Ординатура / Офтальмология / Английские материалы / Asian Blepharoplasty and the Eyelid Crease_Chen_2006

Fig. 3-1 Chinese written characters for ‘double eyelid (skin)’.

Fig. 3-2 Japanese Kanji characters for ‘single eyelid,’ (left) and ‘double (two) eyelid’ (right).

Fig. 3-3 Characters common to Chinese and Japanese for the procedure to construct an eyelid crease, or ‘double-eyelid procedure’.

As described in previous publications by the author,1–9 the crease may be asymmetric in its presentation, or be absent in one eye and present in the other. It may be continuous or segmented (fragmented).

Figure 3-4 shows the various configurations of the Asian eyelid.

Figure 3-5 shows an eyelid without a crease. There is mild degree of upper lid hooding, causing secondary downward rotation of the lashes. Figure 3-6 illustrates an eyelid with a distinctive crease. This is the parallel configuration. Figure 3-7 is an eyelid in which a portion of the crease has been obliterated. An eyelid with an incomplete or partial crease is shown in Figure 3-8. The crease originates in the medial canthus and medial upper lid fold (supracanthal web) and extends halfway across the upper lid. Multiple creases are illustrated in Figure 3-9, where two well-defined creases run parallel to each other. Figure 3-10 shows a minimal nasally tapered crease. The lateral third of the crease may be the same distance from the eyelash margin as the central third, or it may rise slightly to form

a laterally flared crease, in which the lateral third of the crease is further from the lash margin than the central third. A Caucasian upper lid crease is shown in Figure 3-11, where the central third of the crease is farthest from the lash margin.

In Asians with a continuous eyelid crease, the crease may be of the nasally tapering type (NTC) (a less desirable term is ‘inside’ fold) in which the crease converges toward the medial canthus, coming closer to the lashes as it reaches the medial canthal angle (Fig. 3-12A), or it may be a parallel crease (PC) (a less desirable term is ‘outside’ fold), in which the crease runs fairly parallel to the lash margin from the medial canthus to the lateral canthus (Fig. 3-12B).

In eyelids with a nasally tapered crease the crease may gently flare away from the lid margin as it approaches the lateral canthal region, forming a laterally flared crease (LTC) (Fig. 3-13). Another configuration is that the nasally tapering crease may run level to the eyelash margin from the central third of the eyelid laterally (Fig. 3-14).

Asians rarely have a lid crease that is semilunar in shape, as is common in Caucasians (see Figs. 3-4 and 2-5). In a semilunar crease each end of the crease is closer to the respective lid margin than the central portion of the crease. Having a semilunar crease is by far the most frequent complaint heard from Asian patients who have had blepharoplasty performed in the United States2 (Fig. 3-15). This crease is often too high, unnatural, and harsh (termed the ‘huh’ syndrome).

A high crease is one located 10–12mm from the ciliary margin. A high crease may result if a surgeon adheres to an empiric formula for the height of the lid crease, or uses techniques of supratarsal fixation in which a distance of 10mm or more is applied without regard to ethnicity. Either method results in a crease that looks excessively high on an Asian patient. To summarize, such a regimented approach is countereffective in Asian blepharoplasty for the following reasons:

•Asians are usually smaller in build; correspondingly, the upper tarsus measures only 6.5–8.5mm in height on average.

•The distance between the eyebrow and the upper lid margin is smaller on Asians than on Caucasians. A crease located 10–12mm from the lash margin would look much closer to the mid level of the upper lid than is natural (Fig. 3-16).

Not only should ethnicity be a factor in blepharoplasty, but also each individual’s features. When the crease is high, it is farther from the lid margin than the height of the tarsus, the surgically applied crease traverses thick dermis as it approaches the brow and is likely to be associated with hypertrophic scarring. The large distance between the lash margin and the crease also allows little camouflage by the upper eyelashes, and the crease is exposed to scrutiny. A crease is harsh when it

is overtly prominent, deep, and indurated with dermal reaction.

An unnatural crease describes a shape that is not aesthetically pleasing on the face of the person. The most frequent complaint is a semilunar crease. The overall impression of a crease positioned high and semilunar in shape is unnatural for Asians. Removal of an excessive amount of preaponeurotic fat also can cause an unnatural crease. When all the fat pads are removed from the preaponeurotic space, the result is a hollowed eye or ‘famined’ look that appears incongruous on the relatively flat face of an Asian2 (Fig. 3-

17). For Caucasians, the same complete excision of preaponeurotic fat pads used to be a necessary step in the performance of a total cosmetic blepharoplasty.

It is important to recognize that there is a high degree of variation in the anatomy of the upper eyelids of Asians. A common misconception is that all Asians are born without an upper lid crease. In fact, half the Asian population does have a natural crease. For each person, the shape and height of the crease and the relation of the crease to facial configuration should be part of the overall assessment before a cosmetic surgical procedure is performed.

References

1.Chen WPD. Asian blepharoplasty. Ophthalmol Plast Reconstruct Surg 1987;3:135–140.

2.Chen WPD. Review of Aguilar G. Complications of oriental blepharoplasty. In: Mauriello J, ed. Management and avoidance of complications of eyelid surgery. Vol. 3. Philadelphia: Field & Wood, 1994.

3.Chen WPD. Concept of triangular, rectangular and trapezoidal debulking of eyelid tissues: application in Asian blepharoplasty. Plast Reconstruct Surg 1996;97:212–218.

4.Chen WPD. Eyelid and eyelid skin diseases. In: Lee D, Higginbotham E, eds. Clinical guide to comprehensive ophthalmology. Stuttgart: Thieme, 1999: 137–182.

5.Chen WPD. Upper eyelid blepharoplasty in the Asian patient. In: Putterman AM, ed. Cosmetic oculoplastic surgery, 3rd edn. Philadelphia: WB Saunders, 1999: 101–111.

6.Chen WPD. Expert commentary on blepharoplasty and blepharoptosis surgery in Asians. In: Mauriello J, ed. Unfavorable results of eyelid and lacrimal surgery. Oxford: Butterworth–Heinemann, 2000: 68–71.

7.Chen WPD. Aesthetic eyelid surgery in Asians: an East–West view. Hong Kong J Ophthalmol 2000;3:27–31.

8.Chen WPD. Oculoplastic surgery – the essentials. Stuttgart: Thieme, 2001.

9.Chen WPD, Khan J, McCord C. Color atlas of cosmetic oculoplastic surgery. Oxford: Butterworth–Heinemann, 2004.