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Considerations in Asian Cosmetic Surgery
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FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 15 (2007) 387–397
Considerations in Asian Cosmetic Surgery John A. McCurdy, Jr, -
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MD, FACS
Anatomic considerations Preoperative considerations Observations on common surgical procedures Upper blepharoplasty: the double eyelid operation Preoperative considerations
I have had the privilege and good fortune of practicing facial plastic surgery in Hawaii for 30 years. The composition of my surgical practice has reflected the ethnic makeup of Hawaii, the population approximating 70% Asian and 30% white, and my experience with cosmetic surgery of the Asian face has been extensive, ongoing, and evolving. As every surgeon who has experience in Asian cosmetic surgery recognizes, there are considerable differences when compared with aesthetic surgery for white patients. These differences are not only anatomic. In actuality, psychologic aspects of Asian cosmetic surgery often provide a greater challenge than mastery of anatomy and surgical techniques themselves. Coincident with the explosion in demand for Asian facial cosmetic surgery is a dramatic metamorphosis in the desires of the average patient who requests surgical intervention. When I began performing Asian surgery in 1976, most patients desired the relatively radical alterations described as ‘‘westernization.’’ Over the past 30 years, the number of requests for westernization has steadily
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Postoperative course Management of the epicanthus Lower blepharoplasty Asian rhinoplasty Rejuvenation of the aging face Summary References
declined, and in contemporary practice most patients desire relatively conservative changes that improve facial balance and harmony while maintaining ethnic identity. The operative term in the previous statement is ‘‘relatively conservative changes.’’ It is my distinct impression that patient dissatisfaction following procedures performed by Western surgeons is often related to overly aggressive surgery, whereas unhappiness following surgery performed by Asian surgeons is more likely to be related to an overly conservative approach. This article provides a general outline encompassing the following subjects: anatomic and psychologic considerations; preoperative and postoperative considerations; and points I consider to be the most important aspects (or highlights) of the common surgical procedures performed for the Asian face.
Anatomic considerations The Mongoloid race is the largest of Homo sapiens and because of a wide geographic diffusion,
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physical characteristics show considerable variation. At this juncture it is important to recognize that much of Asia is populated by white (Western Asia) and mixtures of white and mongoloid races (Central Asia), whereas individuals of pure mongoloid descent originate from East Asia, a region also known as the Orient. It is incorrect to use the term ‘‘Asian’’ synonymously with individuals of mongoloid descent; correctly, they should be termed ‘‘East Asians.’’ By convention, however, the term ‘‘Asian’’ is synonymous with East Asians and is used in this communication. Westerners tend to possess a stereotyped conception of the physical traits of East Asians: yellow skin pigmentation; straight, coarse black hair; a flat face with high malar eminences; a broad, flat nose; and narrow, slit-like eyes with a rudimentary or absent palpebral furrow and epicanthal fold. Although this stereotype may be loosely applied to East Asians (ie, Chinese, Koreans, and Japanese), the facial plastic surgeon must appreciate that considerable variation exists in all of these physical traits. For example, approximately 40% of East Asians originating from more northerly latitudes has a straight or convex nasal dorsum, and presence of a relatively defined superior palpebral fold increases from north to south. From the point of view of the facial plastic surgeon, the physical diversity of the Asian population not withstanding, certain facial features do necessitate formulation of unique surgical approaches for aesthetic modification and justify specialized study of surgical techniques that are consistent and reliable in producing good aesthetic results in the Asian face. The most notable of these features are the following: 1. The upper eyelid, characterized by an absent or poorly defined superior palpebral fold, abundant periorbital and preseptal fat, and an epicanthal fold of varying size and configuration. 2. A small, flat nose (deficient projection of both lobule and pyramid) with poor lobular definition exhibiting relatively thick, sebaceous skin. Additionally, the columella is often retracted and alar base may be somewhat widened. 3. Prominent, wide malar eminences, zygomatic prominence often being associated with relative hollowness of the temporal fossa, particularly in the aging patient. Prominent mandibular angles (often associated with masseteric hypertrophy) are concerns for some patients, particularly those of Korean ancestry. 4. A tendency toward hypoplasia of the midfacial skeleton with maxillary retrusion and anterior inclination of the maxillary incisors.
