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Asian blepharoplasty
Operative Strategies
Asian Blepharoplasty
The author describes blepharoplasty and related techniques to achieve fresh, youthful, and attractive eyes in the Asian patient. Emphasis is on maintaining ethnic integrity and recognizing the need for appropriate adjunctive procedures. (Aesthetic Surg J 2002;22:558-568.)
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he goal of blepharoplasty in Asians, with or without related procedures, is fresh, youthful, and attractive eyes that retain their ethnic appearance. Sensitivity to Asian anatomic uniqueness and appreciation of Asian aesthetic goals are intrinsic to success.1
Asian eyelids are characterized by shallow orbits; minimally or noncantilevered supraorbital ridges; and skin with thick dermis and abundant subcutaneous, preseptal, and orbital fat making eyelids less inclined to fold, wrinkle, stretch, or attenuate. Even more important is the common absence of visible lid folds from either nonexistent or low and functionally inadequate insertions of the aponeurosis and its extensions into the orbicularis or dermis of the upper lid skin. The result is that without major assistance from the frontalis muscle many lids fail to invaginate sufficiently to prevent upper lid overhang from obstructing vision. Exaggerated frontalis activity commonly results in eyebrows that are held in an unusually high posture, even in very young Asians. Because of this characteristic, a simple sketch of a child with high eyebrows identifies the child as Asian (Figure 1). Half of all Asian teenagers show at least some lid fold, crease, or double eyelid characteristics. Double eye is commonly used among Asians to denote an upper eyelid with a dominant crease in its lower aspect and some visible pretarsal or sublid crease skin, if only in the lateral eyelid portion (Figure 2). Sometimes there is a welldefined lid crease on one side with no visible crease on the other side. Most Asians prefer a distinct lid crease 1 to 4 mm above
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the lash line and extending slightly beyond the lateral canthus (Figure 2, A). The crease echoes the pleasant upper lid margin curvature, providing the illusion of a larger, longer eye. The distant, inaccessible, or, even, Robert S. Flowers, MD, sinister aura conveyed by Honolulu, HI, is a boardthe narrow-fissured aperture certified plastic surgeon and an ASAPS member. which may accompany single or non-invaginating Asian eyelids (Figure 2, B) is considered less desirable than the more open and accessible appearance provided by the double eye. However, this double eye must resemble that which occurs naturally in Asians.
Naturally Occurring Lid Folds In the young Asian, the fold typically parallels the lid margin in the outer two-thirds of the eyelid, closing toward the eyelid margin as it proceeds medially (Figure 3). Sometimes, in Asians with a prominent nasal dorsum, and occasionally in those without, there may be no epicanthal canopy or fold at all. In Western and other non-Asian eyes, lid folds commonly parallel lid margins all the way across the eyelid, sometimes moving away from the lid margins as they progress towards the nose, exposing more pretarsal skin. This is quite distinct from the Asian eye, but sometimes the “crease,” if close to the lid margin, will parallel it (Figure 4, A). The only time we see Asian lids with taller medial pretarsal segments is when there is a natural lid crease and pretarsal component exposed by a fully activated frontalis muscle (Figure 4, B). Eventually, the muscle’s medially-inserted fibers will no longer be successful at clearing the progressive lateral overhang. This compromises the double Asian lid by laterally diminishing or concealing the pretarsal skin leaving a less Asian, unaesthetic, and older appearance (Figure 5). Manual
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elevation of the left brow demonstrates that correction of this problem is not an eyelid operation, which would only worsen the condition, but restoration of brow position.
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Correcting Asymmetry
Figures 1-4: Illustrations by Robert S. Flowers, MD
Figure 1. A, This child has no clear ethnicity. B, High eyebrow position identifies the child as Asian.
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I modify each operation to reduce any illusion of asymmetry; most significant is the amount of globe exposed. Also important is the height of the upper lid pretarsal skin segment. Inequality of this segment, whether caused by asymmetric brow posture or eyelid ptosis or retraction (ptosis increases pretarsal height, while retraction decreases it), often becomes apparent only after Asian blepharoplasty or a frontal lift exposes the pretarsal eyelid, which had previously been concealed by overhang (Figure 6). The next most significant asymmetry may be difference in brow position, and the last is inequality of lateral canthal and lower lid postures.
C Figure 2. A, Naturally-occurring Asian double eyelid. B, Asian lid with no lid fold, termed single eyelid.C, Although not visible, a small fold commonly exists under the overhanging lid tissue.
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Figure 3. The crease in natural Asian lids may (A) fall just above the epicanthal canopy or fold, (B) fuse with the epicanthus at the most medial aspect of the aperture, or (C) descend beneath it. Sometimes the crease and the pretarsal skin beneath it are visible only in the most lateral, or central-lateral, part of the eyelid.
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Figure 4. A, Natural folds, or creases, sometimes parallel the lid margin all the way across the eyelid, but only when they lie close to it. B, Occasionally, we see more pretarsal skin medially. (See description with Figure 5.)
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Several simple maneuvers help with pretarsal height asymmetry and brow asymmetry. My underlying premise is that symmetry of the pretarsal lid segments (lash to lid crease distance) is much more important than symmetry of the lid crease to brow distance. Brow asymmetry and unilateral lid ptosis (or retraction) are factors in most upper lid asymmetry. When one brow is lower, as is usual, juxta-brow and eyelid tissue on the lower side drop to overhang that segment. To achieve pretarsal symmetry without a brow positioning procedure, remove a little more skin and muscle from the lower brow side and design the pretarsal skin component a little taller to attach higher into the anterior tarsus and/or aponeurosis. If a frontal lift is planned, add a maximal superolateral scalp resection on the lower side, and reduce scalp resection or advancement on the higher side by 4.5 to 5 times the millimeter amount of preexisting brow position difference measured and backed off from the point at which the same advancement force is applied to the second side of the scalp as was applied to the first. I resect nothing from the central scalp on the higher side but remove 2.5 times the preexisting central medial brow difference on the lower side. This markedly improves positional brow symmetry. If the low side remains somewhat lower, then compensate for pretarsal asymmetry with more modest applications of increased skin and muscle excision and increased pretarsal skin height (Figure 7).
