In Asians, the orbital septum inserts approximately 3 mm from the base of the eyelid margin, while in non-Asians, it attaches at a higher position, 8–10 mm from the margin. The reason the crease is lower and indistinct in Asians is the levator fibers do not interdigitate as well with the orbicularis muscle and skin as the intervening fat prevents it from doing so.

14.2.3 Orbital Fat

Just posterior to the orbital septum are the fat pads of the upper eyelid. Unlike the lower eyelid, which has three fat pads, the upper eyelid has two fat compartments consisting of a medial and central compartment. The lacrimal gland may prolapse in the upper eyelid and should not be mistaken as a fat pad. Mistaken excision of the gland can lead to dry eye complications. Removal of the central fat pad is rarely required in surgery, as it can create an iatrogenic hollowing postoperatively (A-frame deformity). The medial fat pad is more commonly seen to have mild prolapse and is often conservatively excised in surgery.

14.2.4 Levator Palpebrae Superioris

The main muscle responsible for the eyelid opening is the levator palpebrae superioris muscle, which is innervated by the oculomotor nerve. Mueller’s muscle, which lies posterior to the levator, anterior to the conjunctiva, and above the tarsus, is a smooth muscle responsible for 3–4 mm of eyelid opening. The levator muscle transitions to the aponeurosis at Whitnall’s ligament. The levator aponeurosis sends attachments to the tarsus and to the orbicularis muscle and overlying skin to form the eyelid crease. As stated previously, specific to Asians is a lower attachment of the orbital septum to the aponeurosis. This causes the orbital fat to ride lower in the lid thereby making the eyelid fuller, blunting the attachment of the aponeurosis to the skin, and reducing the crease prominence.

14.3Modern Management of the Upper Eyelid

Dermatochalasis is a significant contributor to the aging upper eyelid. The aged appearance is accentuated by volumetric depletion of fat and soft tissue beneath. In general, the trend in Asian upper blepharoplasty has moved away from the traditional aggressive removal of skin, fat, and muscle to a more conservative skin-only excision. The authors have also transitioned away from routine brow lifting. This is based on photo-documenting patients using current and past photographs. Often times, brows that appear to have fallen with age are noted to have the same or minimally changed position from youth. Accordingly, traditional eyelid

and brow surgery performed in isolation can alter a person’s identity in a fundamental and permanent way. Most young Asian women have a very low eyelid crease and relatively low brow position, but the shape and contour of that brow and eyelid are typically full. Traditional brow and eyelid surgical techniques rejuvenate the areas by extensive resection or lifting, which in turn ultimately increase the distance between the ciliary margin and the eyelid crease. Although a high and arched crease can exist naturally in the Caucasian race, it is generally quite rare to find in the Asian race. The authors believe that converting an Asian woman from a low crease to a high crease through browlift and subtractive eyelid surgery will alter the appearance in an unnatural way.

14.4The Youthful Asian Upper Eyelid and its Age-Related Changes

The youthful Asian upper eyelid has minimal skin excess. The superior orbital rim and infrabrow region appear soft and full. A smooth layer of subcutaneous and submuscular fat exists over the contour of the bony orbital rim and the lateral aspect of the eyelid is free of hooding. In the Asian eyelid, there are three general configurations of eyelid crease. These are characterized by the following:

•Upper eyelids without a crease or fold.

•A naturally present crease, which typically lays 3–5 mm above the eyelid margin.

•A surgically created crease.

Postsurgical creases may be in a naturally occurring or

elevated position. Management of each of these configurations needs to be considered by surgeons who perform Asian blepharoplasty.

During the aging process of Asian upper eyelids, volume depletion as well as progressive dermatochalasia can cause the skin to override the eyelid crease (if it exists). This process can shorten the pretarsal eyelid show (pretarsal skin or lid platform), or, in more severe cases, can lead to skin folding over the upper eyelid lash line. As the volume of the peribrow region diminishes, there is a descent of the lateral brow, further contributing to lateral hooding. The infrabrow volume loss results in skeletonization of the superior orbital rim. In certain cases, there may be mild prolapse of the medial fat pad.

14.5Strategies for the Aging Asian Eyelid

The Asian upper eyelid is remarkably varied. As a result, several findings need to be identified and considered prior to performing these procedures. The essential questions are as follows:

•How does one manage an Asian patient with or without a natural crease who wants to have eyelid and brow rejuvenation?

•How does one manage an Asian patient who already had previous eyelid crease formation?

