We have touched on the cultural diversity and linguistic differences among the Asian races. Ethnically the Asians who often request this type of cosmetic surgery include Chinese, Japanese, Koreans, Philippinos and South-East Asians. It is important to note that in these ethnic groups often more than half of the overall population do have an upper lid crease and that you may be consulting with a patient who wants to look like their fellow Asians, rather than looking like a Caucasian fashion model.
It is crucial for the practitioner to be aware of communication gaps and misunderstanding that may exist between the surgeon and the patient. This is especially critical at the first meeting, when I always have as my goal to try to find out the patient’s needs and assess whether they can be met.
It is interesting to observe that in Japan, China and Korea it is common and acceptable for young adults who do not have a lid crease to undergo cosmetic eyelid surgery. It is often socially acceptable for mothers to encourage their daughters to have the procedure, as compared to the stigma usually associated with rhinoplasty, breast implant or cheek augmentation. The concept that eyelid surgery is a way to improve on the beauty of the person, to ‘open up’ the face while being relatively non-invasive, is in sharp contrast to their views towards other cosmetic surgeries, which involve implantation of synthetic materials in the body, rendering the body ‘not whole’.
This somewhat cavalier attitude on the part of the patients or family members towards eyelid surgery is problematic if the physician and the patient have not come to a mutual understanding. Often I see patients coming in for consultation who had the surgery done by reputable and capable physicians, but are dissatisfied with the result. They are justified when they complain that despite their insistence on a ‘low, natural crease’ the surgeon has given them a high crease ( Figure 5-1 ); the creases are asymmetric ( Figure 5-2 ); the crease disappeared with time ( Figure 5-3 ); or the surgeon gave them a ‘hollow’ over the upper lid crease, usually from over-excision of preaponeurotic fat pads ( Figure 5-4 ). Perhaps the surgeon had his own perception of what the procedure is, as is performed in a traditional blepharoplasty, and applied it to the Asian patient.
The unhappy patients who have suboptimal results often express the opinion afterwards that they ‘did not think that it would be so noticeable’. Not infrequently, they may want the whole process to be reversed. A properly performed placement of crease over the upper lid is natural and blends in with the configuration of that particular patient’s eyes and face. A suboptimal crease may be very noticeable since the eyes are a focus of attention in human interaction.
The patients here in America are often bicultural, and may have a preconceived perception of how the procedure might be performed. This is often their first surgery ever. I find that most patients prefer that their friends not know that they are having it performed, although an equal number are very jubilant and will tell everyone once their wounds have healed to a desirable level. Some patients expect minimal or no swelling following surgery. Some expect no sutures at all, while some expect no incision. Other patients may expect all swelling to subside in a week. Almost all patients are invariably surprised at the height of the crease during the first few weeks, which usually goes down with proper healing.
My first face-to-face interaction with a new patient coming in for an office consultation is a relaxed meeting where we get to know each other’s viewpoints. The patient would express his/her concerns, goals to achieve, perhaps reasons for the goals.
Among the important items that should form part of the ensuing consultation are:
A basic eye evaluation: record of the patient’s best corrected vision, past history of dry eyes, injuries, scar formation or keloid, the sizes of the eyelid opening (vertically and horizontally), the distance between the two eyes, any ptosis or lid retraction, presence or absence of crease on each side, asymmetry, levator function (excursion) of each upper lid. If there is a history of previous surgery in the area, document the extent of scars in each layer of the lid and any crease abnormality, perform various assessments for skin shortage or mid-lamellar scarring.
A demonstration from the patient of what the individual would like to achieve, as well as the surgeon showing the patient what can possibly be achieved, which may be followed by a preview of some crease shapes and of different crease heights.
Going over the patient’s facial attributes, which might favor certain crease dimensions over others. Discuss appropriate remedies and prioritize the steps. With knowledge, the patient may then express their preferred choice of crease shape and dimension. The physician may advise or concur.
Discussion of the procedure: going over preoperative steps and preparations, postoperative care first day, first week, two months. Inform the patient of what to expect in wound healing. Discuss overall success rate or likelihood for secondary touchup, rate of touchup revision, and what the policy of your practice is. If proceeding to surgery, explain possible complications (see below) and sign informed consent.
Preoperative photography for the record, including straight-ahead, upgaze, downgaze, oblique views. For revisional cases I take close-up macro-photographic images of the previous incisional scar for documentation. Preoperative instructions are given including avoidance of anticoagulants and herbal medications.
Postoperative dietary advice – do’s and don’ts.
Postoperative eye movement exercises for some individuals: timing and schedules.
Further Discussion on Height, Shape, Continuity and Permanance
Crease configuration has four contributing parameters: height, shape, continuity and permanence ( Figure 5-5 ). These are each discussed further at the consultation.