The Asian Eyelid

Hi, my name is Catherine Hwang, oculofacial plastic surgeon at the Cleveland Clinic. I'm pleased to be a part of this session on ethnic considerations in Asian eyelid surgery. I'd like to thank the organizers, as well as my colleague Jim Zins, for inviting me to be a part of this virtual meeting. I have no financial disclosures today. I thought I'd share with you five things to think about while addressing the Asian eyelid. 1) Respect the crease. 2) Don't forget the epicanthal fold. 3) Recognize ptosis. 4) Think about volume. 5) Be prepared.

1) Respect the crease. It's easy to make but hard to fix. There's a myth that most Asians don't have a crease, but in fact, 50% of Asian patients have an upper eyelid crease. Actually, I think more Asians have creases than we think. They're just lower and more hooded than Caucasians.

So what makes a crease? A crease is formed by the attachments from the levator to the skin. In Asians, the preaponeurotic fat comes down further due to a lower septal adhesion and therefore interferes with the levator-to-skin attachment, thus making the crease lower or nonexistent. Actually, this diagram is incorrect for the Asian eyelid. The fat comes down further, as you can see on this MRI image. You can see here the preaponeurotic fat and then more subcutaneous fat in the Asian eyelid.

In fact, over the past 10 years, I myself have lost subcutaneous and ROOF fat in my upper eyelids, and now I'm starting to form a lid crease. This is without any surgery, just age. 

In addition, the tarsal height is shorter in Asians than Caucasians, about six to eight millimeters instead of the eight to 10 millimeters, which also contributes to a lower crease found in the Asian population.

So how do we make a lid crease in our Asian patients? The preoperative evaluation is key. Here I like to use a double-crease instrument. You can also use a paper clip or Q-tip. I like to ask the patient what type of crease they want and how high.

Here on the left, you can see a tapered or infold crease, and on the right, a parallel or outfold crease. Most Asians like the tapered crease, but I try to find out what they want prior to surgery. Also, remember, Asian patients want to look Asian with a low lid crease, not Caucasian or westernized with a high lid crease. Maybe back in the 1980s, the lower patient would be a good result, but nowadays patients want a short lid crease with larger eyes.

After we figure out what the patient wants as far as crease configuration, we then figure out if they are okay with a static crease or if they want a dynamic crease. If they want a dynamic crease, we then have to look at their anatomy and see if they're a candidate for suture blepharoplasty. Suture or closed blepharoplasty is better suited for younger patients without excess skin or fat. This allows for a dynamic crease but has less control in the final place of the crease and may not last. Open or incisional blepharoplasty is for older patients with excess skin and fat. This creates a static crease with more control that is permanent, for better or worse.

This patient is an ideal candidate for suture blepharoplasty. She does not have excess skin or fat. She underwent Pang full-thickness sutures. Preoperatively, I like to make a mark where the crease is best formed, and then I create a small incision with Westcott scissors in two to three places to bury the knots. The sutures are placed with double-armed sutures, either Vicryl, silk, or PDS. I like PDS, and the sutures are passed from the conjunctiva to the skin.

I put the second arm of the double-armed suture through the same hole in the conjunctiva, and I use a lid clamp to evert the lid and the suture slightly, and then tie it. I do bury the knot under the skin, but some surgeons leave Vicryl knots until they fall off on their own without a skin incision. You can see here on the right diagram the suture plicates the levator to the skin, theoretically making attachments and forming a crease.

In our patient, we see a nice lid crease on the right postoperatively, but if you look closely, it's not perfect. It's still slightly shorter than the other side, so you can see a good result, but less control than in an open blepharoplasty. Here is a patient who had a Vicryl suture blepharoplasty, and unfortunately the crease was lost on the left over time. Because of this, some surgeons prefer the continuous buried tarsal stitch using a permanent suture.

