Although blepharoplasty is commonly performed on patients of a wide diversity of ethnicities and nationalities, upper eyelid blepharoplasty for the Asian patient is somewhat unique, often requiring a special approach. This is because the upper eyelids of many Asians are anatomically different from most non-Asian people. Specifically, the skin may not form a crease in the upper eyelid of some Asians. In other Asian patients, the crease may be present but may be only partially formed or may be located lower than in their non-Asian counterparts. Approximately 50% of Asians have some form of an upper eyelid crease.
For these patients, a surgeon can surgically create an upper eye-lid crease, allowing for a more open, alert appearance to the eyes. In the case of a shallow or low crease, the crease may be deepened and/or elevated. Most surgeons believe these operations should not result in “Westernization” of the eyes. That is, the result of such surgeries should not lead to a crease that is as high and deep as seen in Caucasian eyes. Rather, a subtle, low crease can create a more elegant, yet natural appearance that is still fitting with the patient’s overall ethnic features.
In the upper eyelid of most individuals, the muscle which opens the eye (the levator orbicularis) also has attachments to the skin of the upper eyelid. This band-like connection forms the crease of the upper lid. As the muscle lifts the eyelid up, the pull on the skin causes this area of skin (the crease) to pull up with the muscle. As this happens, the loose skin above the crease hangs over it to form the fold of skin we typically see above the eyelashes while the eye is open—the so-called “double-fold”. When the eye is closed, the levator muscle is relaxed not pulling the crease skin at all. The upper eyelid is therefore smooth, with no fold visible. With the eye closed, one may see a thin line at the location of the crease—one can think of this as a wrinkle that has formed due to the crease being closed and open again millions of times throughout ones life.
The main difference anatomically in the Asian upper eyelid is the fact that the levator muscle which opens the eye does not have the attachment to the skin. Therefore, no crease forms when the eye opens and the skin therefore does not create a fold over the eyelashes. This appearance is often termed the “single fold” upper eyelid. The skin tends also to be heavier and more fat resides in the upper lids of Asian people. All of this contributes to a narrower eye with more fullness in the lid. The lack of fold means there is not a natural platform onto which eye-makeup may be placed. Many Asian patients seek the surgery with the goal of attaining a more open, attractive eye—not necessarily one that is more Western or Caucasian in appearance.
Although surgeons use a variety of techniques to create a crease and double fold in the Asian upper eyelid, the majority of these procedures can grouped into two general types of surgery: the incisional (open) approach and the suture (closed) approach. For both types of surgery, the goal is to establish a connection between the skin in the region of the desired crease and the levator muscle. In the normal double-fold upper eyelid, it is this anatomical connection that creates the upper lid crease and double fold. Surgery aims to establish this missing anatomical feature in the single fold, creaseless Asian upper lid.
In this method, a precise curved incision is made into the skin above and parallel to the upper eyelid border in the desired position and shape of the new lid crease. Beneath the skin, the connective tissue layers and fat in the upper lid is then separated from the deeper levator muscle. Sometimes a portion of the fat is removed. Once the muscle is exposed, several stitches are placed between the muscle and the soft tissue and skin just below the incision. This creates a connection between the muscle and skin, allowing the desired crease to form with the eye open. Typically the procedure is performed with the patient awake (under sedation and/or local anesthetic) so that the surgeon can observe the eyelid in the closed and open position. This ensures the shape and position of the crease is optimal and symmetrical between the two sides. The skin incision is then carefully closed with fine sutures. The advantage of the incisional approach is that direct adherence of the skin and muscle is established by fully exposing the tissue and placing the connecting sutures. The disadvantage is the formation of a scar at the incision line and increased bruising and swelling after surgery.
In this method, the fixation between the muscle and skin at the desired crease is created by passing stitches beneath the surface of the skin without an external incision. This is accomplished by placing stitches in several loops that reside completely under the skin surface. In order to do this, the needle that passes the suture enters the skin at the skin surface at a point along the desired crease (which is drawn onto the skin beforehand with a surgical marking pen). The needle and suture then pass through the deep tissue of the upper lid and then exit at another point along the desired crease line. The needle is then passed back into the lid at the same exit point from which it just emerged. The path of the needle is then reversed from the last loop, taking a slightly different trajectory, creating a second loop of deep tissue captured by the needle. The needle exits at the original entry point. The two loose ends of the stitch are then tied together into a knot which can be buried under the skin at the original needle entry point. Avoidance of the incision means no external scar will be apparent after surgery. Critics of the suture approach contend that the crease may become less crisp or even disappear over time.
The procedure is typically performed with the patient awake under local anesthesia and/or sedation in an out-patient setting. If the incisional approach was used, the sutures are typically removed within a week after surgery. Swelling of the skin after surgery will cause the fold above the crease to appear thicker and higher than its final appearance and position. The fold will settle into its final position and shape within a few weeks after surgery.
The most common complication following Asian upper blepharoplasty is asymmetry of the creases or folds. This may occur as the result of uneven placement of the skin incisions or asymmetric suture placement. These problems may be remedied through a revision or touch-up procedure. Another complication is partial or complete reversal of the crease formation. In these cases the crease may be re-formed through revision surgery. Other less common complications include thick scar formation, eyelid droop, or an undesired change in the shape of the eye.