This section will elaborate a strategy that combines both

cultural sensitivity and surgical judgment to approach an Asian patient for eyelid rejuvenation by classifying that individual into one of three categories: Asians with a natural eyelid crease, Asians without a crease, or Asians who have had an eyelid crease surgically fashioned in the past.

14.5.1 Asians with a Natural Crease

Although the surgical technique is exactly the same as that for a Caucasian patient, it should be noted that raising the visible eyelid crease height beyond 2–4 mm above the ciliary margin through reductive eyelid and brow surgery ultimately could render an Asian face unnatural in appearance. The “visible” eyelid crease is defined as the distance from the ciliary margin to the folded over upper-eyelid skin edge when the patient is viewed with open eyes and forward gaze. This typically corresponds to a height of 1–2 mm for a typical Asian eyelid. Conversely, the “surgical” eyelid crease refers to the point of fixation of the levator to the dermis, 5–6 mm from the ciliary margin. This will render a visible eyelid crease (after the skin eventually folds over the surgical crease) of 1–2 mm height above the lid margin. It is essential to maintain an eyelid crease position that is natural. This is the fundamental objective of every case. A strategy to maintain eyelid crease position is to avoid brow lifts in almost every case and to maintain or decrease eyelid position by using fat grafting in the upper eyelid and along the brow. Fat transfer to the upper eyelid/ brow complex will reduce the height of the visible eyelid crease (causes skin fold to lower), as opposed to traditional excisional blepharoplasty, which often elevates the position.

If the eyelid skin rests along the ciliary margin, it is recommended to remove a small amount (2–3 mm) of skin (but typically no fat) from the upper eyelid, in conjunction with fat grafting (if necessary) to maintain an appropriate visible eyelid crease position. If the visible eyelid crease is 1 mm or greater above the ciliary margin, removal of skin is unnecessary (and counterproductive), and fat transfer alone is used. If the visible crease is higher than 1–2 mm, additional fat can be used to lower the crease further. Traditionally, 1–2 mL of fat is transferred to the brow and upper eyelid depending on the degree of brow and upper eyelid deflation as well as crease position. Looking at a patient’s old photographs and discussing his or her desired changes should frame each aesthetic consultation.

14.5.2 Asians Without a Crease

already makes the eyes look narrower, so any brow and upper-eyelid deflation can lead to a worsening of the apparent palpebral fissure. Many surgeons simply decide on an arbitrary height at which to remove skin without reference to thinking about the crease. This is problematic for two reasons. First, arbitrary removal of skin without crease fixation can leave behind a visible scar (even if placed right above the ciliary margin) since there is no crease (with overhanging fold) to camouflage it. Second, the already narrow apparent palpebral fissure will not be significantly altered by skin removal without attention to the crease formation. Even if the patient has been accustomed to a narrow palpebral fissure throughout life, the patient expects a sufficient opening of the eyelid to have made the cosmetic endeavor worthwhile. This is difficult to achieve with simple skin removal. This is why fixating a crease is important. Often times, surgeons remove fat from the postseptal space, without crease fixation, with the thought that doing so will open the palpebral fissure. Although removal of eyelid fat without crease fixation can help debulk a prominent eyelid, it can be problematic. In this scenario, a lid crease can develop after surgery which is variable in position, complete or incomplete. This occurs because of unpredictable adhesion between the levator aponeurosis, muscle, and skin.

Two options should be presented to the patient when it comes to treating the Asian patient without a defined crease. One option is to create a crease. Making a crease opens up the eyelid shape enough to make an individual appear more “awake” or “open-eyed.” The full-incision method (see below) is ideal, allowing the dermatochalasia to be directly addressed. Patients must, however, recognize that this procedure will change their “look” since the eyelid will appear rounder in configuration. Additionally, patients must be able to handle a longer healing process associated with a procedure in which a crease is formed.

If the patient does not want a surgically formed crease, then fat grafting to the upper eyelid and brow alone, without skin removal, can be an alternative way (option two) of improving the aesthetics without changing one’s identity. Although the preseptal tissue is already full in both youth and adults in the Asian patient without a crease, converting an aging eyelid contour that is slightly concave to a more convex shape can bring back the look of a youthful eye. The patient must obviously understand the limitations in this approach.

14.5.3Asians with Prior Surgery for Supratarsal Crease Formation

Patients who do not have a natural crease present a much more complicated topic. Oftentimes, the absence of a fold

Asian patients who have a natural appearing but surgically created crease (not too high or overresected) can be treated with an approach similar to what has been described for