Here the height of the tarsus is measured and then marked. A small incision is made laterally to bury the knot, and then a continuous suture is passed laterally to medially, and then medially to laterally, and tied. We can see better crease control and an invisible dynamic crease on downgaze, but be careful with permanent sutures. They can extrude over time and cause corneal issues. The bottom line, though, is suture blepharoplasty is my go-to in younger Asian patients, as it appears more natural but has a downside of being potentially less permanent.

In our older patients with excess skin and fat, open or incisional blepharoplasty is the way to go. We can use this in younger patients to achieve better control, a more permanent lid crease, but the downside is a scar. Usually, a small strip of skin and orbicularis is removed, and then supratarsal fixation is performed. Surgery begins with a lid crease incision. Notice the lid crease is approximately five millimeters above the lash line. A skin flap is raised and then the septum opened to access the fat. In this patient, the patient had excess medial fat as well as central fat, which was debulked.

Next, a small strip of pretarsal orbicularis is removed to access the pretarsal tissues. This allows the lid crease to be formed, engaging the pretarsal tissues. This is a buried 6-0 Vicryl suture, which is placed from the pretarsal tissues, engaging the levator as well as the orbicularis of the new lid crease. Notice the suture is placed just underneath the lid crease. Next, this is placed medially as well as laterally. So, three sutures engaging the pretarsal tissues, levator, and then the orbicularis of the lid crease.

During skin closure in an Asian blepharoplasty, skin to skin is closed, and then skin to pretarsal tissue to skin. This alternates skin to skin and then skin to pretarsal to skin in order to form the lid crease further. This is performed until the lateral canthal angle, where skin-to-skin closure completes the closure of the rest of the incision.

Here is a patient post-incisional Asian blepharoplasty with supratarsal fixation in primary and downgaze, with a nice result. The patient was pleased and liked the more open look of her eyes with the crease formation. On the bottom left photo, you can still see she has an epicanthal fold. This was discussed with her preoperatively, but she did not want to have it addressed.

2) This brings us to point number two. Don't forget the epicanthal fold. We try to identify epicanthal folds preoperatively and discuss the scar associated with it. Usually, it's not needed unless a patient wants a parallel crease or has moderate to severe epicanthal folds. Sometimes a scar is not worth addressing the epicanthal fold. Here is a Z-epicanthoplasty, which works well but can leave a visible scar. I prefer an anchor epicanthoplasty if needed, or modified epicanthoplasty.

The epicanthal fold here is marked, and a point found where it resolves the epicanthal fold, point B. Then a flap is raised and the orbicularis is debulked underneath the flap, and then the skin sutured in place with multiple buried 6-0 Vicryl sutures. You can see on the bottom right the epicanthal fold is improved, but there can still be some irregularities of the medial canthal area after healing.

3) Number three, recognize ptosis and asymmetries. You don't necessarily have to fix it, but you should definitely point it out prior to surgery. For example, this patient had significant periorbital asymmetries. By recognizing she has a small right orbit, ptosis, and crowded eyebrows, we were able to combine ptosis surgery and endoscopic brow lift to create more symmetry between her tarsal platform show. Her eyes are now more symmetric, and she still appears Asian, retaining her ethnicity.

This patient had previous upper blepharoplasty by another surgeon and was unhappy due to the tarsal platform asymmetry. If you look closely, she has mild ptosis of the left upper lid and compensatory lid retraction on the right. Therefore, left upper eyelid ptosis surgery was performed. Notice, postoperatively, she has a slight Hering's phenomenon on the right, and the lid crease drops, therefore lengthening the lid crease. It's still high, and her eyes look a bit westernized, but she was pleased with and happy with the results.

With ptosis surgery, you do have to be careful. It is okay not to address ptosis. Also, remember the MRD1 is lower in Asians than Caucasians. If you are going to address ptosis, I would recommend posterior approach ptosis surgery and not levator advancement, as there can be more contour and height issues.