Epicanthal Folds The next step is to decide whether to modify the epicanthal
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Figure 5. Age-compromised Asian lid contour is demonstrated. In most people the frontalis muscle inserts preferentially into the medial aspect of the eyebrow. This means the muscle is less effective at raising the lateral brow than the medial brow. The overhang that results restricts vision and stimulates frontalis muscle activation. This exposes crease and pretarsal skin medially, but incompletely corrects the lateral overhang. A, Demonstrates how this compromises Asian lid aesthetics. B, A good lateral emphasis frontal lift, (performed manually for demonstration) clears the lateral overhang which cancels the need for constant frontalis activation. Now the medial brow can drop to a normal resting level. Remember that raising the lateral brow usually causes an elevated medial brow to drop.
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Figure 6. Demonstrates pretarsal asymmetry. A, Preoperative view of a 20-year-old woman shows a lower right brow, which would predispose to a smaller pretarsal segment on that side after a symmetrical lid fold procedure. Leaving a 2-mm higher pretarsal segment and removing 1.5 mm more skin and 1 mm more muscle on the lower brow side actually overdid my preemptive plan to prevent the right side from becoming smaller. B, Postoperative view after 1 month shows early overcompensation for brow asymmetry, which I expect to correct. Note the drop in compensated brow elevation that commonly follows blepharoplasty.
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Figure 7. A, Preoperative view of a 26-year-old woman with significant brow and lid asymmetry. B, Postoperative view 1 year after an asymmetrical coronal lift, including a small 4-mm right upper lid skin excision taken from just above her natural lid crease. She also underwent extended canthopexy and malar lift.
folds. My indications for the epicanthoplasty are (1) prominent folds that create even the slightest hint of telecanthus or internal strabismus, (2) an epicanthus inversus with the free canopy border turning laterally onto the lower eyelid (Figure 8, A), (3) a lid crease that dives beneath the epicanthal canopy as it moves medially, and (4) little to no epicanthal canopy in Asian women, 45 years or older, with abundant loose skin around the inner canthus. Figure 8 demonstrates the preferred technique, my modification of the Uchida medial epicanthoplasty.2 I keep the W limb dimensions as tiny as possible, from 1.5 to 2 mm to as long as 3.5 to 4 mm for unusually large epicanthi. I make sure that the upper limb of the W is always well above the medial extent of the upper
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lid incision to avoid a scar contracture recreating the epicanthus.
Frontal Lifts Repositioning the brow with a frontal lift procedure rejuvenates appearance, emphasizing or reemphasizing the hidden natural lid creases or folds and preventing the suggestion of surgical alteration.3 I routinely use this procedure in patients 35 years or older to restore youthful anatomy or limit the profound brow drop that commonly occurs after Asian blepharoplasty (Figure 9). A frontal lift may also benefit 20-year-olds or teenagers with profoundly low resting eyebrow levels that are compensated for by frontalis brow elevation.4
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Illustration by Robert S. Flowers, MD
Figure 8. Demonstrates my modification of the Uchida medial epicanthoplasty: A, Mark the central point of the W 0.5 to 1 mm lateral to the desired medial extent of the eye fissure or aperture, at the inner canthus. B, Draw the W, varying in size with the prominence of the epicanthal fold. C, Excise the 2 triangles together with a 1- to 3-mm skin bridge connecting them. D, Extend the defect with a precise cut directed down toward the medial canthus. E, Suture the angles created into the wings of the W with 7 tiny taper needle sutures. Keeping the upper limb of the W well above the medial extension of the lid-fold incision avoids a deforming band of contracture from recreating an epicanthus and also avoids an overly high medial extension of the lid crease. Sometimes muscle and fibrous tissues contribute to the epicanthal fold and require release before closure. Sometimes the triangular flaps have to be further trimmed or mobilized. Patients who have undergone medial epicanthoplasty can be seen in Figures 6, 7, and 16.
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Figure 9. A, Preoperative view of a 56-year-old woman with brow ptosis that is compensated for with marked frontalis activity. B, Postoperative view soon after Asian blepharoplasty. The patient refused to undergo frontal lift to prevent profound and inevitable brow posture drop after blepharoplasty. She is now planning the initially recommended frontal lift now that she has seen her “high” eyebrow drop. Observing a patient with eyes closed and brows relaxed, you can determine the resting brow level, which the patient’s brow will assume after lid overhang and visual obstruction are eliminated.
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Figure 10. A, Preoperative view of a 45-year-old woman. B, Postoperative view after a coronal lift with corrugator resection and medial epicanthoplasty.
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Figure 11. A, Preoperative view of a 44-year-old woman with brow and lid asymmetry and deep lid hollows. B, Postoperative view 1 year after asymmetrical frontal lift combined with extended 2-layered tendon-into-bone and bicularis muscle canthopexy-malar lift. Note the lid and brow symmetry and, especially, the correction of the hollow upper lids by lower-lid tightening.
Illustration by William M. Winn, Atlanta, GA.
Figure 12. Demonstrates the wire paper clip method for precise planning and determination of upper lid skin resection. I either fix the brow manually to the position I predict it will assume after an accompanying brow lift, or, for isolated Asian blepharoplasty, I forcefully (if necessary) maintain the brow in its relaxed, eye-closed resting posture while invaginating the lid with the paper clip to the planned tarsal fixation level of the pretarsal segment (designated X in Figure 13). For another, perhaps even more effective way to determine the amount of skin resection, manually elevate the opposite brow without doing so on the wire clip invagination side. With this manipulation, bilateral unobstructed vision should be possible with complete frontalis muscle relaxation, sending the eyebrow on the wire clip side to its absolute resting position for precise eyelid measurement according to Figure 13.
The key to success in frontal lifting is resecting or advancing the superolateral portions of the scalp flap with little to nothing removed or advanced centrally except for what has been recommended to correct brow asymmetry. Figure 10 demonstrates the results of a coronal lift and a small medial epicanthoplasty without a blepharoplasty or lid-fold procedure. However, isolated
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frontal lifts tend to increase the visibility of hollowed out upper lids. Consider diminishing the hollowed effect by also performing a canthopexy midface lift to tighten the lax lower lid structures, adding fullness to the upper lid (Figure 11). Cautious lipoinjection along the inferior orbital rim may also be helpful according to information I received from Dr. Sydney Coleman in 1995.
