individuals with a natural eyelid crease. Unfortunately, for many Asians who have undergone double eyelid procedures, their crease was surgically created during a time in which “Westernization” procedures were in vogue, i.e., overzealous fat and skin removal were in fashion along with very high crease formation. These patients offer a difficult situation to address. Removing additional skin or elevating their brows can make their crease appear even more unnatural and should be avoided.

Interestingly, 20 years following a Westernization procedure, the visible crease height can approximate a “normal” or low position of ~1 or 2 mm with ongoing brow and eyelid deflation. These individuals can be identified in that their visible crease appears to be of a normal, low height but there is something unmistakably unnatural appearing about their eyelids. The reason for this unnatural appearance is that the thick brow skin (all that remains after excessive eyelid skin removal) falls over the surgical eyelid crease and creates a thickened upper eyelid appearance. Removing more skin or lifting the brow can unmask a poor prior result, making the eyes appear more unnatural. If the surgeon is uncertain whether the previously created surgical crease is too high, he or she can simply lift the brow skin during the consultation. For these patients who have had a “Westernized” eyelid, adding fat along the brow and upper-eyelid complex may improve the overall aesthetic appearance. Even though a “thick” upper eyelid can appear unnatural, adding fat to the brow complex can actually improve the appearance as it converts a concave structure (which is unnatural) to a more convex structure thereby camouflaging the thick-skin appearance.

14.6Eyelid Crease Formation

The primary goal of this technique is to create a natural appearing, eyelid crease. The desire to have a “double eyelid” is largely cultural, as this feature is considered attractive. To successfully perform this requires a comprehensive understanding of the natural eyelid crease shape as well as mastery of the surgical techniques required to fashion it.

Numerous techniques for Asian upper-eyelid blepharoplasty have been described in the literature, including suture ligation, external incision, and double suture twist (DST) methods [4, 5]. Mikamo [6] is thought to have published the first description of the suture ligation method in 1896. This was later elaborated on in a large series by Uchida [7]. The external incision method was described in 1929 when Maruo [8] reported both suture and incision techniques. It was not until 1961 that Pang [9] described what we now recognize as the partial-incision technique, with placement of fullthickness eyelid sutures to form an upper eyelid crease. It should be noted that during the era of Westernization upper

blepharoplasty, the focus was on creating a high supratarsal crease found in Caucasian eyes. It was the evolution of results of this era that led to the current philosophy of preserving ethnic characteristics. The current techniques can be broadly categorized into suture-based, partial-incision, and full-inci- sion techniques.

The suture ligation method is relatively noninvasive, with limited postoperative swelling and reversibility of the procedure by removing the sutures. However, crease asymmetry, cyst formation, and crease attenuation requiring full revision can occur. The disappearance of upper eyelid crease has been found to be higher in those with thicker skin of excess subcutaneous fat. The partial-incision method often requires multiple stab incision or needle passes through the skin to achieve the exposure and suture anchoring required to create an upper eyelid crease [5]. Again, crease attenuation can be problematic. The full-incision technique is favored because of its (1) relative permanent results compared with other methods, (2) independence from buried sutures to maintain the crease formation, (3) wide exposure to facilitate identification of structures, and (4) ability to manage dermatochalasis in the aging eyelid. The major disadvantage of the full-incision method is the 1–2-week recovery period and persistent swelling, which can remain for months if not a full year. Scarring has proven to be insignificant if the tissues near the epicanthus are avoided.

14.6.1Preoperative Eye Evaluation and Crease Positioning

The patients’ lids are evaluated for the presence or absence of a natural crease, and if asymmetries exist between the eyelids. How the fold terminates medially is then determined. Although several variations have been described, they essentially fall into one of two categories: inside fold or outside fold. This refers to the termination of the medial portion of the incision lateral to or medial to the epicanthus, respectively. The shape of the crease is then determined based on the preoperative consultation with the patient. The shape can be parallel to the normal anatomic shape of the eye (rounded) or slightly flared laterally (oval). The authors’ preference is to pair an inside fold with a flared, oval configuration (Fig. 14.3).

14.6.2 Surgical Marking

The shape and configuration of the crease determined preoperatively are used as a guide to patient marking during surgery. The patient should be placed in a supine position, and the upper eyelid skin is held taut so that the eyelashes are slightly everted. Using calipers, the crease is demarcated