Ethnic differences

Depending on the study and the population sampled, approximately 50 percent of the Asian population have upper eyelid creases (including Chinese, Koreans, and Japanese – all descendants of the Han race). The remaining 50 percent are not born with an eyelid crease or may have only rudiments of a crease. Asians who do not have an eyelid crease have been described as having ‘single eyelids.’ Those with a distinctive crease (‘double eyelids’) appear to have two segments of eyelid skin between the eyebrow and the eyelashes. The upper eyelid crease seems to be present in most Caucasians. A person with an eyelid crease appears to have a wider palpebral fissure or a bigger eye than a person without an eyelid crease, even though the physical dimensions of the palpebral fissures are the same.

Psychological and aesthetic needs

The desire of some Asian women to have an eyelid crease surgically formed as a way to beautify themselves (i.e. to have ‘bigger’ eyes) is sometimes perceived as an attempt to westernize (occidentalize) their appearance. In my opinion, most of the individuals who want to have an eyelid crease placed do not wish to appear Caucasian, although they are well aware that western surgical techniques make this cosmetic change possible. Some people argue that because very few of these operations were performed until after World War II, it must be the influence of westerners that catalyzed this enthusiasm for placement of an upper eyelid crease in Asians. From my extensive travels in Asia, it is my perception that this concept of beauty reaches even the most remote area and that the desire for ‘double eyelids’ did not start just in the last 60 years. These patients need only to be aware that such surgical procedures are available without necessarily wanting to resemble Caucasians or even knowing what westernized means. Furthermore, I do not believe that Asian patients who live in the Western Hemisphere want to have the procedure to blend in with Caucasians.

Anatomy

Upper eyelids

The difference between the Asian and Caucasian eyelid lies at the lower point of fusion of the orbital septum with the levator aponeurosis.¹ In Caucasians (Fig. 9-1), the orbital septum fuses with the levator aponeurosis at approximately 8–10 mm above the superior tarsal border, limiting the downward extent of the preapo-neurotic fat pads while allowing the terminal inter-digitations of the aponeurosis to insert toward the subdermal surface of the pretarsal upper eyelid skin, starting along the superior tarsal border and heading inferiorly. As a result, when the levator muscle contracts and pulls the upper eyelid up, the skin forms a crease above the superior tarsal border and the skin above the crease forms the fold.

Figure 9-1 Schematic drawing showing a cross-section of Caucasian upper eyelid.

In Asians who do not have this crease (Fig. 9-2), as suggested by the anatomic studies of Doxanas and Anderson,¹ the point of attachment of the orbital septum to the levator aponeurosis is lower, frequently as low as the superior tarsal border. This position allows the preaponeurotic fat pads to be present at a lower point on the upper eyelid, giving it a fuller appearance, and is found conjointly with a lack of attachment of the terminal strands of the levator aponeurosis from attaching to the subdermal surface of the pretarsal upper eyelid skin. The result is an apparently puffier ‘single eyelid’ without a crease (Fig. 9-3A).

Figure 9-2 A midsagittal section through an Asian upper eyelid without a crease. The orbital septum is usually seen fused to the levator aponeurosis along the superior tarsal border in an Asian without an upper eyelid crease.

Figure 9-3 Schematic diagrams (A–G) showing the different configurations of creases in the Asian upper eyelid. A, Absence of a lid crease and fullness of upper eyelid. B, Continuous crease. C, Discontinuous crease. D, Incomplete crease. E, Multiple creases. F, Inside fold with tapering of the eyelid crease toward the medial canthal angle and gentle lateral flare of the crease. G, Parallel crease. H, Typical Caucasian eyelid crease.

In terms of fat distribution and compartments, Uchida ² first described the presence of four areas of fat pads in Asian eyelids:

• Subcutaneous fat.

• Pretarsal fat.

• Central fat pads, which are more appropriately termed submuscular or preseptal fat pads.

• Preaponeurotic fat pads, which he termed ‘orbital fat pads’.

Face

Onizuka and Iwanami ³ note that Asians, particularly the Japanese, have a flat face and a head shape that is mesocephalic. The eyes tend not to be recessed deep in the orbit. These authors also find the lateral canthus to be 10 degrees superior to the medial canthus. They believe that creating an upper eyelid crease and removing any upper lid hooding would make the palpebral fissure appear wider and more open, which is aesthetically pleasing. I do not believe that all Asians have a lateral canthus 10 degrees above the medial canthus; however, certainly some of the other observations by these authors may be true.

Eyelid crease

The configuration of the crease in the upper eyelids of Asians varies greatly. As I describe in other publications,⁴^–⁶ the crease may be absent in one eye (see Fig. 9-3A) and present in the other. It may be continuous (see Fig. 9-3B) or discontinuous (see Fig. 9-3C). The crease may be partial or incomplete (usually present from the medial canthal angle and then fading laterally) (see Fig. 9-3D), and there may be multiple creases on an eyelid (see Fig. 9-3E).

Individuals who have a continuously formed eyelid crease may have either the inside-fold (nasal tapering) type of crease (see Fig. 9-3F) or a crease that is more parallel to the ciliary margin from the medial canthus to the lateral canthus (see Fig. 9-3G). With the inside-fold type, the crease may start from the medial canthal angle and gently flare away from the eyelid margin as it reaches the lateral canthal region (lateral flare) (see Fig. 9-3F

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