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D Figure 13. I measure how much skin overhang to remove (Z), to attain (Y), the desired amount of visible pretarsal skin. I double the length of Z, and I add 1.5 mm for the caudal bend, depending on skin thickness, to arrive at the amount of skin to be removed at that point on the lid. This exercise may be repeated at 2 or more points along the lid. X represents pretarsal height. If a frontal lift is to accompany, I assess the skin in this same way, but with the measured lid’s corresponding eyebrow held in my “best guess” estimate of where the “post lift” brow will reside in 6 months.
Creating Lid Folds With an Open Method There are 2 basic techniques for surgical lid fold creation: the open anchor or invagination blepharoplasty and the closed suture method. Both procedures usually generate a profound drop in the resting eyebrow posture (Figure 9). Figures 12 and 13 demonstrate how I plan the open anchor method, popular in both America and Asia, that I developed in 1970 and have been using since 1972 on most Asian patients.5 The procedure remains the same, but I have shortened the vertical height of the pretarsal skin segment. To precisely target the amount of eyelid skin, if any, that needs removal, I either raise the eyebrow manually to its predicted long term resting position, for blepharoplasty with an accompanying eyebrow lift, or for an isolated Asian upper blepharoplasty, I secure it downward, with manual pressure if needed, to the brow’s eye-closed relaxed frontalis posture while invaginating the corresponding eyelid with a wire paper clip, contoured just
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E
Figures 13-14: Illustrations by Robert S. Flowers, MD
Figure 14. A, In the operating room, turn the lid over and measure the tarsus. B, With the skin under uniform traction, mark the incision, or the lower margin of the skin excision with a Jameson caliper: 8 to 9 mm above the lashes for a 4-mm–tall pretarsal segment, 8 mm for a 2.5- to 3-mm segment, and 7 mm for a 1.5- to 2-mm pretarsal segment. The 2 mm added by including the lashes and lid margin compensate for the tightly stretched skin and the inward curvature necessary to reach the anterior tarsus. C, Mark the upper border of skin excision on the basis of information from Figures 12 and 13. D, Skin excision rarely extends beyond the orbital rim and the actual lid creasing. E, Next, remove a sliver of orbicularis bordering the pretarsal skin flap. I never tent this up during excision for fear of transecting aponeurosis.
for that purpose (Figure 12). Position the curved wire on the upper lid surface at the level of the desired crease or lid fold. With the eye open, gently invaginate the skin to that level so that the natural open-eye position of the eyelid margin is not raised. Then measure how much overhang must be reduced to expose the desired height of pretarsal skin (Figure 13). Take whatever that quantity is in millimeters, multiply it by 2, and add 1 to 1.5 mm to compensate for the caudal “bend” in the overhanging eyelid. This indicates the amount of skin to remove. Assessing it at 2 or more points ensures precise removal all across the lid. Another effective method for determining the exact amount of skin to be resected in isolated Asian blepharo-
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Figures 15-16: Illustrations by William M. Winn
Figure 15. (A-F) A, Because the sling of septum and aponeurosis that houses the orbital fat descends lowest laterally, that is the point where the orbital septum is most safely entered and the sling opened. Slight pressure on the globe helps identify the orbital fat bulge, and its characteristic appearance indicates the correct space. B, Cross-section of the septoaponeurotic sling, which houses the orbital fat. C, This step requires an understanding of the anatomy of the “sling” in order to avoid accidental sectioning of the aponeurosis. After entering the septum, the scissors must be angled cephalad, cutting from lateral to medial. Note that the caudal margin of this sling parallels the lid margin of the open eye in the lateral two-thirds of the lid. D, At the junction of the lateral two-thirds and medial third of the lid, I change to a slightly caudal angulation, continuing the cut through the superficial slip of the septum, across the lid towards the medial canthus. This separates septum from aponeurosis across the lid without injuring key structures. E, F, With the pretarsal skin flap turned downward over my finger, I transect the aponeurosis down to the tarsus with scissors sliding along the tarsus surface just above the level of the lash bulbs. There are multiple layers to cut through before the bare tarsus emerges. I remove the filmy pretarsal connective tissue for better fixation. In Asians, expect more pretarsal fatty tissue, especially over the medial tarsus. Attached to the pretarsal skin flap there will be residual connective tissue. Remove it and debulk pretarsal orbicularis muscle, leaving less tissue to become postoperatively edematous. This encourages better fixation and a flat smooth somewhat stylized pretarsal skin surface.
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Figure 15. (G-J) G, Demonstrates how I attach the dermis of the pretarsal skin flap to the anterior superior aspect of the tarsus and to the free edge of the aponeurosis, or into its septoaponeurotic extension. Placement of this absorbable suture into the anterior surface of the tarsus at a sufficient height helps smooth out the pretarsal skin, but not evert the lashes. H, Cross-section showing dermis-aponeurosis-tarsus closure with 6-0 absorbable suture and buried knot. I, Laterally, where the tarsus begins to dwindle in height, the suture(s) join only the aponeurosis to the dermis. J, Skin closure incorporates the edge of the aponeurosis into the skin repair across the lid.
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Figure 16. A, Preoperative view of a 26-year-old woman who desires Asian blepharoplasty. B, Postoperative view 6 years later demonstrates that her “double eyes” create a nice aesthetic balance.
