6 Double Eyelid Surgery
Abstract
Double eyelid surgery, also known as Asian blepharoplasty, is one of the most common facial procedures performed on the Asian face. The desired outcome is based on the patient’s facial anatomy and personal preference for final outcome. Double eyelid surgery may be performed to relieve a functional superior visual field loss or address dissatisfaction in the upper eyelid crease such as absent eyelid crease, partial eyelid crease, multiple eyelid creases, and tapering eyelid creases. Additional reasons for aesthetic and functional double eyelid surgery are many and include: enhancing the face and creating a more aesthetically pleasing vertical and horizontal eyelid palpebral fissure, relieving eyelash ptosis, creating a greater eyelid platform (margin fold distance) for the application of cosmetic products (eyeliner and eyeshadow), and relieving nonsurgical applications to improve the eyelid height and contour. Some patients may spend a significant amount of time using adhesive glues and tapes to create an eyelid appearance that they desire. Clear discussion of a patient’s goal in single or double eyelid surgery is critical to ensure total patient satisfaction.
6.1 Introduction
This chapter focuses on the anatomical differences between Asians and Caucasians and the unique surgical considerations in double eyelid surgery. Asian eyelids refer to the varied eyelid morphologies on the continent of Asia, including those of Chinese, Korean, Japanese, Indian, Middle Eastern, South East Asia, and other descent. In the past, for surgeons and patients, the goal of Asian eyelid surgery was the western Caucasian look. However, the western look makes the patient appear unnatural. As a result, a frameshift has occurred toward the unique and beautiful ideals of an Asian aesthetic. The surgical discussion with the patient should inform the patient about his/her own periorbital anatomy with particular attention to the eyelid relationship to the eyebrow and forehead, the eyelid crease, and the medial and lateral canthal areas. Frequently, Asian patients will have an overactive brow prior to blepharoplasty. Listening and responding to a patient’s concerns and personal preference is mission critical.
The upper facial surgeon must help the patient understand what can and cannot be achieved. Discussions must be frank and include items such as current eyelid crease and fold positions as well as concomitant aponeurotic ptosis, eyebrow ptosis, and eyelid skin hooding when indicated. Careful documentation in the chart of the patient’s response to the discussion and preferences is critical. When a plan is agreed, a thorough discussion on patient financial expectations and pre- and postoperative care is needed. Preoperatively, this discussion includes smoking cessation and avoidance of blood thinners such as aspirin, nonsteroidal anti-inflammatories, warfarin, heparin, and herbal remedies. The postoperative discussion includes downtime needed for recovery, use of ice and warm compresses, bruising expectations, and when a patient can return to work.
6.2 Anatomical Considerations
6.2.1 The Eyelid Crease and Fold
About half of all Asians have some form of an eyelid crease; therefore, there are half that do not have an eyelid crease and fold. 1 In Asians of Chinese, Korean, and Japanese descent, the upper tarsal plate is smaller (6.5–8 mm) than that of Americans and Europeans (9–11 mm). 1 ID#b573a300_2 – 3 The importance of this difference lies in where to judiciously place the upper eyelid crease in designing a patient’s surgical plan. It is thought that the upper eyelid crease results from the presence of subcutaneous internal interdigitations of the levator aponeurosis in the pretarsal and superior tarsal border. 4 Further, in Asians without an upper eyelid crease, there is a thicker skin–orbicularis oculi–fat complex. 5 Kakizaki et al found that the distance from the orbital septum attachment site to the superior tarsal border is similar in Asians and Whites; however, there was a tendency to a lower extension of the preaponeurotic fat pads in Asians. 6 , 7 Taken together, a smaller tarsal plate and more inferior fat extension in the upper eyelid may account for the differences in the Asian and White eyelids.
The relationship of the fat pads may also contribute to the presence or absence of the upper eyelid crease. 8 These fat pads include subcutaneous, pretarsal, preseptal/postorbicularis, postseptal (preaponeurotic or orbital), and submuscular or subbrow area (Fig. 6.1). 9 The submuscular fat is superficially located under the orbicularis muscle and is contiguous with the retro-orbicularis oculi fat (ROOF) of the brow. In Asians without an eyelid crease, the fat pads intertwine and comingle in a way not seen in Asians and Caucasians with a crease. 10 , 11 It must be noted that these racial differences are generalizations and are not 100% specific to individuals of various ethnicities. Further, when most Asians request a double eyelid from a single one, they wish to look Asian and not have a higher eyelid crease and fold.
Careful documentation of crease presence, crease asymmetry between sides, segmented crease, and multiple creases is important to preoperative surgical planning. Careful preoperative photographs should be taken of the patient, including frontal view, oblique side views, upgaze, and downgaze. If a patient has had prior surgery, this should be documented.
6.2.2 The Medial Canthal Area
Most Asians have a medial canthal fold. The fold may be tapered into the medial canthus or parallel (Fig. 6.2). Some Asians request a change in the medial canthal fold area from a tapered crease to a parallel one. The discussion to change the medial canthal fold appearance must be frank; changing the epicanthal fold from a tapered fold to a parallel one will induce a change in the face appearance.
6.2.3 The Lateral Canthal Area
In blepharoplasty, it is important to consider the lateral eyelid and orbit. The levator aponeurosis spans the lacrimal gland, creating orbital and palpebral lobes. Documenting the lateral fullness and defining how a patient prefers the lateral angle are critical in double eyelid surgery. Rarely, some patients request a slight upward widening over the lateral segment of the eyelid rather than a leveled configuration.
6.2.3 Goals of Intervention/Indications
The main goal of upper blepharoplasty in the Asian patient is to meet the patient’s desires.
Improvement in the superior field of vision.
Enhancement of the face by creating a more aesthetically pleasing vertical and horizontal eyelid palpebral fissure.
Relief of eyelash ptosis.
Creation of a greater eyelid platform (margin fold distance) for the application of cosmetic products (eyeliner and eyeshadow).
Relief from nonsurgical applications to improve the eyelid height and contour.
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