18.1 Goals

Asian blepharoplasty, commonly known as “double eyelid surgery,” or “ssangkkeopul” surgery in South Korea where the practice has been popularized, refers to surgery designed to create or define an upper eyelid crease. Due to the unique anatomic characteristics of the Asian eyelid as well as specific functional and aesthetic expectations from patients, Asian blepharoplasty surgery has been the topic of entire textbooks and a large body of research. In this chapter, we will distill this body of research and our experience into key points for performing successful Asian blepharoplasty surgery.

18.2 Advantages

Asian blepharoplasty surgery lends itself to incorporating adjunctive techniques such as excision of dermatochalasis, ptosis modification, epicanthoplasty, and palpebral fissure widening to significantly alter the anatomy and appearance of the eyelids, while at the same time improving visual functioning. Therefore, it is critical for the surgeon to understand patient expectations and clarify the goals and limitations of surgery before embarking on the surgical journey.

18.3 Expectations

We cannot overemphasize the importance of understanding patient expectations when planning Asian blepharoplasty surgery. Asians are not a homogeneous group and it can be counterproductive to make generalizations. Beauty ideals differ between the various Asian ethnicities and cultures, in addition to specific individual patient preferences. Our experience tells us, however, that nearly all patients expect short recovery time and minimal scarring. And most patients seeking Asian blepharoplasty surgery do so because they desire larger appearing eyes. It is important to clarify the following expectations before surgery:

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  What is the desired crease height and tarsal platform show?

  
  
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  What is the desired crease depth? Does the patient want a deep or “harsh” crease or a softer more natural crease that is less visible with the eyelids closed but has a higher risk of fading away over time?

  
  
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  Is the goal of surgery to have larger appearing eyes or to change the shape of the eyes? If so, what are the patient’s thoughts on adjunctive procedures like ptosis modification, epicanthoplasty, or lateral Hotz procedure to widen the palpebral fissure in multiple vectors?

18.4 Key Principles

The Asian eyelid has several key anatomic differences from the Caucasian eyelid, which are well documented in the medical literature ^{1 ,​ 2} and succinctly summarized by Kiranantawat et al. ³

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  The Asian eyelid skin is often thicker, with pretarsal and sub-orbicularis oculi muscle adipose layers that are rarely present in the Caucasian eyelid.

  
  
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  The inferior most extent of the preaponeurotic fat pad lies lower in the Asian eyelid. While the mechanism of this descent remains a topic of debate among anatomists, there is emerging evidence that the fusion area between the orbital septum and the distal levator aponeurosis plays a role. This area of fusion has been variably termed “septoaponeurosis junctional thickening,” “septoaponeurotic vehicle,” or simply “junctional thickening.” ⁴

The two primary methods of creating an eyelid crease are non-incisional and incisional. The non-incisional technique is less invasive and forms a more natural appearing eyelid crease with faster postoperative recovery, but carries a higher risk of long-term surgical failure. Patient selection is critical in determining which surgical method to use.

18.5 Indications

Indications for surgery include eyelid asymmetry; incomplete, redundant, or missing creases; and desire for cosmetic improvement. Patients are candidates for non-incisional (suture) crease formation if they do not require excess skin excision and have relatively thin eyelid soft tissues that can maintain a crease temporarily created by indenting the eyelid with a Q tip at the desired crease line. Patients who require skin excision to achieve the desired amount of tarsal platform show, those with thick eyelid tissues that do not maintain a temporary crease, and patients with scarring from previous blepharoplasty surgery are better suited for incisional blepharoplasty.

18.6 Contraindications

While no true contraindications exist, it is important to recognize that eyelid surgery is elective in nature, and should be balanced against the patient’s general medical health as well as psychological wellbeing. Caution should be exercised and appropriate medical consultations obtained when recommending sedation for patients in poor health. Similarly, patients who exhibit signs of body dysmorphic disorder should be dissuaded from surgery and/or referred for counseling. The principle of “first do no harm” is especially important when undertaking elective surgery.

18.7 Preoperative Preparation

The preoperative surgical design process is critical. This dynamic maneuver should be performed with the patient seated upright at the surgeon’s eye level. With the patient looking down, a clean toothpick or surgical tool designed for this purpose is used to gently depress the eyelid skin at the level of the intended eyelid crease. In our experience, the optimal location for the Asian eyelid crease is 7 to 8 mm from the eyelid margin. An eyelid crease placed at this height is aesthetically pleasing and facilitates deeper dissection and fixation as needed. With 7 to 8 mm as a starting point, the patient is then asked to look straight ahead as the toothpick is removed while the contour and durability of the eyelid fold is assessed. This maneuver is repeated until the crease location and design is optimized, then a marking pen is used to dot along the intended eyelid crease.

The amount of skin to be excised depends on the desired pretarsal show. If a large amount of skin excision is needed, either the skin pinch or raise-and-drop methods may be used to gauge the amount of skin to be excised. Most cosmetic Asian blepharoplasty surgeries, however, require only a few millimeters, if any, of skin excision. In these cases, the amount of skin excision can be directly measured, subtracting 1 to 1.5 mm in patients with thick skin to account for the width of the tissue forming the base of the skin that drapes over the eyelid crease (Fig. 18‑1).

It is our practice to have patients discontinue the use of any blood thinners 7 to 10 days prior to surgery.

Surgery is generally performed under local anesthesia or light sedation such that the patient is able to open and close the eyes intraoperatively to allow the surgeon to gauge symmetry and crease formation. In our experience, oral diazepam or intravenous ketamine, in conjunction with intravenous or intramuscular midazolam, creates the optimal level of sedation while maintaining the patient’s ability to cooperate with eye opening and closure. Intravenous propofol can render the patient less cooperative.

After instillation of proparacaine or tetracaine anesthetic eye drops, local anesthetic consisting of 2% lidocaine with epinephrine 1:100,000 is injected subcutaneously across the entire surgical area, using a 30-gauge needle, administered in 0.2 to 0.3 mL aliquots. Injecting above the orbicularis oculi muscle plane avoids hematoma formation, which could cause difficulties gauging symmetry during surgery. Surgeons have the option of adding hyaluronidase (to facilitate anesthetic diffusion) and/or sodium bicarbonate (to buffer the pH and decrease pain with injection) to the local anesthetic mixture. We recommend avoiding longer-acting anesthetics such as bupivacaine in case of unintended spread to the levator muscle causing prolonged intraoperative ptosis that render it difficult for patients to open and close the eyes during surgery. One should always have local anesthesia available on the sterile field for intraoperative administration as needed. The entire face is prepped with dilute betadine solution.