EyeNet Magazine

Clinical Update: Oculoplastics
Perfecting Blepharoplasty in Patients of Asian Heritage
By Marianne Doran, Contributing Writer

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Blepharoplasty in the patient of Asian heritage is challenging, whether performed for cosmetic or functional reasons, according to William P. D. Chen, MD, clinical professor of ophthalmology at the University of California, Los Angeles. But respecting the technical differences between eyelid surgery on Asians and non-Asians is not the only key to a successful procedure. The first step involves setting aside misconceptions about what patients of Asian ethnicities are looking for in an upper eyelid procedure.

Avoiding Assumptions

The most prevalent misconception is that Asian patients are seeking to “Westernize” their eyes. “I have yet to find anyone who wants to have a Western shape or the height of a Western crease,” said Dr. Chen, who is also senior surgical attending physician in the ophthalmic plastic surgery service at Harbor–UCLA Medical Center in Torrance. “Asian patients who want a lid crease intuitively understand that a Western crease would be too high and too wide. Almost invariably they will bring in pictures of an Asian model or an Asian movie star.”

Tamara R. Fountain, MD, associate professor of ophthalmology at Rush University Medical Center in Chicago, also emphasized the importance of not having preconceptions of what an Asian patient wants. “This is where people can get into trouble—you can do a flawless surgical procedure, but if you create an appearance that the patient wasn’t prepared for and didn’t want, then you’ve done something wrong,” she said.

Seeking a subtle change. For some Asian patients, the motivation for blepharoplasty is simply to improve eyelid function—to relieve a feeling of heaviness or fatigue—or to make wearing eye makeup easier. “A woman may want just a little bit of a tarsal platform to put her makeup on but doesn’t want a thinned-out lid or a high lid crease,” noted Stuart R. Seiff, MD, emeritus professor of ophthalmology at the University of California, San Francisco. “Men may still want almost a ‘single’ eyelid appearance, but they don’t want the skin and fat that’s pushing their eyelashes down.”


Counseling the Patient

The traditional idea of an Asian eyelid is a full lid with an epicanthal fold and no lid crease. But about half of Asian people have a natural crease, which is often low and parallel to the lid margin. Asian creases also can be partial, discontinuous or tapered. “The Asian population has a complete spectrum of eyelid crease locations, lid fullness and epicanthal folds,” said Dr. Seiff. “It’s not like there is one configuration that is Asian and one that is occidental and you try to make one look like the other. This is where understanding the patient’s expectations is so important—and they are likely to be somewhere between a ‘single’ Asian eyelid and a ‘double’ Western eyelid.”

Offer patients an idea of the result. Regrets can be preempted by talking with patients and finding out exactly what they are looking for, Dr. Chen said. He uses images in albums and PowerPoint presentations to demon- strate the various looks created by setting the eyelid crease at different heights. Using a bent paperclip and a mirror, he shows patients how a particular crease will look on them.

Dr. Fountain uses a similar approach. “I spend a lot of time talking with patients and making sure that I understand what they want and that we are on the same page.” She demonstrates the different crease possibilities by making an indentation and rolling the excess skin out of the way with the wooden end of a cotton-tipped applicator. She also has a network of previous patients who have agreed to let her show their pictures and who are willing to share their experiences with the surgery and how they feel about the results that were achieved.

She added that some patients are very sure about what they want—often a definite crease but one that is not too prominent—whereas others are more ambivalent. “Sometimes it’s not the patient who has strong ideas about the crease but the family members—commonly the spouse, but also parents of young adults and teenagers. It’s good to remember that your duty is to the patient. That is the person to whom you must direct your counseling.”


Anatomic Considerations

Several morphologic factors should be considered when planning blepharoplasty in a patient of Asian descent.

Body size. Physical frame is an important consideration. “Most Asian physiques are smaller than Westerners,’ so the crease must be facially proportional,” Dr. Chen said. This smaller size also places greater demands on the surgeon because even slight deviations in facial features are more noticeable.

Eyelid fullness. Asian eyelids contain more fat. “We try to maintain the fullness of Asian eyelids, whereas we might de-fat and thin out an occidental lid,” said Dr. Seiff. Leaving adequate fat is important, he added, because the fat provides a barrier to the formation of a high occidental lid crease, which most Asians don’t want.

