Asian blepharosplasty

Introduction to Asian Blepharosplasty

Jung I. Park

Blepharosplasty in Asia is almost synonymous with double eyelid operation. The double eyelid operation
is a technique has come full circle since it was described by the Japanese Surgeon Mikamo, 1 who reports
a suture technique in 1896 (Figure 1-1). In 1929 Maruno2 was the first to describe the incision technique
(Figure 1:2). In 1939 Hayashi3 introduced the technique of excising a strip of orbicularis oculi muscle
(Figure 1-3), 15 years before Sayoc4 published his widely quoted paper in 1954 (Figure 1-4). Mitsui5
ventured further in 1950 by excising the muscle, connective tissue, and fat in pretarsal area (Figue 1-5).
In 1960 Fernandez6 reported the most radical approach yet: removal of the skin, orbicularis oculi
muscle, orbital septum, and orbital fat. He than fixated dermis to the levator aponeurosis (Figure 1-6). In
1963 Boo-Chai7 described a pretarsal and orbital soft tissue technique similar to Mitsuis method (Figure
1-7). After a series of progressively aggressive approaches, the 100-year-old suture technique ia again
favored by clinicians in East Asian countries.

Preferences for the Asian eyelid have changed with time, from a mild traditional-looking double fold to
an aggressive wide fold and then back to a scarless, conservative double eyelid. The choice of suture
material has not drawn as much attention; surgeons have preferred to use absorbable cutgut or
removeable or permanent sutures. In the incisional technique tissues are fixated between the skin and
the tarsus or levator aponeurosis. In 1999 Park8 reported a technique usingthe orbicularis oculi muscle
(rather than the skin) as the tissue that fixates to the levator aponeurosis (Figure 1-8). Doxanes et al9
demonstrates the anatomic differences of the Asian and the Caucasians to support the lack of
supratarsal crease in the Asian eyelid. The lack of the levator aponeurosis penetration into pertarsal
orbicularis oculi muscle, the lower fusion point to between the levator septum and the levator
aponeurosis, and the lower prenetration of the preaponeurotic fat in the pretarsal area have been
suggested as causes of the single eyelid in Asian population (Figure 1-9). Operative procedures are
designed to recreate the anatomic features that produce the double eyelid fold. Although the incisional
technique may give a more distinctive and longer lasting crease,10-15 more surgeons are willing to follow
the trend to satisfy the patients with a simple and effective but somewhat compromised procedure. The
correction of the epicanthal fold has been largely ignored because it cause visible scar. With a
conservative, small double eyelid formation, the average-sized epicanthal fold does not diminish the
cosmetic improvement of the double eyelid surgery.

As the double eyelid operation becomes more aggressive, the presence of the epicanthal fold becomes
more visible (Figures 1-10), At times, it gives the appearance of a round eye (Figure 1-11). More
importantly, public desire for surgical enlargement of the eyes has caused sugeons to seek better
technique to eliminate the epicanthal fold. Variations of direct excision, V-Y advancement, W-plasty and
Z-plasty techniquehave been published. Despites numerous method available, many surgeons are
reluctant to perform medial epicanthal plasty because of the potential for the visible scar formation.
The popularity of the scarless surgery also diminished the demand for the procedure. However, it
cannot be denied that a well-executed epicanthoplasty adds significant beauty to the eyelid without a
visible scarring. Some surgeons perform a lateral canthotomy/canthoplasty is an attempt to enlarge the
eyes.

The oldest Asian patient presents an entirely different set of aesthetic challenges for the surgeon. In
addition to creating a double eyelid, the surgeon must be concerned with redundancy of the eyelid. The
fullness f the upper eyelid secondary to brow ptosis adds to the complexity of upper eyelid surgery on
the older Asians patient. These patient have been reluctantly accepted unsightly and prolonged upper
lid edema and puffines after double eyelid surgery (figure 1-2). These problems stem from the excision
of large amounts of thin pretarsal skin and the creation of a fold in which remaining eyelid skin is much
ticker and closer to the eyebrow. A forehad lift resolves this issue adequately; the ticker eyebrow skin is
pulled up and out of the way, and the tinner pretarsal skin is used to create a more delicate double
eyelid fold (Figure 1-13). The forehead lift for the Asian has an additional purpose; to prevent an
unwanted ticker post operative double eyelid fold. Patients often have to be persuaded of the benefits
of the procedure and encouraged to accept it.

References

1. Mikamo K: A technique in the double-eyelid operation, J Chugaishino, 1986.

2. Mauro M: Plastic construction of a double eyelid, Jpn J Clin Ophthamol 24:393, 1929.
3. Hayashi K: The modification of the Hotz method for plastic construction of a double eyelid, Jpn
Rev Clin Opthamol 34:369, 1939.
4. Sayoc BT: Plastic construction of the superior palpebral fold, Am J Opthalmol 38:556-559,
1954.
5. Mitsui Y: Plastic construction of a double eyelid, Jpn Rev Clin Opthamol 44:19, 1950.
6. Fernandez LR: The double-eyelid operation in double-eyelid operation in the Oriental in
Hawaii, Plast Reconstr Surg 31:74-78, 1963.
7. Boo-Chai K: Plastic construction of the superior palpebral fold. Plast Reconstr Surg 31:74-78,
1963.
8. Park Ji: Orbicularis-levator fixation in double-eyelid operation, Arch Facial Plast Surg 1 (Apr-
June):90-95, 1999.
9. Doxanes MT, Anderson RL: Oriental eyelids: An anatomic study, Arch Opthamol 102:1232-
1235, 1984.
10. Moutou Y, Moutou H: Intradermal double eyelid operation and its follow-up results, Br J Plast
Surg 25:285, 1975.
11. Weingarton CZ: Blepharoplasty in the oriental eye, Tram Acad Ophth Otol 82:442, 1976.
12. Matsunaga RS: Westernization of the Asian eyelid, Arch Otolaryngol 111:149, 1985.
13. Hiraga Y: Blepharoplasty in Orientals. Problems in plastic and reconstructive surgery, 1:504,
1991.
14. Chen WPD: Revision and correction of suboptimal results. In Chen WPD: Asian blepharoplasty,
Newton, MA, 1995, Butterworth-Heinemann, p 84.
15. Lee JS: Simplified anatomic method of double eyelid operation: Septodermal fixation
technique, Plast Reconstrc Surg 100:170, 1997.