Upper Eyelid of Asians Without Crease
Approximately half of all Asians have some form of an upper eyelid crease; thus, there are about 50% of Asians who do not have a crease. This seems to affect Asians of Han origin, including the Chinese, Koreans, Japanese, and China’s minority tribes. The incidence within any given family appears to parallel the above statistic in that I often elicit the history that one of the parents has an upper lid crease whereas the other parent does not, and this also seems to hold true among the siblings.
In the past, the stereotypic conclusion that all Asians are without an upper eyelid crease may stem from the fact that Western plastic surgeons often may get to examine only those Asians who have no crease and therefore seek their services, although many do not.
We will describe some of the commonly observed features in Asians who do not have a crease ( Figs 2.1 & 2.2 ), and also, among the Asians who do have a crease, what crease shape and size these tend to be.
Asians, as compared with Americans and Europeans, tend to be more petite. This is simply an observation that their body height, weight, and facial features all tend to be lesser in dimension. The upper tarsal plate (tarsus) of Asians usually measures only in the 6.5 to 8mm range, with the tarsal height in the majority, when measured over the central portion of the upper lid, being within 6.5 to 7.5mm. The upper border of the superior tarsus normally corresponds to where a natural upper lid crease would sit, assuming that this is measured in a young adult and that there has not been any involutional change in the lid skin or levator aponeurosis. Compared with a non-Asian’s upper tarsus, which is often in the 9–10.5mm range, this is a substantial difference. The critical importance of this clinical observation has to do with the placement of the height (or width as measured from the upper eyelash margin) of the desired crease. If one were to assume that 10 or 11mm is a standard crease and apply it to an Asian face, the resultant look will not be aesthetically acceptable, due to its high placement and proximity to the mid segment of the upper eyelid skin. Other complications, including injury to underlying tissues such as the septum and levator, as well as inadvertent creation of multiple creases and segmentation, may occur.
It has been postulated that Asians without an upper lid crease have a lower point of fusion of the orbital septum onto the anterior surface of the upper tarsus, or that the lower positioning of the preaponeurotic fat pad is the culprit that disrupted or prevented crease formation. It is uncertain as to which came first – whether the inferior point of fusion of septum to aponeurosis is the reason for absent crease or the lower migration of the fat. Rather, the true reason may be multifactorial and these are just findings by association.
There are at least four types of fat seen in the upper eyelids:
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pretarsal fat;
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preseptal or suborbicularis oculi fat;
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postseptal (preaponeurotic) or orbital fat; and
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submuscular or sub-brow fat.
The preseptal fat of the upper lid and the sub-brow fat seem to occupy contiguous space within the same general tissue plane over the periorbital and supra-brow regions. All four types of fat pads have been observed among Asians with or without an upper lid crease, as well as in Caucasians with crease, thus these four types of fat are not unique to Asians. It is just that among Asians without a crease, the intermingling of these four types of fat seem to be of a greater extent and the boundaries are much less distinct ( Fig. 2.3 ).
Most Asians have some form of medial canthal folds, even among those who have a crease. The medial canthal fold may be present with the nasally tapered crease (which is a shape prevalent in two-thirds to three-quarters of those who have a crease) or with the parallel crease shape. Both are compatible, natural, and not pathologic at all. The majority of requests for medial canthoplasty or epicanthoplasty or epicanthal fold excision are based on preconceived perception or on patients who have pathologic epicanthus associated with congenital blepharophimosis syndrome as reported in the Western medical literature.
Lash ptosis, a secondary downward angulation of the upper eyelashes as a result of the presence of a fold of redundant skin over the ciliary margin, is a feature often seen in Asians without a crease ( Fig. 2.4 ). It seldom causes any direct corneal touch or symptoms, and is not to be equated with true trichiasis. Rarely, one does see patients who have corneal touch as a result of prominent eye position, and, even more rare, one may see some Asians who may have very coarse, kinky or straight upper eyelashes, as is sometimes seen in older individuals with the floppy eyelid syndrome.
Epiblepharon is another curious finding sometimes seen in younger Asian patients near the medial portion of their lower eyelids. It may result in secondary trichiasis and can be relieved by simple infraciliary excision of this redundant skin–muscle fold.
Distichiasis, especially medially over the upper as well as the lower lids, may occur and is treated by Asian blepharoplasty of the upper eyelid without any need for tarsal rotation; and in the lower lid by a combination of excision of epiblepharon and/or segmental tarsal rotation.
Asians often manifest a subtle head-back position, with the forehead-to-chin plane about 5–10 degrees tilted backwards. Perhaps this is an adaptive head posture to allow greater pupillary clearance with the presence of a single eyelid’s redundant fold. We will come back to discuss this point in the section on postoperative management of Asian blepharoplasty patients in Chapter 7 .
Curiously, some Asians may manifest a relatively poor upgaze in the absence of clinically noticeable ptosis or known neuromuscular disorders. Some other patients may have only fair or borderline levator function; these patients may have true ptosis and this will present a challenge when the time comes to perform ptosis repair as well as attempting to crease a dynamic upper lid crease.
The above two conditions are often associated with an overactive forehead or brow action, as a compensatory move.
The aesthetic purposes of creating an upper lid crease are several fold:
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to enhance and create a visually apparent eyelid opening, in terms of both the vertical as well as the perceived horizontal dimensions of the palpebral fissure size;
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to create a more consistent platform for the application of cosmetics, eye-shadow, and eyeliners;
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to correct and reverse the downward angulation of the upper eyelashes in patients with absent crease;
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to improve on the vision of those who notice any partial field block or interference in their visual field as a result of the lashes, whether it is secondary trichiasis, or visual awareness of the lashes, which is like seeing through a picket fence when they are down-turned;
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to allow freedom from cosmetic application for those who desire it that way; and
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to free the patient from the continued need for application of other non-surgical adjunctive means in order to achieve the goals mentioned above.
Of these, some are aesthetically based and others have a true functional basis.
There are some patients who spend 30 minutes to 2 hours in the morning using adhesive glue, various tissue tapes, and even physical manipulations using wires, hairpins, and tooth picks in order to create a temporary crease. Some have been doing it for years and are plainly tired of it.
A nasally tapered crease tends to have a medially converging upper lid crease that may or may not completely join or touch the medial canthal skin ( Fig. 2.5 ).