5. Experience suggests that small degrees of microgenia are somewhat more common in Asians than in whites. Skin texture and pigmentation exhibit substantial individual variation. In general, those Asians originating from more southerly latitudes exhibit darker pigmentation. Approximately 75% of individuals who originate from the northern and central latitudes of eastern Asia (Northern Chinese, Koreans, and Japanese) have a lightly colored somewhat milky skin pigmentation, the remainder exhibiting various degrees of brownish coloration. The yellowish tint of Asian skin is largely consequence of the number and distribution of melanin granules rather than variations in skin or other biochemical components. Regardless of the extent of skin pigmentation, Asians generally exhibit a thicker dermis than equivalently pigmented whites. This greater collagen density is manifested in a tendency toward a more vigorous fibroplastic response during wound healing, which results in hypertrophic scarring and prolonged erythema during scar maturation even in lightly pigmented Asians. Clinically, hypertrophic scarring is most common in the epicanthal region and the postauricular (and occasionally temporal) incisions for rhytidectomy. For unknown reasons, hypertrophic scarring rarely occurs on the lower eyelids or following alar base excision. Despite the fact that hypertrophic scarring may occur in the previously noted areas, frank keloid formation is rare, being noted most commonly in the ear lobule after piercing. Increased dermal thickness may account for substantially lower incidence of fine facial rhytids in both darker and fair complexion Asians compared with whites of the equivalent age. This may account for the myth that the Asian face ages more slowly than the white face. In actuality, a considerable number fair-skinned Asians do develop fine wrinkles as aging progresses, but Asian skin tends to respond to sun exposure and the aging process with an accelerated development of pigmented dermatoses (lentiges, actinic keratoses, seborrheic keratoses, and so forth) compared with white skin. Skin malignancies of all types are markedly less common in Asians than in whites. There is a tendency for the aging process in the Asian patient to be characterized by an accumulation or ptosis of fat, particularly in the jowls, nasolabial mound, buccal area, and submental region to a greater extent than noted in whites of comparable age. This necessitates special attention in planning facial rejuvenation procedures. In other patients, particularly Koreans, facial aging is often accompanied by atrophy of fat in the buccal region and temporal fossa.
Considerations in Asian Cosmetic Surgery
Preoperative considerations In general there are three prerequisites that a patient should meet before acceptance for cosmetic surgery: 1. A treatable aesthetic concern that is within the technical skills of the surgeon to correct with a reasonable expectation of a good result. 2. Motivation for surgical correction that is reasonable and comes from within rather than being the desire of a loved one, parent, or other individual. 3. Realistic expectations and an understanding that the goal of cosmetic surgery is improvement, not perfection. During the preoperative interview with an Asian patient, it should be understood that, generally speaking, requests for cosmetic surgery are seldom requests for ‘‘westernization.’’ Rather, contemporary Asian patients generally request improvement that ‘‘matches my Asian face,’’ not conversion of ethnicity. The surgeon must be aware of the fact that effective communication may be impaired by several factors including language barriers, respect for the physician that may stifle patient comments and questions, and an assumption on the part of the patient that a learned and competent surgeon knows exactly what is best for each face. I have found that use of actual preoperative and postoperative photographs in preoperative consultation is by far the most effective means of accurate and precise communication regarding patient desires for cosmetic transformation. Because asymmetry is the most common cause of postoperative dissatisfaction in Asian patients (especially of the eyelids and nares-alae), it is critically important to point out and document pre-existing asymmetries that may not be entirely correctable surgically. The surgeon must stress the limitations of cosmetic surgery and carefully discuss the required healing period. Expect price sensitivity during the preoperative consultation. Remember that as with all patients, Asians hope for and may expect perfection (ie, perfect symmetry, no residual wrinkles, and rapid convalescence with minimal edema or ecchymosis). The surgeon must anticipate the difficulty of conveying some aspects of these preoperative discussions and ensure that all the essentials are well documented.
Observations on common surgical procedures Operative details of these procedures are discussed elsewhere in this issue. In the following sections,
considerations related to planning and communication with Asian patients are reviewed.