plasty is to manually elevate the brow on the side opposite to the wire clip, leaving the brow undisturbed on the wire clip side. This manipulation allows bilateral unobstructed vision with complete frontalis muscle relaxation, which frees the wire-invaginated side’s eyebrow to assume its absolute resting posture for precise lid skin measurement, as depicted in Figure 13. To start the operation, turn the lid over and measure the height of the tarsus (Figure 14). In Asians it is usually 9.5 to 10 mm, but may be as short as 7 mm. The goal is a lid fold that defines a pretarsal skin segment with a height of 1.5 to 4 mm. To achieve a 4-mm height, I incise the stretched skin 8 to 9 mm above the lash line. To achieve a 2.5- to 3.5-mm height, the incision is 8 mm above the lash line, and for 1.5 to 2 mm, 7 mm above the lash line. The smaller measurements leave little room for subsequent brow drop. Figure 14, B and C, demonstrates the initial steps. I am always cautious to open the septum in a way that preserves maximum aponeurosis length (Figure 15, A to D), or at least to preserve the septoaponeurotic extension,6 to assure a proper connection without creating lid retraction. Prominent eyes tend to predispose patients to lateral upper lid retraction and, unfortunately, prominent eyes frequently accompany shallow Asian orbits. Such patients are good candidates for a “closed” repair.5 For my actual anchor-invagination technique, after sectioning the pretarsal extension of the aponeurosis as low as possible (Figure 15, E and F) I use a 6-0 absorbable suture to create a union between skin, tarsus, and aponeurosis (Figure 15, D to H). The tarsal attachment (Figure 15, G) adds an extra secure anchor that also prevents lash eversion, which is all too common after lid fold procedures. The dermal connection to the aponeurosis keeps the pretarsal skin taut. Laterally, where the tarsus loses vertical height, the aponeurosis is attached only
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E Illustration by Robert S. Flowers, MD
Figure 17. Demonstrates the closed technique commonly used in Asia for lid surgery in those without fat excess or significant skin redundancy and heavy eyelid skin and tissues. A, Locate and define the top of the tarsus. B, Delineate the cephalad margin of tarsus on the skin. C, Tiny incisions will allow knots to bury deep beneath skin. D, Nonabsorbable sutures, placed through the lid, run subconjunctivally on the deep side of the upper tarsus, and exit and travel subdermally to create a nice lid fold. Large external incisions are not necessary. E, Sutures viewed from the underside of eyelid. This technique is especially useful when combined with frontal lifting.
to the dermis of the pretarsal skin flap (Figure 15, I), similar to the basic technique proposed by Dr. Fernandez in 1960.7 The skin closure incorporates the edge of aponeurosis into the skin repair (Figure 15, J). Figure 16 demonstrates the results of this procedure. Although this procedure has not failed in my hands, some results have become obscured by brow descent as patients age. In
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Figure 18. A, Preoperative view of an 85-year-old woman with lid overhang obstructing vision in spite of maximum frontalis muscle activation. B, Postoperative view several days after skin excision blepharoplasty positioned just above the lashes. She now has clear, unobstructed vision and a refreshed appearance without major change in features.
those patients I have used a frontal lift, often combined with a restoration canthopexy extended to include midface lifting.
Creating Lid Folds With a Closed (Suture) Method Occasionally, the closed, or suture, method works superbly well, especially for patients with very thin eyelids with minimal fat and for patients with prominent eyes. The suture is usually placed at the top of the tarsus; however, it can be made 2-to-3 mm lower, in which case the suture transgresses the tarsus itself (Figure 17). In so doing, the permanent buried suture runs a risk of irritating the cornea. Fortunately, it usually develops a trough that prevents corneal irritation. A suture within the substance of the tarsus could also contribute to chalazion. Other problems with closed repair include lack of longevity and no chance to reduce tissue and fat.
even in the mid-lid area. With extreme skin redundancy, in which maximal brow elevation fails to clear visual obstruction, simple skin or skin-muscle reduction helps tremendously (Figure 18). However, these excisions result in lines of dermal weakness that leave unanticipated lid creases, even in excisions next to the lashes. Good results in Asian blepharoplasty flow from a balanced use of eyelid procedures combined with, or replaced by frontal lifts, often with tendon and muscle extended canthopexy, midface lifts, and lower blepharoplasty. Tunnel vision focus on lid-fold creating procedures for Asian eyelids is as inappropriate as it is disappointing. ■ Reprint requests: Robert S. Flowers, MD, 677 Ala Moana Blvd., Suite 1011, Honolulu, HI 96813. Copyright © 2002 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/2002/$35.00 + 0 70/1/130138 doi:10.1067/maj.2002.130138
Simple Skin Excision in Asian Upper Lids Frequently, surgery is not required on the upper lids. Progressive lid overhang resulting from aging commonly responds well to frontal lift but sometimes excess remains or subsequently appears. With aging, maximum brow elevation is sometimes inadequate to clear lid overhang and visual obstruction. In other cases, such as a hollow lid with redundancy but no fold, or a lid with a well defined natural or surgically-created lid fold, simple skin or skin-muscle excision is sometimes a good choice. A minimal excision just above the skin crease or surgical scar frequently solves the overhang. People without folds, who do not desire them, may have too much overhang (pseudo blepharoptosis) to correct with frontal lift alone. In these patients, excess skin may be removed just above the lashes or, with older patients,
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References 1. Flowers RS. The art of eyelid and orbital aesthetics: multi-ethnic considerations. Clin Plast Surg 1987;14:703-704 2. Uchida J. Cosmetic surgery of the eye. In: Handbook of Plastic Surgery. Tokyo:Nankado, 1969:175. 3. Flowers RS. Frontal lifts as the key to periorbital aesthetics. Presented at the Asian sectional meeting of the International Confederation of Plastic and Reconstructive Surgeons; Tokyo; 1982. 4. Flowers RS. Postgraduate courses on Asian blepharoplasty, blepharoplasty with frontal lifts, and coronocanthopexy with midface lifting at annual meetings of American Society of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, and International Society of Aesthetic Plastic Surgery from 1984 to 2001. CD-ROM course syllabus for year 2001. 5. Anchor blepharoplasty. Presented by Robert S. Flowers, MD, at the Pan Pacific Surgical Association Congress in Plastic and Reconstructive Surgery in 1972, and presented to the Annual meeting of the American Association of Plastic Surgeons, New Orleans, 1974. 6. Flowers RS. Upper blepharoplasty by eyelid invagination: anchor blepharoplasty. Clin Plast Surg 1993;20:193-207.
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7. Fernandez LR. Double eyelid operation on the Oriental in Hawaii. Plast Reconstr Surg 1960;25:257.
Flowers RS. Blepharoplasty. In: Courtiss E, editor. Male aesthetic surgery. St Louis: Mosby; 1981. p. 207-239. Flowers RS. Cosmetic surgery in the non-Caucasian. Honolulu: Peninsula Press; 1978.
Bibliography
Flowers RS. Anchor blepharoplasty. Transactions of the Sixth International Congress of the International Confederation for Plastic and Reconstructive Surgeons. Paris:1975. p. 470-471.
Flowers RS, Duval C. Blepharoplasty and periorbital aesthetic surgery. In: Aston S, Beasley R, Thorne C, editors. Grabb and Smith plastic surgery. Philadelphia: Lippincott-Raven; 1997.
