Asian Blepharoplasty
William P. Chen
INTRODUCTION
The term double eyelid surgery has been used to describe a procedure that adds an upper eyelid crease to an eyelid that is without a crease. It is a very popular aesthetic procedure in Asian women of all ages. I first coined the term “Asian Blepharoplasty” in 1987 while attempting to define the skills and pitfalls necessary for performing primary and revision surgery in Asian patients. Along the way, various terminologies that are more precise ophthalmologically were developed. I will describe my technique, which is an external incision approach.
HISTORY
The common perception that all Asians are single lid without a crease is incorrect. There is approximately a 50% incidence of having a crease among Asians of Han origin (Chinese, Koreans, Japanese). Their crease, when present, tends to be located approximately 6.5 to 7.5 mm from the upper eyelashes. The current anatomic view of the distinguishing features of an upper eyelid with crease versus one without crease, in Asians, seems to be the presence or absence of terminal interdigitations of levator aponeurotic fibers into the pretarsal orbicularis oculi intermuscular septae and fibers, located in an area just slightly below or along the upper border of the tarsal plate (superior tarsal border).
PHYSICAL EXAMINATION
There are two main variants of the Asian crease:
The nasally tapered crease (Fig. 6.1) is a low-set crease that runs parallel to the ciliary margin over the central and lateral portion of the upper lid, while over the medial one-third, it converges inward toward the medial canthus, and often blending into a small ethnic medial canthal fold of upper lid skin.
The parallel crease (Fig. 6.2) runs parallel to the ciliary border over its entire extent, and at its medial section, it simply runs independent to and above any residual medial canthal fold.
Most individuals who are seen in our practice desire a permanent placement of a natural, Asian-appearing eyelid crease. The following are typical findings that they may present, though not necessarily having all findings listed below:
A slight to mild excess of upper lid skin presenting as a hooded look.
Fullness of the upper lid, especially over the preseptal portion of the lid; presumably due to a relative excess of inferior positioning of preaponeurotic adipose tissue (and to a lesser extent at times, the preseptal adipose tissue as well as pretarsal fullness).
FIGURE 6.1 The nasally tapered crease.
An absence of crease, or a mixture of incomplete or partial crease, with asymmetry between the two eyelids.
May have a medial canthal fold of the upper lid skin.
Secondary down-turning of the upper eyelid lashes.
May have clinically undiagnosed latent ptosis in one or both sides.
Pseudoesotropia (in-turning or slight crossing inward of the eyes).
INDICATIONS
A good candidate is a motivated, oriented individual who has some of the above findings and desires to have a crease added, for a valid reason. Typically, my patients have done some research as to their own needs and should be able to clearly voice what they desire. This is preferred as compared to an individual who wants the clinician to make all the decisions for them. They should understand that the individual surgical outcome may not be precise and are not completely predictable or guaranteed.
CONTRAINDICATIONS
Patients with unrealistic expectations.
Patients who expect instant healing.
Patients with shifting ideas.
Patients who do not seem to understand the preoperative discussion regarding necessary postoperative care.
Patients who are strongly influenced in their decisions by others, including family members, no matter what their age.
Patients with a significant history of keloid formation around the periocular areas, as well as dermatologic ailments that carry a higher incidence of unpredictability in crease formation.
PREOPERATIVE PLANNING
Detailed in-office history and examination, noting palpebral fissure sizes, any unusual ophthalmic findings like ptosis, tear function and dry eyes, or use of contact lenses.
Discussion of goals and expectations.
FIGURE 6.2 The parallel crease.
Discussion of the height and shape of the crease; formulate a mutually agreed on plan. Document this in the chart.
Signing of informed consent for primary Asian blepharoplasty or revision attempts (in revision Asian blepharoplasty, need to list exactly what is involved).
Preoperative photos of primary findings, as well as previous eyelid scars if it is revision surgery.
Go over it again immediately before surgery.
SURGICAL TECHNIQUE
The appropriate oral premedications analgesic (one tablet of Vicodin and sedative; 5 to 10 mg of Valium) are given 1 hour prior to surgery. Intravenous line is started. The upper lid skin is infiltrated with 2% Xylocaine with 1:100,000 dilution of epinephrine, along the incision line. (A #30 gauge needle is used, and the volume injected is seldom over 0.5 to 0.75 mL for each eyelid.) After a 5-minute period for the anesthetic solution to disperse, the upper face and eyelids are cleansed, prepped, and draped. The patient is placed in a supine position, and cardiac monitors and a pulse oximetry sensor are applied.
Marking—Attention is turned to the right eye. A black protective corneal eye shield is applied over the right globe. The tarsal plate of the upper lid is everted (Fig. 6.3), and a caliper is used to measure the vertical height of the central portion of the tarsal plate (it is usually between 6.5 and 8 mm). The lid is returned to its normal position, and methylene blue ink is used to mark the central point of the crease incision, usually at about 7 mm from the lashes. If the shape of the crease chosen was a nasally tapered crease, the crease marking is merged toward the medial canthus. For a parallel crease shape design, the surgeon should make a conscious effort to stay parallel to the lash line as one approaches the medial canthus.
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