Fifty percent of Asians do not have an upper eyelid crease, while the other 50% have at least some form of crease.  Eyelids without a lid crease are called a “single eyelid,” while eyelids with a lid crease are called “double eyelids.”  

Asian upper blepharoplasty is the most commonly requested cosmetic surgery by Asian patients.  The Asian patient usually wants to form a double eyelid from a single eyelid, partial creased eyelid, asymmetric eyelids, or shielded double eyelids. The Asian patient usually does not desire a “westernized,” Caucasian eyelid, but prefers a double eyelid that “matches” the Asian face or is similar to the double eyelid that occurs naturally on other Asians.

 The anatomic differences between the Asian and the Caucasian eyelid are many.  First, in the double eyelid, the filaments of the levator aponeurosis interdigitate with the anterior tarsus, pretarsal orbicularis, and skin which form the lid crease (Fig 1).  In the single eyelid, there is an absence of attachments of levator aponeurosis to the pretarsal orbicularis and skin, thus there is no crease (Fig 2).  Second, in the double eyelid, the orbital septum fuses with the levator above the superior tarsal border and restricts the pre-aponeurotic fat from descending anterior to the tarsus (Fig 1).  In the single eyelid, the pre-aponeurotic fat descends inferiorly, anterior to the tarsus (Fig 2). Third, Asians usually possess an epicanthal fold, which arises from the medial canthus.  Fourth, the Caucasian eyelid has a higher peak at the center of the crease above the pupil, while the Asian eyelid has a crease that is narrower nasally and widens temporally or has a crease that is parallel to the eyelashes across the length of the lid.  Fifth, the Asian crease is lower to the lashes (4 to 9 mm) compared with the Caucasian crease (7 to 12 mm).

 In preoperative consultation, three decisions are necessary.  First is the amount of pre-tarsal platform and skin to show (i.e. crease and fold height).  Second is shape of the pre-tarsal platform and skin to show (e.g. nasally tapered, parallel).  Third is whether the crease will originate from the epicanthal fold or nasal to the epicanthal fold.

 The double eyelid surgery may be performed using a closed, suture technique or an open, incision technique.  We prefer an open incision technique because it allows better control of placement of the crease and allows for more permanence of the crease.

 In general, for Asians, we plan a conservative upper blepharoplasty with various amounts of skin excision depending on the patient’s age, anatomy and desires.  The incision is variable, but usually lower than in Caucasians, between 4 to 7 mm above the cilia.  A modified pinch technique is used to identify the appropriate amount of skin excision. Meticulous measuring and remeasuring of the proposed inferior and superior incisions is done, always striving for symmetry, and compensating for preoperative asymmetry.   After marking, injecting and prepping, the skin is excised with a diamond blade.  A thin strip of orbicularis is excised.  Varying amounts of fat are removed depending on the specific anatomy.  Closure is performed with a 6-0 prolene suture, with fixation of the skin to the orbicularis just above the tarsus with every other bite.  This ensures a double eyelid.  However, it provides a softened crease which looks more natural and non-surgical (Fig 3a,b).

 In the aging Asian eyelid, if the skin hangs over the eyelashes and affects the peripheral vision, then insurance usually covers the surgery (Fig 4a,b).  Photos, visual fields, and documentation of the lid position with functional MRD1 are submitted to the insurance carrier to support coverage of the procedure.

EYESTHETICA

Oculofacial and Cosmetic Surgery Associates                                                                   

 Steven C. Dresner, M.D.       www.DrDresner.com

Michael A. Burnstine, M.D.   www.DrBurnstine.com

Melanie Ho Erb, M.D.

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