Asian Blepharoplasty

Asian blepharoplasty, commonly termed double-eyelid surgery, refers to surgery designed to place a pretarsal crease in Asian eyes that are absent a fold. Patients typically desire to look more bright-eyed and want to make applying eyeliner easier. Patients also seek to remove the puffy and tired look associated with a fatty upper lid. In current American society, Asian patients almost never seek to westernize their appearance, and surgeons should be wary of modifying a patient's ethnic appearance, even in the rare case when it is requested. ^[1]

The earliest reference to upper lid fold creation appears in the Japanese literature in the late 1800s. The case involves a surgeon who created a fold in the second eye of a patient born with a fold in only 1 eye.

In the English literature, Sayoc and Millard furnished early descriptions of the procedure. ^{[2, 3]} In addition to securing the aponeurosis to the skin, Millard, a plastic surgeon, relied on orbital lipectomy to create the fold. This technique was specifically to westernize the eyelid at the patient's request (D. R. Millard, verbal communication, August 1993).

Leabert Fernandez, also a plastic surgeon trained by James Barrett Brown, developed the technique of suturing pretarsal skin to the levator aponeurosis expansion. ^[4] Fernandez's technique remains the hallmark of the modern double eyelid operation and remains probably the most common technique of incisional double eyelid surgery. Plastic surgeon Robert Flowers' anchor blepharoplasty (described below) expanded the artistic possibilities of the Fernandez procedure by emphasizing the creation of a crisp line and smooth pretarsal skin by securing the fold to the tarsal plate in addition to the levator aponeurosis. ^[5]

Asian patients with a puffy upper lid and an absent crease may dislike such an appearance. The patient may report difficulty applying eyeliner because of the overhanging fat and may wish to have a crease similar in appearance to Asian friends who were born with such a crease. Patients generally do not want to change their ethnic appearance.

A study by Kitazawa and Yuzuriha indicated that a puffy, creaseless upper lid may represent not just an aesthetic issue but a functional one as well, with the superior visual field (SVF) being narrower for individuals with such eyelids. Among the study’s 20 patients (40 eyelids absent a crease), the investigators found the preoperative median SVF area to be 34,443 degrees², compared with 50,796 degrees² postoperatively. ^[6]

Frequency

Approximately 50% of people of Pacific Asian descent (eg, Korean, Japanese, Chinese) have a pretarsal crease.

Traditional theory states that the pretarsal fold represents the insertion of the levator aponeurosis expansion into the dermis. Presumably, Asians have a lower insertion point than white persons, leading to smaller or absent folds. An alternative theory is that the fold corresponds to the level of the septoaponeurotic sling. Lower height of the sling in Asians allows the fat to sit lower in the eyelid, leading to a smaller fold.

Traditional approaches to placing a pretarsal crease involve suturing the dermis to the levator expansion at the appropriate height. Alternative approaches attempt to create a septoaponeurotic sling at the desired lid height.

Most commonly, the patient for this procedure is female and presents in mid adolescence with her mother or is female and is in her early 20s. Male patients, seen occasionally, tend to be slightly older, aged in the late 20s to early 30s. Female patients may report difficulty applying eyeliner. Not infrequently, females may apply cellophane tape to create a fold as part of the daily makeup ritual; the patient desires surgery to spare herself this inconvenience.

Occasionally, an older patient presents to report problems related to the aging upper eyelid and/or periorbital area. The patient may have had prior pretarsal crease placement.

Surgeons should consider the maturity of patients when they request such surgery. Occasionally, a mother brings a young teenaged daughter in for surgery. Patients should be mature enough to participate in oral or intravenous sedation for surgery and should understand and accept the risk of complications.

In Asians with a fold, the height of the normal lid fold lies 8-10 mm from the lash line with the skin gently stretched. Nasally, it begins close to the lash line and then reaches a maximum height at mid pupil. It stays at this height, extending to the orbital rim laterally. In contrast, folds in non-Asians tend to be larger and have less orbitopalpebral fat.

The primary difference between the non-Asian versus Asian eyelids is that the prelevator fat lies in a more inferior level; ie, the septo-aponeurotic sling hangs lower. In non-Asians, the supratarsal fold marks the inferior limit of the prelevator fat. This inferior limit is also the point at which the levator aponeurosis attaches to the dermis, creating an upper lid crease. In the Asian eyelid, this dermal attachment rests lower, resulting in a smaller crease, or it does not attach to the skin at all, resulting in an absent fold.

Choi et al identified three skin zones in the Asian upper eyelid with respect to Asian blepharoplasty. According to the investigators, zone 1 appears to have only thin skin on the orbicularis oculi muscle (OOM), while in zone 2, the anterior lamella seems to be made up of skin, white fascia (with a venous network), and OOM in a gross field. Zone 3 includes thick skin and a thick subcutaneous fatty layer, along with OOM. ^[7]

The surgical strategy for creating an Asian eyelid fold is either to recreate the dermal attachment of the levator aponeurosis or to prevent the fat from descending below the desired eyelid fold height. The nonincision suture method of eyelid surgery creates the fold by recreating this dermal attachment using nonabsorbable sutures. The incisional method of Asian eyelid surgery recreates the fold by removing the inferior portion of the prelevator fat and sealing off this area. A hybrid version, the semi-open method, combines aspects of both techniques by using buried nylon sutures to recreate the fold but also removing a portion of the prelevator fat through a small incision. The incisional method and semi-open method are described in Surgical therapy. In any case, the surgeon should not remove too much fat from the Asian eye because this results in a westernized appearance, which should be avoided.

The height of the proposed crease is determined by using a height of 7-10 mm from the lid margin (see Surgical therapy), which corresponds to the height of the tarsal plate. Because the tarsus shape varies in its configuration ^[8] , the point of maximum height is used.

The nasal area of the fold bears a variable relationship to the medial epicanthus. A fold may begin on the undersurface of the epicanthal fold or on the visible outer surface. These are referred to as an "inside" fold or an "outside" fold, respectively. When the fold is set relatively high, the crease usually folds on the outside.

The medial epicanthal fold can be variable in configuration. The Flowers classification is based on the how much of the caruncle is visible. In type I, the caruncle is visible and resembles a white person's anatomy. In type II, the caruncle is partially obstructed, while in type III, the fold is prominent and has an inversus component. Type IV resembles type I, except that the medial epicanthal fold is thick. A medial epicanthoplasty is recommended for patients with type III or IV and is optional for patients with type II.

Consider the maturity level of the patient, especially if he or she is young. At age 15-16 years, many teenagers do not have adequate coping mechanisms for potential complications. For these patients, consider the simplest and least morbid procedure.