Upper blepharoplasty: the double eyelid operation Upper blepharoplasty is the most commonly requested cosmetic operation by Asian patients, and because of the large Asian population now residing in the West, it is important that facial plastic surgeons have a working knowledge of techniques available for this procedure. Although, upper blepharoplasty in the Asian is a variation of standard upper blepharoplasty as performed in the white patient, important anatomic differences that characterize the Asian eyelid warrant intensive study of possible surgical options. This is a challenging procedure that requires focused planning and meticulous intraoperative technique if consistent and reliable aesthetic results are to be achieved. One of the major differences between Asian blepharoplasty and standard upper blepharoplasty in whites is the variability in sculpturing the upper eyelid configuration offered by relatively subtle modifications in surgical technique. Differences in the level of the palpebral fold and depth of the palpebral sulcus produce substantial effects on the appearance of the eyelid. Surgeons who wish to become expert in this operation must possess a clear understanding of the interactions between the various factors that allow construction of upper eyelids and vary in size, shape, and palpebral sulcus depth. It is of paramount importance to emphasize that most patients do not request ‘‘westernization’’ of the eye. Most contemporary Asian patients, particularly those born in Western countries, wish to maintain the character of the upper lid while enhancing its natural beauty. Westernization requires reduction of lid fullness and creation of a large, deep upper lid by removing large amounts skin and fat and effacement of the epicanthal fold. In contrast, modern double eyelid surgery is characterized by placement of incisions closer to the ciliary margin, resection of smaller amounts of skin and fat, and conservative manipulation of the epicanthus. This type of procedure is the choice for most young Asians whether living in the United States or in Asia. In my experience, westernization procedures have been requested with markedly decreased frequency during the past 30 years and are sought primarily by recent immigrants to the West or patients who have an existing small double eyelid. In fact, patients who have undergone westernization procedures years ago often request surgery to create a more natural look that matches their face. Because such revision surgery is difficult it is incumbent on
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the surgeon to understand the desires of each primary patient regarding postsurgical eyelid appearance to avoid patient unhappiness by production of a result that may be difficult or impossible to modify. Gone are the days in which a surgeon could perform the same operation on every Asian upper eyelid; the ability to individualize each and every operation is essential to success in contemporary practice. All surgeons owe their patients an opportunity to choose the type of eyelid transformation that they desire; patients should not be condemned to construction of a classic ‘‘westernized’’ eyelid that was the sine qua non of this procedure in earlier years. As a group, approximately 50% of Asians exhibit a ‘‘single eyelid,’’ so-called because in the absence of a superior palpebral fold, the lid hangs like a curtain from the supraorbital ridge. Creation of a palpebral sulcus divides the lid into well-defined pretarsal and preseptal segments. The incidence of the single eyelid is higher in Asian populations that have remained homogeneous (ie, Japanese, Koreans), whereas double eyelids are more common in heterogeneous populations and those originating from more southerly latitudes, and Southeast Asia where Malay and Mongoloid influences have combined. Most Asians with natural double eyelids, however, exhibit a small fold accompanied by abundant periorbital and submuscular fat and excess skin with considerable pretarsal laxity.
Preoperative considerations The major goal of blepharoplasty in the Asian upper lid is creation (or enhancement if the patient exhibits a small or poorly defined fold) of a crisp, well-defined palpebral fold. Because of the many possible surgical variations in achieving this goal (ie, the level of the palpebral fold, the depth of the palpebral sulcus, and the appearance of the epicanthal region that can be controlled by variations in technique), careful preoperative evaluation and counseling of each prospective patient are mandatory in planning this operation. Many patients desire only the creation of a palpebral fold and wish to retain the other characteristics of the Asian eyelid. Others, however, prefer a more radical westernization that requires modification of the epicanthal fold and reduction of lid fullness by removal of redundant skin and fat. Several methods assist the surgeon and patient in selecting the type of eyelid transformation desired. In my practice, patients are advised that three basic decisions are necessary: (1) size of the new eyelid, (2) the shape of the eyelid, and (3) the disposition of the epicanthal fold.