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Volume 22, Number 6
Asian Blepharoplasty
The author describes blepharoplasty and related techniques to achieve fresh, youthful, and attractive eyes in the Asian patient. Emphasis is on maintaining ethnic integrity and recognizing the need for appropriate adjunctive procedures. (Aesthetic Surg J 2002;22:558-568.)
T
he goal of blepharoplasty in Asians, with or without related procedures, is fresh, youthful, and attractive eyes that retain their ethnic appearance. Sensitivity to Asian anatomic uniqueness and appreciation of Asian aesthetic goals are intrinsic to success.1
Asian eyelids are characterized by shallow orbits; minimally or noncantilevered supraorbital ridges; and skin with thick dermis and abundant subcutaneous, preseptal, and orbital fat making eyelids less inclined to fold, wrinkle, stretch, or attenuate. Even more important is the common absence of visible lid folds from either nonexistent or low and functionally inadequate insertions of the aponeurosis and its extensions into the orbicularis or dermis of the upper lid skin. The result is that without major assistance from the frontalis muscle many lids fail to invaginate sufficiently to prevent upper lid overhang from obstructing vision. Exaggerated frontalis activity commonly results in eyebrows that are held in an unusually high posture, even in very young Asians. Because of this characteristic, a simple sketch of a child with high eyebrows identifies the child as Asian (Figure 1). Half of all Asian teenagers show at least some lid fold, crease, or double eyelid characteristics. Double eye is commonly used among Asians to denote an upper eyelid with a dominant crease in its lower aspect and some visible pretarsal or sublid crease skin, if only in the lateral eyelid portion (Figure 2). Sometimes there is a welldefined lid crease on one side with no visible crease on the other side. Most Asians prefer a distinct lid crease 1 to 4 mm above
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the lash line and extending slightly beyond the lateral canthus (Figure 2, A). The crease echoes the pleasant upper lid margin curvature, providing the illusion of a larger, longer eye. The distant, inaccessible, or, even, Robert S. Flowers, MD, sinister aura conveyed by Honolulu, HI, is a boardthe narrow-fissured aperture certified plastic surgeon and an ASAPS member. which may accompany single or non-invaginating Asian eyelids (Figure 2, B) is considered less desirable than the more open and accessible appearance provided by the double eye. However, this double eye must resemble that which occurs naturally in Asians.
Naturally Occurring Lid Folds In the young Asian, the fold typically parallels the lid margin in the outer two-thirds of the eyelid, closing toward the eyelid margin as it proceeds medially (Figure 3). Sometimes, in Asians with a prominent nasal dorsum, and occasionally in those without, there may be no epicanthal canopy or fold at all. In Western and other non-Asian eyes, lid folds commonly parallel lid margins all the way across the eyelid, sometimes moving away from the lid margins as they progress towards the nose, exposing more pretarsal skin. This is quite distinct from the Asian eye, but sometimes the “crease,” if close to the lid margin, will parallel it (Figure 4, A). The only time we see Asian lids with taller medial pretarsal segments is when there is a natural lid crease and pretarsal component exposed by a fully activated frontalis muscle (Figure 4, B). Eventually, the muscle’s medially-inserted fibers will no longer be successful at clearing the progressive lateral overhang. This compromises the double Asian lid by laterally diminishing or concealing the pretarsal skin leaving a less Asian, unaesthetic, and older appearance (Figure 5). Manual
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elevation of the left brow demonstrates that correction of this problem is not an eyelid operation, which would only worsen the condition, but restoration of brow position.
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Correcting Asymmetry
Figures 1-4: Illustrations by Robert S. Flowers, MD
Figure 1. A, This child has no clear ethnicity. B, High eyebrow position identifies the child as Asian.
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I modify each operation to reduce any illusion of asymmetry; most significant is the amount of globe exposed. Also important is the height of the upper lid pretarsal skin segment. Inequality of this segment, whether caused by asymmetric brow posture or eyelid ptosis or retraction (ptosis increases pretarsal height, while retraction decreases it), often becomes apparent only after Asian blepharoplasty or a frontal lift exposes the pretarsal eyelid, which had previously been concealed by overhang (Figure 6). The next most significant asymmetry may be difference in brow position, and the last is inequality of lateral canthal and lower lid postures.
C Figure 2. A, Naturally-occurring Asian double eyelid. B, Asian lid with no lid fold, termed single eyelid.C, Although not visible, a small fold commonly exists under the overhanging lid tissue.
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Figure 3. The crease in natural Asian lids may (A) fall just above the epicanthal canopy or fold, (B) fuse with the epicanthus at the most medial aspect of the aperture, or (C) descend beneath it. Sometimes the crease and the pretarsal skin beneath it are visible only in the most lateral, or central-lateral, part of the eyelid.
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Figure 4. A, Natural folds, or creases, sometimes parallel the lid margin all the way across the eyelid, but only when they lie close to it. B, Occasionally, we see more pretarsal skin medially. (See description with Figure 5.)
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Several simple maneuvers help with pretarsal height asymmetry and brow asymmetry. My underlying premise is that symmetry of the pretarsal lid segments (lash to lid crease distance) is much more important than symmetry of the lid crease to brow distance. Brow asymmetry and unilateral lid ptosis (or retraction) are factors in most upper lid asymmetry. When one brow is lower, as is usual, juxta-brow and eyelid tissue on the lower side drop to overhang that segment. To achieve pretarsal symmetry without a brow positioning procedure, remove a little more skin and muscle from the lower brow side and design the pretarsal skin component a little taller to attach higher into the anterior tarsus and/or aponeurosis. If a frontal lift is planned, add a maximal superolateral scalp resection on the lower side, and reduce scalp resection or advancement on the higher side by 4.5 to 5 times the millimeter amount of preexisting brow position difference measured and backed off from the point at which the same advancement force is applied to the second side of the scalp as was applied to the first. I resect nothing from the central scalp on the higher side but remove 2.5 times the preexisting central medial brow difference on the lower side. This markedly improves positional brow symmetry. If the low side remains somewhat lower, then compensate for pretarsal asymmetry with more modest applications of increased skin and muscle excision and increased pretarsal skin height (Figure 7).
