Beauty is in the Eye of the Beholder. Asian Eyelid Surgery (San Jose, CA)
Asian aesthetics is a field in aesthetic (cosmetic) plastic surgery that focuses on understanding the anatomic differences between Asians and non-Asians and how that impacts the respective ethnic perspective of beauty. The plastic surgeon performs procedures to improve the aesthetic appearance of the patient while maintaining the patient’s ethnic identity and respecting the cultural norms of beauty. There are structural anatomic differences between different ethnic groups from the skin down to the bone. Nowhere is this more evident than the differences between the Asian upper eyelid and the Western upper eyelid. One procedure that epitomizes Asian aesthetics is the Asian eyelid surgery (blepharoplasty) or “double eyelid surgery.” The goal of the surgery is the creation of an upper eyelid fold or the accentuation and elevation of a fold that is already there (Figure 1).
The incidence of single eyelid surgery in the US is similar to Asia. About 50% of San Jose Asian eyelid surgery patients lack the upper eyelid crease commonly seen in the majority of Western upper eyelids (Figure 2). There are many reasons why patients wish to have Asian double eyelid surgery. For those with a single eyelid, de novo creation of a double eyelid is a personal cosmetic preference. Some women feel that have a double eyelid makes the eyes look bigger and more attractive. The double upper eyelid also aids in eye makeup application. Other patients have an existing double eyelid but the crease is too low or too weak. These patients like their double eyelid eyes but want an enhancement of their existing eyelids (Figure 3). The third category of patients have pre-existing asymmetries between the two eyes (one single and one double) (Figure 4). Patients with asymmetries just want to look balanced. Since it is impossible to convert a double to a single eyelid and most patients find their double eyelid to be more attractive, the symmetry procedure will convert the single to a double eyelid. Whichever of these reasons applies to you, Asian blepharoplasty (Asian double eyelid surgery) is the most common surgical procedure performed in Asia and San Jose. Asian eyelid surgery is also the most common Asian aesthetic surgery procedure in the United States.
There are anatomic differences between the Asian eyelid and the Western eyelid. The main anatomic differences are 1) levator dermal attachments or adhesions 2) retroseptal fat quantity and inferior displacement 3) orbicularis oculi muscular hypertrophy and 4) presence of medial epicanthal fold. Each of these components is evaluated during the patient consultation to determine which component(s) needs to be surgical addressed to give the patient the desired end result.
Levator dermal attachments
In the Western eyelid, the levator-tarsal apparatus and the upper eyelid skin are connected by levator-dermal attachments or adhesion planes. Upward displacement of the levator muscle during eye opening pulls the upper eyelid skin down, resulting in a fold. The result is a gliding of the inferior skin beneath the upper skin creating a double fold. In Western eyelid, the number of attachments is greater and the insertion is over a longer distance (including higher up along the eyelid). In the Asian eyelid, the insertions are less and over a shorter distance (lower on the eyelid) or absent all together resulting in a thin double eyelid crease or a single eyelid, respectively. These levator-dermal attachments are precisely what we are surgically re-creating when we perform the double suture technique (DST) for our San Jose Asian eyelid surgery (blepharoplasty) patients.
Retroseptal fat quantity and inferior displacement
For some patients of San Jose, Asian eyelid surgery is not just about creating a new levator-dermal attachment (aka skin crease). Candidates who are not candidates for the double suture (DST) often have “heavy” or “puffy” eyes. These patients require an “open” or incisional technique because of excess tissue that needs to be removed. One component of the excess soft tissue is from the retroseptal fat (Figure 5). Unlike in the Western patient’s eyelids, the retroseptal fat of the Asian patient’s eyelid can be more prominent. This is also accentuated by the fact that the septum inserts lower on the tarso-levator complex. Instead of being higher on the eyelid, the inferiorly displaced fat sits lowers and makes the eyelid appear puffy. Whether the puffy eyelid is due to excess fat, lower positioned fat or both, the surgical correction must be tailored to the anatomy of the patient.