Variable anatomy. Dr. Fountain noted that the insertion point of the septum into the levator aponeurosis is lower in Asians. The consequences of this anatomic difference are that the fat behind the septum can move lower on the eyelid, making the lid look fuller and the eyelid crease lower or nonexistent. She added that Asians also tend to have more fat in front of the septum, just beneath the skin, and some debulking may be undertaken as needed or if the patient desires a less prominent lid.

“Everyone does it a little differently,” Dr. Fountain said. “Some surgeons will be very aggressive about fat removal, whereas others like a little fuller look. Again, this issue should be part of the preoperative counseling.”

Muscle mechanics. As for creation of a new upper eyelid crease, Dr. Seiff compared the basic concept to the workings of a Roman window shade. “The crease of the upper eyelid forms at the highest point of attachment. The levator aponeurotic fibers move anteriorly and insert into the skin and muscle complex such that when the eyelid opens or pulls upward, the levator fibers pull on the skin and create a fold—a little like a Roman window shade. The way we modify where the crease forms—which the fold then hangs down from—is to either permit or obliterate attachments from the levator to the skin and muscle complex.”

Dr. Seiff and others have published papers pointing out that anatomic differences between Asian and occidental lids must be taken into account when considering other types of eyelid surgery on an Asian patient.1,2 “These differences will play into the aesthetic results you achieve even when you are doing functional surgery in an Asian lid, and a lot of people don’t think much about that,” he said.


Surgical Pearls

Dr. Chen, who has taught courses in Asian blepharoplasty at the Academy’s Annual Meetings for nearly 20 years, shared some of his insights and surgical practices.

Easy on the anesthetic. For starters, he uses less anesthetic than he might for other procedures in order to avoid distorting the tissue.

Mark accurately. He is exceptionally precise in marking the incision line. An ink marker, he noted, is too broad and can easily turn a 7-mm marking into an 8-mm marking. Instead, he uses the carefully sharpened wooden point of a cotton-tipped applicator.

Plan the crease. Crease height is based on central tarsal height, which averages 6.5 to 8.0 mm in Asians. To preserve an Asian look, the crease shape should be either parallel (running equidistant from the lid margin, from the medial canthus to the lateral canthus) or nasally tapered (converging with the medial canthus), not semilunar, as in Caucasian eyes. The crease also should form a continuous, permanent line that does not disappear over time. Dr. Chen also emphasized the importance of creating a dynamic crease, one that mimics a physiologic, naturally acquired crease. Like a natural crease, the surgically created one should become shallow and less visible when a person looks down. But a popular type of eyelid surgery often performed in Asia violates this principle. In the simplified procedure, the surgeon tucks the tissue and buries three stitches where the crease will be. According to Dr. Chen, this type of crease looks artificial because it is deeply indented and remains static when the individual looks down.

Target the incision. For the incision, Dr. Chen uses a blade through the skin and a cautery through the orbicularis muscle in a beveled fashion. “Using a knife through multiple tissue planes always causes more damage if it is done as a straight vertical. So I use a cautery in a slanted fashion through the next layer of tissue, leaving only healthy tissue under the skin incision.”

Preserve some fat. He removes only as much underlying fat as necessary to allow formation of the crease, usually about 10 to 15 percent of the available fat. Removing too much fat gives the eyes a sunken or “famine” look, he noted, and makes patients look older than they are.3,4

Mastering the technical aspects of Asian blepharoplasty requires good instruction and time. But in the end, a successful outcome depends in large part on the same elements that govern the success of all cosmetic procedures—a well-trained surgeon, clear communication between doctor and patient and realistic expectations of what the surgery can achieve.

1 Seiff, S. R. Facial Plast Surg Clin North Am 1996;4:1–5.
2 Kim, M. K. et al. Ophthal Plast Reconstr Surg 1989;5:118–126.
3 Chen, W. P. D. Plast Reconstr Surg 1996;97:212–218.
4 Chen, W. P. D. Plast Reconstr Surg 2007;119:379–386.

None of the physicians interviewed for this story report related financial interests.


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