This patient has some right upper eyelid ptosis but isn't bothered by that. He does have a millimeter and a half of relative left upper eyelid ptosis. After correction, the lid height is good, and sometimes we can get a lid crease with ptosis surgery. If not, we can do lid crease formation later, which the patient was okay with. I do discuss this with them prior to this surgery, but I like to see if a lid crease will form.

Sometimes, in older patients, we can do both ptosis surgery and lid crease formation at the same time, but you do have to be careful, and there are a lot of moving parts that can affect tarsal platform show and brow height. In this patient, we predicted the brow height and had a nice result with improved MRD1 and lid crease formation. Notice the MRD1 is not four, but rather closer to three.

4) Number four, volume, volume, volume. Be cognizant of the aging Asian eyelid. Here is my mom aging over 50 years. At 22, on the left, she has a very low lid crease, full brows, and subcutaneous fat. With aging, she developed supraorbital hollows and a higher lid crease, mostly from loss of brow fat and subcutaneous fat. She also develops more rhytids and lower eyelid hollows, similar to Caucasians.

Similar findings can be seen in actress Lucy Liu over 20 years. You can notice supraorbital hollows, brow deflation, rhytids, but no lid crease formation. In these patients with fat loss, we want to fill the superior sulcus hollow with volume. Our preferred treatment is hyaluronic acid gel fillers, either diluted or not diluted, and there are a variety available.

It's important during injection to lift the brow so this area can be filled safely above the orbital rim. Here I like to use a cannula. A needle port is made for the cannula, and then the cannula is placed suborbicularis in the ROOF fat. This allows for nice placement and coverage. My other hand is used to feel the tip of the cannula so that I know where it is at all times, constantly moving the tip of the needle to avoid any vascular structures. Next, a Q-tip is used to contour on the orbital rim.

Be careful with this injection. Do not inject filler in the eye, and always know where the tip of the needle is at all times. Also, remember, the area is very vascular, with the supraorbital and supratrochlear arteries, and there is a risk of blindness. With my rabbit studies, we found retrobulbar hyaluronidase may not be effective, and neither is nitro paste. So please inject with caution in this area, and discuss this risk with your patients.

This is our patient when she was younger, and by filling in both superior sulcus hollows, we can efface the orbital rim, remove the worried look, and restore a more youthful configuration. Fat can also be used in select patients, but also still be very careful with this. You can not only have fat embolism causing blindness, but you can also have contour irregularities with the fat.

5) And finally, number five, be prepared. Asian patients can sometimes be challenging due to very high patient expectations and sometimes cultural barriers. Each has their ideals of beauty and have varying needs and goals. Some may have a particular crease they want, but their anatomy limits results. Some may have hypertrophic scarring or prolonged edema or redness. I tell all patients undergoing Asian blepharoplasty to expect edema and redness for at least three months postoperatively. On the upper right, you see a poor incision design as well as prolonged redness and scarring of the lateral canthus.

Below, the patient has volume issues. It's important to realize the superior sulcus hollowing that happens with most Asian patients as they age and try to preserve volume if possible. This patient also didn't have the medial fat addressed and so therefore has herniation and hollows. Sometimes we transpose the fat centrally to help with these volume issues.

And finally, remember, even with the perfect surgery, you can have an unhappy patient. Also, be careful with what you do. It is very difficult to fix complications, especially to lower the crease, lower the MRD1 after too much ptosis surgery. See the patient up top: her left upper eyelid is rounded and too high. This is from levator advancement surgery. You can also get a tethered ptosis, as seen in the patient on the lower right upper lid. She has scarring as well, and it is very difficult to revise these scars. Bottom line, it's best to avoid these complications rather than fix them.

So, in summary, when addressing Asian eyelids, keep in mind these five points. We should have a healthy respect for Asian eyelids, making sure we customize our treatment for the patient and consider and conserve their ethnicity. I hope this will help you in your approach to the Asian eyelid. Thank you for your attention.