Orbicularis oculi muscular hypertrophy
Similar to the retroseptal fat, the orbicularis oculi muscle of the Asian eyelid can also be hypertrophic (enlarged) contributing to a “puffy” upper eyelid. In order to achieve a clean and crisp upper eyelid crease, the excess tissue that sits between the levator muscle and skin needs to be debulked. This includes the inferiorly displaced retroseptal fat and the preseptal orbicularis oculi muscle. The orbicularis oculi muscle is a natural sphincter (circular) muscle that helps our eyes close and squint (Figure 6, above). In many Asian patients, the orbicularis muscle over the upper eyelid is thickened (Figure 6, below). Debulking of this muscle does not alter the function of the upper eyelid.
Medial epicanthal fold
Lastly, the medial epicanthal fold is the extra medial eyelid skin often seen in Asian patients (Figure 7). The degree of the medial epicanthal fold can vary from a mild (small) fold to a severe (large) fold. The excess skin fold covers the medial part of the eye and can give the eye a more narrowed or pointed appearance. Whereas lack of a medial epicanthal fold in the Western eyelid produces a parallel crease, presence of a medial epicanthal fold can result in a tapering of the eyelid crease at it approaches the nose (nasal taper). This is a personal aesthetic opinion, as many of our patients are not bothered by their epicanthal fold and find the nasally tapered crease pleasing. Many Asian models and movie stars have a nasal-tapered crease. Preservation of the epicanthal fold can be important to maintain a patient’s ethnic identity. Release of the epicanthal fold is often criticized as a “Westernizing” procedure. Many Asian patients do not want to look “Western” but rather want an improvement if their underlying aesthetic appearance while preserving their ethnic identity. Unlike the other blepharoplasty incisions that are nicely hidden in the upper eyelid crease, correction of the medial epicanthal fold (medial epicanthoplasty) requires placement of a surgical incision in the center part of the face in a visible area. Though the scar is small and fades over time, many patients are reluctant to have a potentially visible scar.
From Korea to Japan to Taiwan to San Jose, Asian eyelid surgery has arrived to Liu Plastic Surgery. Both Drs. Jerome and Tom Liu are passionate about Asian double eyelid surgery (Asian blepharoplasty) for their patients in the San Jose- Bay Area. Asian eyelid surgery begins with a thorough analysis of your eyelid to evaluate your underlying anatomy and determine which procedure is right for you. At Liu Plastic Surgery we believe successful aesthetic rejuvenation starts with listening to the patient’s aesthetic concerns and goals. Your visit starts with a consultation with one of our plastic surgeons in San Jose-Los Gatos who have advanced fellowship training in facial aesthetic procedures. Your plastic surgeon will listen to your concerns and analyze your face focusing on the facial anatomy that is causing the area of concern and providing you with an individualized aesthetic goal. The plastic surgeons at Liu Plastic Surgery will give you a thorough and honest assessment to determine if you are a patient who would benefit from Asian eyelid surgery and whether a suture or incision technique is best for you.
Contact Liu Plastic Surgery (San Jose – Los Gatos) at 408-418-0808 to discuss surgical your surgical options for Asian eyelid surgery.
This is a 29-year old San Jose-Bay area Asian eyelid surgery patient. She was born with a single eyelid. She did not like the shape of her eyes and had problems with makeup application. She wanted to have a double fold but wanted a small fold width for a more natural and subtle look. She was not a candidate for suture blepharoplasty (DST) because of her puffy upper eyelid (muscle hypertrophy and excess fat). Shown is her postop result after open incisional upper eyelid surgery.
This is a 26-year old San Francisco-Bay area Asian eyelid surgery patient. She has an existing double crease but it is narrow and low. She would like a higher and wider eyelid crease. She does not have a puffy upper eyelid and is a good candidate for double suture technique blepharoplasty (DST). Fold width is determined by the patient’s preference. Shown is her postoperative result after double suture technique blepharoplasty (DST).