For planning purposes, double eyelids are arbitrarily divided into small, medium, and large sizes, depending on the amount of visible pretarsal skin and the depth of the palpebral sulcus. Likewise, eyelids are classified as either round or oval in shape. In discussing the epicanthal region, differences between the so-called ‘‘inside’’ and ‘‘outside’’ folds are demonstrated with preoperative and postoperative photographs, enabling a more rational discussion of possible variations (Fig. 1). Patients are then shown preoperative and postoperative photographs illustrating the various sizes and shapes of eyelids (Figs. 2–4). In many patients, it is possible to demonstrate the approximate size and shape of the lid by manipulating the eyelid skin with a bent paper clip, forceps, or a special instrument produced in Asia that is designed for this purpose. Some patients bring pictures of magazine models to the consultations, and although it must be stressed to the patient that a surgeon cannot construct an eyelid to the patient’s exact specifications, examining these pictures in conjunction with preoperative and postoperative photographs allows the surgeon to determine the general size and shape of the eyelid that each individual desires. My general surgical approach to Asian upper blepharoplasty is an external excisional technique to gain access to the levator system and create suture fixation of the skin to the levator or tarsus at the desired crease location. Variations in the height and shape of the incision, amount of tissue excised (skin, muscle, periorbital fat), the point of fixation, and modification of the epicanthal fold allow for tremendous variation in the postoperative appearance [1].
Postoperative course The early postblepharoplasty period is characterized by marked edema of the pretarsal portion of the lid and by variable degrees of blepharoptosis. Blepharoptosis is generally not objectionable
Fig. 1. The left eye exhibits an outside fold (epicanthal effacement), whereas the right eye exhibits an inside fold (no epicanthal effacement). Both eyelids are medium in size and oval in shape.
Considerations in Asian Cosmetic Surgery
Fig. 2. (A, B) Surgical creation of a small, round double eyelid with an inside fold. The incision was placed 6 mm above the ciliary margin, and 3 mm of skin was excised.
following removal of fixation sutures on the seventh postoperative day but may occasionally cause persistent concern because of resultant asymmetry. Slowly resulting asymmetric ptosis is often related to hematoma or edema of Mu¨ller’s muscle. Occasionally, residual pretarsal edema may be detectable for up to 6 months, but is usually satisfactorily camouflaged by cosmetics following suture removal. Lid edema and size is generally greater in the morning than in the evening because of postrecumbency edema. I tell patients that this serves as a guide to determine the progress of healing. Healing is complete when intraday differentials in pretarsal edema are no longer apparent. For small double eyelids, edema is generally undetectable 3 to 4 weeks postoperatively, whereas following the creation of a medium-sized eyelid, slight edema may persist for 6 weeks or more. Following westernization procedures, residual edema may be detectable for 3 and as long as 6 months postoperatively. Undoubtedly the most common source of dissatisfaction in Asian patients undergoing upper blepharoplasty is postoperative asymmetry of the lid folds. This deformity occasionally occurs even in the hands of the most experienced surgeon. Postoperative asymmetry is more likely to occur when lid or brow asymmetry exists preoperatively, and each prospective candidate for upper
blepharoplasty must be carefully evaluated in this regard. Minimal ptosis also predisposes postoperative asymmetry. If preoperative asymmetry exists, it must be carefully pointed out to the patient, explaining that exact postoperative symmetry is more difficult to achieve. Such asymmetry must be carefully documented in the medical record by preoperative photographs. Meticulous preoperative marking with the skin tensed, detailed measurements, and repeated comparison of the two sides as fixation sutures are placed before skin closure is critical to minimizing the development of postoperative asymmetry. Slight asymmetry in the early postoperative period is very common because of differential swelling of the eyelids and the slight degree of ptosis that may temporarily follow fixation procedures. Although patients are concerned about this asymmetry, my approach is carefully to explain this problem and defer any consideration of revision until edema has resolved. Occasionally, more marked lid asymmetry caused by obvious failure of one or more fixation sutures deserves earlier correction, repair being easily accomplished by replacement of the failed sutures as described elsewhere [1–4]. The keys to a happy patient are clear communication of goals related to eyelid appearance;
Fig. 3. (A, B) Surgical creation of a medium, oval double eyelid with an inside fold. The incision was placed 8 mm above the ciliary margin, and 50% of the maximum amount of skin that could be removed (as determined by forceps pinching) was actually removed.
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Fig. 4. (A, B) Surgical creation of a large, round double eyelid with an outside fold. The incision was placed 9 mm above the ciliary margin, and the maximum amount of skin that could be removed as determined by forceps pinching, less 3 mm, was actually removed.
management of expectations (eg, possibility of asymmetry); and meticulous technique.
