In the opening chapter of this book I discussed, in common terms but in an exacting way, what an eyelid crease is, both from a layman’s point of view as well as from a scientific neuromuscular standpoint. The two are complementary. Figure 4-1 shows a typical Asian eyelid without a crease, usually denoted as a ‘single eyelid’ or ‘mono-lid’ (but remember that the incidence of absent crease among Asians is 50%, meaning the other 50% are born with an eyelid crease).
A crease that is located at a height of 8–10 mm from the ciliary margin is considered ‘too high’ for Asians. This may be a result of surgeons adhering to an empirical formula for the height of the lid crease; or following techniques of supratarsal fixation where a distance of 9–10 mm or more is applied without regard to ethnicity, since for Caucasians the upper tarsus usually measures 10 mm in its vertical dimension. In either case, the crease looks excessively high when it is applied on an Asian patient for the following reasons. First, Asians are usually smaller in build and their upper tarsus measures only 6.5–8 mm in height on the average. Second, the distance between the eyebrow and the upper lid margin is proportionately less in Asians. Therefore, if one were to apply a crease at 10–12 mm from the lash margin, it would look much closer to the mid section of the upper lid.
When the crease is farther from the lid margin than the height of the tarsus for that patient, the surgically applied crease traverses through thicker dermis as we get closer to the brow and is more likely to be associated with hypertrophic scarring. Being farther away results in less camouflage by the upper eyelashes and the crease is more exposed to scrutiny by the individual and their peers. It also brings in an associated functional problem that will be covered later (in Chapter 21 ). I consider a crease as harsh when it is overtly prominent, deep and indurated with dermal reaction.
By ‘unnatural’, I mean that the crease assumes a shape that is aesthetically not attractive on the face of the individual. The main offender is a semilunar crease. The overall impression created by a crease positioned high and with a semilunar shape is of an unnatural look for an Asian individual. Another cause for an unnatural crease is if an excessive amount of the preaponeurotic fat pad is removed. When a major portion of the fat pad is removed in the preaponeurotic space the result is a hollowed-eye (‘famined’) look which appears incongruous in the relatively flat facies of an Asian person. By contrast, removal of preaponeurotic fat may be a necessary step in age-related cosmetic blepharoplasty for those Caucasian patients who in their youth had a deep-set supratarsal sulcus. (Of course, not all Caucasians have a deep-set sulcus and for those who had full eyelids, some fat preservation is desirable.)
Figure 4-2 shows arbitrary placement of a high, 10 mm crease on an Asian upper eyelid. It shows a 10 mm crease that is semilunar in shape, hypothetically applied to an Asian eye anatomy (upper lid margin with black eyelashes). This would be considered a very high crease and not the typical Asian crease configuration. (The effect can be mimicked by using temporary devices like lid crease tape or glue.)
The red arrows represent a line connecting the two ends of the abnormally high semilunar crease to the Asian eyelid’s true canthi. They cross at an angle of θ 2 as it passes through each canthus. If one superimposes a Caucasian eyelid opening whose horizontal dimensions are 5–10% larger (which they often are), assuming and keeping the same vertical opening (brown upper eyelashes) with the exact same semilunar crease shape and height, the end-of-crease to end-of-canthus lines (green arrows) will form a smaller angle of θ 1 for the Caucasian eye.
Angle of θ 2 > θ 1