Sculpting the Asian eye

Paris - To be a successful cosmetic eyelid surgeon, the physician must understand ethnic anatomic differences, as well as culturally diverse aesthetic principles.

In today's multicultural and multiracial societies, eye surgeons are being challenged to refine, adapt and enhance their thought processes and surgical skills in order to address the diverse needs of their patients. Asian eyes, for example, require extreme surgical precision at every stage of a blepharoplasty procedure, and can pose unique and challenging cases for a physician.

"Asian blepharoplasty can mean applying standard blepharoplasty techniques to an aging Asian eyelid to reverse the stigmata of aging, essentially contouring prolapsing fat and removing redundant skin. But the term Asian blepharoplasty also means adding a crease to an eyelid that is lacking a crease. Management of this eyelid crease is the essential component of Asian eyelid surgery."

Eastern idiosyncrasies

Dr. Schiller says that Asian eyes are very diverse. About half of the Asian eyelids lack a crease; this is termed a "single eyelid," as opposed to an eye with a "double eyelid" which has a crease.

Another difference is that some eyes have an inner or tapered crease, as opposed to an outer or parallel crease. Asian eyelids can have no crease, interrupted creases, multiple shallow creases and creases that are parallel to the lid margins or taper away from it. The main anatomic difference between the Asian and Western eyelid is that in the Asian eyelid, the orbital septum inserts much lower on the levator aponeurosis.

"This has several consequences. In the Western eyelid, there is a system of interconnected fibers which both attach the skin to the levator aponeurosis creating the lid crease, and hold the skin and orbicularis flat against the tarsus. In half of Asians, the lower insertion of the septum does not allow formation of these attachments, hence the lack of a crease and the absence of a platform of skin in front of the tarsus," Dr. Schiller tells Dermatology Times.

There is a common misconception that on the whole, blepharoplasties are done in Asians to "Westernize" the way they look. Dr. Schiller says that it is the palpebral aperture that appears larger with a crease and it is this characteristic that makes the Asian eye appear more expressive, alert and youthful. These are universal aesthetic values, not only Western.

The surgeon explains that, "All blepharoplasty surgeons know how to create a crease, but the Asian patient and their anatomy require an extreme degree of precision, to achieve consistent, predictable and reliable results. Precision is required in the analysis of the patient's anatomy, in communicating with the patient about what can be achieved, in planning the procedure and in execution."

Ways to double eyelid

There are two basic techniques to create a double eyelid - open incisional and closed non-incisional, as well as variations incorporating both techniques.

When performing a crease, Dr. Schiller favors the open incisional technique in which skin, fat and muscle can be debulked, and he prefers a CO₂ laser as his cutting instrument, effecting little bleeding and little thermal damage. Because Asian skin is thicker and prone to hypertrophic scarring, the surgeon uses a scalpel to cut through the skin, avoiding thermal damage. In this "mini-blepharoplasty" technique, a varying amount of skin, orbicularis and fat is resected, and crease-forming sutures are passed from the anterior lamella, either the skin or the orbicularis, to the levator aponeurosis.

As in most procedures, there are potential complications. They include asymmetry, early or late loss of creases, hypertrophic scarring, ecchymosis or hematoma and multiple crease abnormalities, including creases that are too high or too low, duplicated creases or a sulcus deformity.

The most common surgical technique used in Asia is the closed non-incisional technique (also confusingly called the suture technique). Dr. Schiller explains that three Prolene (Ethicon) or nylon sutures are passed beneath the skin and tied, and the knot is buried. Surprisingly, the suture is left externalized on the conjunctiva at the superior tarsus and allowed to "cheese wire" itself into the back of the eyelid.