Epicanthal Folds The next step is to decide whether to modify the epicanthal
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Figure 5. Age-compromised Asian lid contour is demonstrated. In most people the frontalis muscle inserts preferentially into the medial aspect of the eyebrow. This means the muscle is less effective at raising the lateral brow than the medial brow. The overhang that results restricts vision and stimulates frontalis muscle activation. This exposes crease and pretarsal skin medially, but incompletely corrects the lateral overhang. A, Demonstrates how this compromises Asian lid aesthetics. B, A good lateral emphasis frontal lift, (performed manually for demonstration) clears the lateral overhang which cancels the need for constant frontalis activation. Now the medial brow can drop to a normal resting level. Remember that raising the lateral brow usually causes an elevated medial brow to drop.
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Figure 6. Demonstrates pretarsal asymmetry. A, Preoperative view of a 20-year-old woman shows a lower right brow, which would predispose to a smaller pretarsal segment on that side after a symmetrical lid fold procedure. Leaving a 2-mm higher pretarsal segment and removing 1.5 mm more skin and 1 mm more muscle on the lower brow side actually overdid my preemptive plan to prevent the right side from becoming smaller. B, Postoperative view after 1 month shows early overcompensation for brow asymmetry, which I expect to correct. Note the drop in compensated brow elevation that commonly follows blepharoplasty.
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Figure 7. A, Preoperative view of a 26-year-old woman with significant brow and lid asymmetry. B, Postoperative view 1 year after an asymmetrical coronal lift, including a small 4-mm right upper lid skin excision taken from just above her natural lid crease. She also underwent extended canthopexy and malar lift.
folds. My indications for the epicanthoplasty are (1) prominent folds that create even the slightest hint of telecanthus or internal strabismus, (2) an epicanthus inversus with the free canopy border turning laterally onto the lower eyelid (Figure 8, A), (3) a lid crease that dives beneath the epicanthal canopy as it moves medially, and (4) little to no epicanthal canopy in Asian women, 45 years or older, with abundant loose skin around the inner canthus. Figure 8 demonstrates the preferred technique, my modification of the Uchida medial epicanthoplasty.2 I keep the W limb dimensions as tiny as possible, from 1.5 to 2 mm to as long as 3.5 to 4 mm for unusually large epicanthi. I make sure that the upper limb of the W is always well above the medial extent of the upper
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lid incision to avoid a scar contracture recreating the epicanthus.
Frontal Lifts Repositioning the brow with a frontal lift procedure rejuvenates appearance, emphasizing or reemphasizing the hidden natural lid creases or folds and preventing the suggestion of surgical alteration.3 I routinely use this procedure in patients 35 years or older to restore youthful anatomy or limit the profound brow drop that commonly occurs after Asian blepharoplasty (Figure 9). A frontal lift may also benefit 20-year-olds or teenagers with profoundly low resting eyebrow levels that are compensated for by frontalis brow elevation.4
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Illustration by Robert S. Flowers, MD
Figure 8. Demonstrates my modification of the Uchida medial epicanthoplasty: A, Mark the central point of the W 0.5 to 1 mm lateral to the desired medial extent of the eye fissure or aperture, at the inner canthus. B, Draw the W, varying in size with the prominence of the epicanthal fold. C, Excise the 2 triangles together with a 1- to 3-mm skin bridge connecting them. D, Extend the defect with a precise cut directed down toward the medial canthus. E, Suture the angles created into the wings of the W with 7 tiny taper needle sutures. Keeping the upper limb of the W well above the medial extension of the lid-fold incision avoids a deforming band of contracture from recreating an epicanthus and also avoids an overly high medial extension of the lid crease. Sometimes muscle and fibrous tissues contribute to the epicanthal fold and require release before closure. Sometimes the triangular flaps have to be further trimmed or mobilized. Patients who have undergone medial epicanthoplasty can be seen in Figures 6, 7, and 16.
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Figure 9. A, Preoperative view of a 56-year-old woman with brow ptosis that is compensated for with marked frontalis activity. B, Postoperative view soon after Asian blepharoplasty. The patient refused to undergo frontal lift to prevent profound and inevitable brow posture drop after blepharoplasty. She is now planning the initially recommended frontal lift now that she has seen her “high” eyebrow drop. Observing a patient with eyes closed and brows relaxed, you can determine the resting brow level, which the patient’s brow will assume after lid overhang and visual obstruction are eliminated.
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Figure 10. A, Preoperative view of a 45-year-old woman. B, Postoperative view after a coronal lift with corrugator resection and medial epicanthoplasty.
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Figure 11. A, Preoperative view of a 44-year-old woman with brow and lid asymmetry and deep lid hollows. B, Postoperative view 1 year after asymmetrical frontal lift combined with extended 2-layered tendon-into-bone and bicularis muscle canthopexy-malar lift. Note the lid and brow symmetry and, especially, the correction of the hollow upper lids by lower-lid tightening.
Illustration by William M. Winn, Atlanta, GA.
Figure 12. Demonstrates the wire paper clip method for precise planning and determination of upper lid skin resection. I either fix the brow manually to the position I predict it will assume after an accompanying brow lift, or, for isolated Asian blepharoplasty, I forcefully (if necessary) maintain the brow in its relaxed, eye-closed resting posture while invaginating the lid with the paper clip to the planned tarsal fixation level of the pretarsal segment (designated X in Figure 13). For another, perhaps even more effective way to determine the amount of skin resection, manually elevate the opposite brow without doing so on the wire clip invagination side. With this manipulation, bilateral unobstructed vision should be possible with complete frontalis muscle relaxation, sending the eyebrow on the wire clip side to its absolute resting position for precise eyelid measurement according to Figure 13.
The key to success in frontal lifting is resecting or advancing the superolateral portions of the scalp flap with little to nothing removed or advanced centrally except for what has been recommended to correct brow asymmetry. Figure 10 demonstrates the results of a coronal lift and a small medial epicanthoplasty without a blepharoplasty or lid-fold procedure. However, isolated
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frontal lifts tend to increase the visibility of hollowed out upper lids. Consider diminishing the hollowed effect by also performing a canthopexy midface lift to tighten the lax lower lid structures, adding fullness to the upper lid (Figure 11). Cautious lipoinjection along the inferior orbital rim may also be helpful according to information I received from Dr. Sydney Coleman in 1995.
