Asian blepharoplasty

Abstract

One of the defining features between an individual of Asian descent and someone of Western descent is the presence of an upper eyelid crease. Approximately 50% of Asians do not have an upper eyelid crease. The double eyelid operation, or creation of a supratarsal crease, is the most common cosmetic procedure requested in Asia and the third most common procedure requested by Asian Americans. In this comprehensive article, we explore the art of creating an eyelid crease in the individual who either does not have a crease or has an indistinct crease. We will review the history of the development of Asian blepharoplasty, explain the anatomy of the Asian eyelid and how it differs from the Caucasian eyelid, and clarify how this anatomy then translates to differences in external appearance. The two main schools of surgical techniques will be discussed along with pearls, pitfalls, and personal observations.

Keywords: Asian; blepharoplasty; double eyelid; supratarsal crease.

Figure 1

Cross section of Caucasian eyelid showing extensions from levator aponeurosis to orbicularis and skin.

Figure 2

Cross section of Asian eyelid showing lower point of fusion of orbital septum and levator, with inferior descent of preaponeurotic fat, and absence of connection between aponeurosis, orbicularis, and skin.

Figure 3

Caucasian eyelid with invagination of skin as the levator contracts upward.

Figure 4

Asian eyelid with no invagination of skin as levator contracts upward.

Figure 5

Asian eyelid with a medial epicanthal fold and no supratarsal crease.

Figure 6

Asian eyelid with a “parallel crease,” or a fold that remains parallel to the lid margin along its entire length.

Figure 7

Asian eyelid with a “nasally tapered crease,” or a fold that converges with the lid margin medially.

Figure 8

Caucasian eyelid with a “semilunar crease,” where the fold is typically closer to the lid margin medially and laterally than in the center of the eyelid.

Figure 9

Three points of suture placement are marked along the planned location of the crease in the suture method.

Figure 10

Transconjunctival method of suture technique: One needle is passed from point A to subcutaneous layer and back through point B. The needle is then passed through the same points from B to A, and the knot is tied on the conjunctiva side.

Figure 11

Full-thickness transconjunctival method of suture technique: Each needle of a double-armed suture is passed through the full thickness of the eyelid. One needle is then passed through the same exit hole to meet the other at a stab incision in the skin. The knot is then tied subcutaneously through the stab incision.

Figure 12

Suture technique with stab incision and adhesion between aponeurosis and skin/subcutaneous layer: One needle is passed through a stab incision, point A, to the level of the aponeurosis layer, rather than full thickness, and exits at point B. The same needle then enters through point B and is passed back through the stab incision, where the knot is left subcutaneously. Limited debulking of orbital fat can also occur through stab incisions.

Figure 13

Skin-levator-skin external incisional method: Suture is passed through the interior edge of the skin incision, through the levator aponeurosis, and back through the superior edge of the skin incision.

Figure 14

Levator aponeurosis to inferior subcutaneous plane external incisional method: Suture is placed from subcutaneous tissue at the inferior edge of the incision through the aponeurosis, and the knot is tied in the subcutaneous layer.

Figure 15

Markings for Park epicanthoplasty: Point A is the point on the epicanthal fold corresponding with the medial end of the underlying lacrimal lake; point B is where the epicanthal fold meets the lower eyelid skin; point C is placed medial to point A, at a distance equivalent to A–B. Point D, not marked here, is the medial end of the lacrimal lake; and point E lies along the line of the planned supratarsal crease. These same markings are demonstrated on Figs. 17 and 18, where the epicanthal fold has been stretched medially to expose the medial end of the lacrimal lake.

Figure 16

Flap EABD is elevated, and the tissue within triangle ECA is surgically removed. Flap EABD is placed into triangle ECA. Point A can then be sutured to point D and the incisions closed. The resulting scar is shown at the right.

Figure 17

Markings for Park Z-epicanthoplasty, as explained in Fig. 15.

Figure 18

Markings for Park Z-epicanthoplasty with epicanthal fold stretched medially so that point D becomes exposed.