Nonincisional Blepharoplasty for Asians

Various nonincisional techniques for double eyelid surgery have been introduced in the past. They are simple, noninvasive, and efficient techniques to create a double eyelid. The authors prefer the full-thickness single continuous method using the 7-0 nylon, round long needle. Appropriate choice of the patients and surgical method results in a natural, esthetically pleasing eyelid and decreases the loss of eyelid crease.

Key points

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Nonincisional blepharoplasty (suture method) is the preferred method for double eyelid creation because it provides a more natural appearance, is a simple and easy technique, causes only mild swelling and less scarring postoperatively, and enables fast recovery.
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Proper selection of patients for double eyelid creation using the suture method yields a good cosmetic result with long-lasting double folds.
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Medial epicanthoplasty is usually performed simultaneously with double eyelid surgery for larger and more attractive eyelid creases, especially in patients with an epicanthal fold.

Introduction

Upper eyelid blepharoplasty is one of the most frequently performed esthetic procedures in Asia. Asian blepharoplasty, also known as double eyelid surgery, involves the surgical creation of a supratarsal crease.

It is generally agreed that approximately 50% of Asians are born with upper eyelid creases; however, the height of the double eyelid crease is low in many of them. Moreover, well-defined double eyelids are present in only approximately 10% of Asian men and 33% of Asian women.

The goal of blepharoplasty for Asians is to achieve fresh, youthful, and attractive eyes, while retaining their ethnic appearance. The Asian upper eyelid has several distinct anatomic characteristics, such as a low, poorly defined, or absent eyelid crease; a narrow palpebral fissure; and/or an epicanthal fold. The upper eyelid margin of a single eyelid in East Asians is, in most cases, covered by the upper eyelid skin. Therefore, after double eyelid surgery, in which the upper eyelid skin is pulled upward, an apparent increase in the size of the eyes is noted. East Asians consider that double eyelid surgery makes the eye appear larger and more esthetically pleasing.

Double eyelid surgery is performed not only for cosmetic purposes but also for the correction of problems such as entropion, lash ptosis, and ptosis ( Fig. 1 ). Most patients prefer that the correction of these problems and double eyelid surgery be performed simultaneously. Furthermore, when patients with blepharoptosis undergo double eyelid surgery, the palpebral fissures become wider, resulting in a more pleasing eye shape ( Fig. 2 ).

The primary goal of double eyelid surgery is to create a supratarsal crease that is consistent with the natural configuration present in the general Asian population and not that in the Western population.

Anatomy of the Asian eyelid

An absent or exceptionally low eyelid crease and a puffy upper eyelid are the most obvious characteristics of Asian eyelids. Asian eyelids with no eyelid crease are referred to as single eyelids. Asian eyelids can be divided into 3 types: single eyelid, low eyelid crease (double eyelid structurally, but apparently single eyelid), and double eyelid. Although not visible, a small fold commonly exists under the overhanging eyelid skin.

The reasons for an absent or a low eyelid crease in an Asian upper eyelid are as follows: (1) fusion of the orbital septum and levator aponeurosis below the superior tarsal border; (2) extension of the preaponeurotic fat pad and a thick subcutaneous fat layer prevent the fusion of the levator fibers toward the skin near the superior tarsal border; and (3) the primary insertion of the levator aponeurosis into the orbicularis muscle and upper eyelid skin near the eyelid margin. ^,

Candidates of the nonincisional technique for double eyelid surgery

There are 3 types of double eyelid surgery: the nonincisional technique, the partial incisional technique, and the incisional technique. The choice of technique is based on the preference, skin quality, and volume of orbital fat in the upper eyelid of the patient.

The incisional and nonincisional techniques have their own advantages and disadvantages. The nonincisional technique (suture method) is preferred over the incisional technique because it provides a more natural appearance, is a simple and easy technique, causes only mild swelling and less scarring postoperatively, and enables a fast recovery. The disadvantages of the nonincisional technique are the inability to completely deal with preaponeurotic fat and soft tissue, which leads to the possibility of disappearance of the double eyelid crease, and development of inclusion cyst or exposure of a knot because of a buried suture ( Fig. 3 ).

Patient selection is important for successful double eyelid creation with the nonincisional technique to achieve a good cosmetic result with long-lasting double folds. The indications for the suture technique are as follows: (1) relatively thinner skin and nonredundant or mild redundant skin; (2) little orbicularis muscle bulk or orbital fat; (3) disappearance of the eyelid crease after the incisional technique or partial incisional technique; and (4) reoperation owing to various complications after eyelid crease surgery ( Figs. 4–7 ).

Nonincisional technique with medial epicanthoplasty

The epicanthal fold in Asian eyelids is a unique feature in combination with the single eyelid. The prevalence of epicanthal folds ranges from 50% to 80%. ^, The epicanthal fold, which is common in Asians, is characterized by a curved skin fold that partially hides the caruncle and lacrimal lake. The epicanthal fold may cause weakening of the esthetic appearance after blepharoplasty because it reduces the height and horizontal length of the palpebral fissure.

Medial epicanthoplasty is a procedure to release the epicanthal fold. This operation is generally performed with double eyelid surgery and has 2 important aspects. First, the released epicanthal fold lengthens and modifies the medial corner of the palpebral fissure. Medial epicanthoplasty reveals a more nasal scleral triangle and simultaneously decreases the interepicanthal distance. Thus, it creates a balance between the nasal and lateral scleral triangles by exposing the obscured caruncle. Second, the shape of the eyelid crease depends on the shape of the epicanthal folds. If the crease line meets the epicanthal fold, it is called an onfold (outside crease: fan type). If the crease line lies above the epicanthal fold, it is called an outfold (outside crease: mixed or parallel crease). If the crease lies below the epicanthal fold, it is called an infold (inside crease).

The tendency to create an infold is higher in patients with an epicanthal fold. The creation of an onfold or outfold requires modification or removal of the epicanthal fold. Medial epicanthoplasty is usually performed simultaneously with double eyelid surgery for larger and more attractive eyelid creases, especially in patients with an epicanthal fold ( Fig. 8 ).