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D Figure 13. I measure how much skin overhang to remove (Z), to attain (Y), the desired amount of visible pretarsal skin. I double the length of Z, and I add 1.5 mm for the caudal bend, depending on skin thickness, to arrive at the amount of skin to be removed at that point on the lid. This exercise may be repeated at 2 or more points along the lid. X represents pretarsal height. If a frontal lift is to accompany, I assess the skin in this same way, but with the measured lid’s corresponding eyebrow held in my “best guess” estimate of where the “post lift” brow will reside in 6 months.
Creating Lid Folds With an Open Method There are 2 basic techniques for surgical lid fold creation: the open anchor or invagination blepharoplasty and the closed suture method. Both procedures usually generate a profound drop in the resting eyebrow posture (Figure 9). Figures 12 and 13 demonstrate how I plan the open anchor method, popular in both America and Asia, that I developed in 1970 and have been using since 1972 on most Asian patients.5 The procedure remains the same, but I have shortened the vertical height of the pretarsal skin segment. To precisely target the amount of eyelid skin, if any, that needs removal, I either raise the eyebrow manually to its predicted long term resting position, for blepharoplasty with an accompanying eyebrow lift, or for an isolated Asian upper blepharoplasty, I secure it downward, with manual pressure if needed, to the brow’s eye-closed relaxed frontalis posture while invaginating the corresponding eyelid with a wire paper clip, contoured just
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Figures 13-14: Illustrations by Robert S. Flowers, MD
Figure 14. A, In the operating room, turn the lid over and measure the tarsus. B, With the skin under uniform traction, mark the incision, or the lower margin of the skin excision with a Jameson caliper: 8 to 9 mm above the lashes for a 4-mm–tall pretarsal segment, 8 mm for a 2.5- to 3-mm segment, and 7 mm for a 1.5- to 2-mm pretarsal segment. The 2 mm added by including the lashes and lid margin compensate for the tightly stretched skin and the inward curvature necessary to reach the anterior tarsus. C, Mark the upper border of skin excision on the basis of information from Figures 12 and 13. D, Skin excision rarely extends beyond the orbital rim and the actual lid creasing. E, Next, remove a sliver of orbicularis bordering the pretarsal skin flap. I never tent this up during excision for fear of transecting aponeurosis.
for that purpose (Figure 12). Position the curved wire on the upper lid surface at the level of the desired crease or lid fold. With the eye open, gently invaginate the skin to that level so that the natural open-eye position of the eyelid margin is not raised. Then measure how much overhang must be reduced to expose the desired height of pretarsal skin (Figure 13). Take whatever that quantity is in millimeters, multiply it by 2, and add 1 to 1.5 mm to compensate for the caudal “bend” in the overhanging eyelid. This indicates the amount of skin to remove. Assessing it at 2 or more points ensures precise removal all across the lid. Another effective method for determining the exact amount of skin to be resected in isolated Asian blepharo-
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Figures 15-16: Illustrations by William M. Winn
Figure 15. (A-F) A, Because the sling of septum and aponeurosis that houses the orbital fat descends lowest laterally, that is the point where the orbital septum is most safely entered and the sling opened. Slight pressure on the globe helps identify the orbital fat bulge, and its characteristic appearance indicates the correct space. B, Cross-section of the septoaponeurotic sling, which houses the orbital fat. C, This step requires an understanding of the anatomy of the “sling” in order to avoid accidental sectioning of the aponeurosis. After entering the septum, the scissors must be angled cephalad, cutting from lateral to medial. Note that the caudal margin of this sling parallels the lid margin of the open eye in the lateral two-thirds of the lid. D, At the junction of the lateral two-thirds and medial third of the lid, I change to a slightly caudal angulation, continuing the cut through the superficial slip of the septum, across the lid towards the medial canthus. This separates septum from aponeurosis across the lid without injuring key structures. E, F, With the pretarsal skin flap turned downward over my finger, I transect the aponeurosis down to the tarsus with scissors sliding along the tarsus surface just above the level of the lash bulbs. There are multiple layers to cut through before the bare tarsus emerges. I remove the filmy pretarsal connective tissue for better fixation. In Asians, expect more pretarsal fatty tissue, especially over the medial tarsus. Attached to the pretarsal skin flap there will be residual connective tissue. Remove it and debulk pretarsal orbicularis muscle, leaving less tissue to become postoperatively edematous. This encourages better fixation and a flat smooth somewhat stylized pretarsal skin surface.
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Figure 15. (G-J) G, Demonstrates how I attach the dermis of the pretarsal skin flap to the anterior superior aspect of the tarsus and to the free edge of the aponeurosis, or into its septoaponeurotic extension. Placement of this absorbable suture into the anterior surface of the tarsus at a sufficient height helps smooth out the pretarsal skin, but not evert the lashes. H, Cross-section showing dermis-aponeurosis-tarsus closure with 6-0 absorbable suture and buried knot. I, Laterally, where the tarsus begins to dwindle in height, the suture(s) join only the aponeurosis to the dermis. J, Skin closure incorporates the edge of the aponeurosis into the skin repair across the lid.
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Figure 16. A, Preoperative view of a 26-year-old woman who desires Asian blepharoplasty. B, Postoperative view 6 years later demonstrates that her “double eyes” create a nice aesthetic balance.
