated along each proposed incision to maintain symmetry.
After 10 minutes are allowed to transpire for proper hemostasis and anesthesia, a #15 blade is used to incise the skin down through the orbicularis oculi muscle, taking care not to pass the blade much further than that initial depth ( Fig. 3 ).