plasty is to manually elevate the brow on the side opposite to the wire clip, leaving the brow undisturbed on the wire clip side. This manipulation allows bilateral unobstructed vision with complete frontalis muscle relaxation, which frees the wire-invaginated side’s eyebrow to assume its absolute resting posture for precise lid skin measurement, as depicted in Figure 13. To start the operation, turn the lid over and measure the height of the tarsus (Figure 14). In Asians it is usually 9.5 to 10 mm, but may be as short as 7 mm. The goal is a lid fold that defines a pretarsal skin segment with a height of 1.5 to 4 mm. To achieve a 4-mm height, I incise the stretched skin 8 to 9 mm above the lash line. To achieve a 2.5- to 3.5-mm height, the incision is 8 mm above the lash line, and for 1.5 to 2 mm, 7 mm above the lash line. The smaller measurements leave little room for subsequent brow drop. Figure 14, B and C, demonstrates the initial steps. I am always cautious to open the septum in a way that preserves maximum aponeurosis length (Figure 15, A to D), or at least to preserve the septoaponeurotic extension,6 to assure a proper connection without creating lid retraction. Prominent eyes tend to predispose patients to lateral upper lid retraction and, unfortunately, prominent eyes frequently accompany shallow Asian orbits. Such patients are good candidates for a “closed” repair.5 For my actual anchor-invagination technique, after sectioning the pretarsal extension of the aponeurosis as low as possible (Figure 15, E and F) I use a 6-0 absorbable suture to create a union between skin, tarsus, and aponeurosis (Figure 15, D to H). The tarsal attachment (Figure 15, G) adds an extra secure anchor that also prevents lash eversion, which is all too common after lid fold procedures. The dermal connection to the aponeurosis keeps the pretarsal skin taut. Laterally, where the tarsus loses vertical height, the aponeurosis is attached only
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E Illustration by Robert S. Flowers, MD
Figure 17. Demonstrates the closed technique commonly used in Asia for lid surgery in those without fat excess or significant skin redundancy and heavy eyelid skin and tissues. A, Locate and define the top of the tarsus. B, Delineate the cephalad margin of tarsus on the skin. C, Tiny incisions will allow knots to bury deep beneath skin. D, Nonabsorbable sutures, placed through the lid, run subconjunctivally on the deep side of the upper tarsus, and exit and travel subdermally to create a nice lid fold. Large external incisions are not necessary. E, Sutures viewed from the underside of eyelid. This technique is especially useful when combined with frontal lifting.
to the dermis of the pretarsal skin flap (Figure 15, I), similar to the basic technique proposed by Dr. Fernandez in 1960.7 The skin closure incorporates the edge of aponeurosis into the skin repair (Figure 15, J). Figure 16 demonstrates the results of this procedure. Although this procedure has not failed in my hands, some results have become obscured by brow descent as patients age. In
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Figure 18. A, Preoperative view of an 85-year-old woman with lid overhang obstructing vision in spite of maximum frontalis muscle activation. B, Postoperative view several days after skin excision blepharoplasty positioned just above the lashes. She now has clear, unobstructed vision and a refreshed appearance without major change in features.
those patients I have used a frontal lift, often combined with a restoration canthopexy extended to include midface lifting.
Creating Lid Folds With a Closed (Suture) Method Occasionally, the closed, or suture, method works superbly well, especially for patients with very thin eyelids with minimal fat and for patients with prominent eyes. The suture is usually placed at the top of the tarsus; however, it can be made 2-to-3 mm lower, in which case the suture transgresses the tarsus itself (Figure 17). In so doing, the permanent buried suture runs a risk of irritating the cornea. Fortunately, it usually develops a trough that prevents corneal irritation. A suture within the substance of the tarsus could also contribute to chalazion. Other problems with closed repair include lack of longevity and no chance to reduce tissue and fat.
even in the mid-lid area. With extreme skin redundancy, in which maximal brow elevation fails to clear visual obstruction, simple skin or skin-muscle reduction helps tremendously (Figure 18). However, these excisions result in lines of dermal weakness that leave unanticipated lid creases, even in excisions next to the lashes. Good results in Asian blepharoplasty flow from a balanced use of eyelid procedures combined with, or replaced by frontal lifts, often with tendon and muscle extended canthopexy, midface lifts, and lower blepharoplasty. Tunnel vision focus on lid-fold creating procedures for Asian eyelids is as inappropriate as it is disappointing. ■ Reprint requests: Robert S. Flowers, MD, 677 Ala Moana Blvd., Suite 1011, Honolulu, HI 96813. Copyright © 2002 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/2002/$35.00 + 0 70/1/130138 doi:10.1067/maj.2002.130138
Simple Skin Excision in Asian Upper Lids Frequently, surgery is not required on the upper lids. Progressive lid overhang resulting from aging commonly responds well to frontal lift but sometimes excess remains or subsequently appears. With aging, maximum brow elevation is sometimes inadequate to clear lid overhang and visual obstruction. In other cases, such as a hollow lid with redundancy but no fold, or a lid with a well defined natural or surgically-created lid fold, simple skin or skin-muscle excision is sometimes a good choice. A minimal excision just above the skin crease or surgical scar frequently solves the overhang. People without folds, who do not desire them, may have too much overhang (pseudo blepharoptosis) to correct with frontal lift alone. In these patients, excess skin may be removed just above the lashes or, with older patients,
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References 1. Flowers RS. The art of eyelid and orbital aesthetics: multi-ethnic considerations. Clin Plast Surg 1987;14:703-704 2. Uchida J. Cosmetic surgery of the eye. In: Handbook of Plastic Surgery. Tokyo:Nankado, 1969:175. 3. Flowers RS. Frontal lifts as the key to periorbital aesthetics. Presented at the Asian sectional meeting of the International Confederation of Plastic and Reconstructive Surgeons; Tokyo; 1982. 4. Flowers RS. Postgraduate courses on Asian blepharoplasty, blepharoplasty with frontal lifts, and coronocanthopexy with midface lifting at annual meetings of American Society of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, and International Society of Aesthetic Plastic Surgery from 1984 to 2001. CD-ROM course syllabus for year 2001. 5. Anchor blepharoplasty. Presented by Robert S. Flowers, MD, at the Pan Pacific Surgical Association Congress in Plastic and Reconstructive Surgery in 1972, and presented to the Annual meeting of the American Association of Plastic Surgeons, New Orleans, 1974. 6. Flowers RS. Upper blepharoplasty by eyelid invagination: anchor blepharoplasty. Clin Plast Surg 1993;20:193-207.
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7. Fernandez LR. Double eyelid operation on the Oriental in Hawaii. Plast Reconstr Surg 1960;25:257.
Flowers RS. Blepharoplasty. In: Courtiss E, editor. Male aesthetic surgery. St Louis: Mosby; 1981. p. 207-239. Flowers RS. Cosmetic surgery in the non-Caucasian. Honolulu: Peninsula Press; 1978.
Bibliography
Flowers RS. Anchor blepharoplasty. Transactions of the Sixth International Congress of the International Confederation for Plastic and Reconstructive Surgeons. Paris:1975. p. 470-471.
Flowers RS, Duval C. Blepharoplasty and periorbital aesthetic surgery. In: Aston S, Beasley R, Thorne C, editors. Grabb and Smith plastic surgery. Philadelphia: Lippincott-Raven; 1997.
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