Management of the epicanthus Although approximately 90% of Asians exhibit an epicanthus of variable size, in most individuals the fold is relatively small. Aesthetically successful effacement only rarely requires complex procedures described for management of this condition in the white eyelid. A major reason for the relative ease in managing the Asian epicanthal fold is that, in contrast to the epicanthus encountered in whites, in which a vertical shortage of skin is problematic, the epicanthal fold in the Asian lid is usually associated with horizontal skin redundancy of the entire upper lid. This can be demonstrated by medial displacement of the skin with cotton-tipped applicator. Successful effacement of the fold can be conceptualized as an advancement procedure. The goal of this advancement, in addition to effacement of the fold itself, is to elongate the entire palpebral fold in the medial direction. Further benefits to this maneuver are the production of a longer-appearing eyelid in patients concerned with small eyes because of large epicanthal folds (effacement results in an apparent increase in the lateral dimension of the eye) and an apparent narrowing of the nasal dorsum, a wide dorsum being of concern to many individuals with prominent epicanthal folds. In many patients, no specific intervention in the epicanthal area is necessary. This group includes those who desire an inside fold and other patients with a small, almost rudimentary epicanthus in whom the surgical approach used to create the lid fold results in sufficient medial advancement of the epicanthus to achieve aesthetically beneficial effacement. A major advantage in minimizing surgery in that medial canthus region is reduction in the risk of hypertrophic scarring. This region exhibits
a biologic predisposition to hypertrophic scar formation, and even the most meticulously performed procedure in this area may be complicated by an aesthetically unpleasant scar. In keeping with the reduction in requests for westernization of the Asian eyelid, most patients who desire epicanthal modification can be treated by conservative procedures involving undermining, small excision of pretarsal orbicularis beneath the epicanthal fold, and medial advancement with fixation sutures. More extensive procedures for epicanthal modification are described in detail elsewhere [1,2]. Many surgeons, citing concerns about hypertrophic scarring, encourage patients not to undergo surgical modification of the epicanthus, further suggesting that such surgery invariably produces an unnatural look incompatible with the Asian face. Failure to modify the epicanthus deprives many eyes of their full aesthetic potential, however, and in many cases is a source of patient unhappiness with an otherwise successful blepharoplasty. The flexibility in a range of effacement possible using available procedures allows the aesthetic surgeon to select an operation that results in a modified epicanthus that blends harmoniously with the eyelid and face. To combat the tendency toward hypertrophic scar formation, inject 0.1 mL of triamcinolone (10 mg/mL) in each epicanthal region (regardless of the type of intervention) intraoperatively before closure. This technique markedly diminishes the incidence of hypertrophic scars and postoperative induration in this area. Postoperatively, massage of the epicanthal aspect of the incision with or without topical corticosteroid creams is of additional benefit in reducing scar formation. Occasionally, postoperative triamcinolone injection is indicated. Such treatment invariably results in satisfactory healing.
Considerations in Asian Cosmetic Surgery
Lower blepharoplasty As in the upper eyelid, the Asian lower lid characteristically exhibits a considerable volume of periorbital fat that frequently produces a puffy appearance even at an early age. In many patients, considerable fat is present in the submuscular plane (superficial to the orbital septum), accentuating fullness. Although a wide spectrum exists, Asian skin is generally thicker than white skin and deeply etched rhytids extending laterally occur less frequently. Eccrine syringomas occur on the lower eyelid skin in some individuals and such patients must understand that these blemishes are not eliminated by blepharoplasty. Pigmented lesions are also common on the lower eyelids. Frequently, hypertrophy of the orbicularis muscle is present. Such patients must be counseled regarding the differences between fullness caused by fat protrusion and orbicularis hypertrophy and the aesthetic and technical limitations of partial muscle resection. The fullness of the Asian lower lid may tempt the surgeon to recommend a transconjunctival approach. Most Asian patients, however, are firmly convinced that ‘‘too much skin’’ is a component of their problem, and dissatisfaction often follows an operation that does not remove skin. This observation, coupled with the fact that transconjunctival blepharoplasty does not allow modification of orbicularis hypertrophy, is the reason that the skin-muscle flap approach is my procedure of choice for all but the very young patient with no concern about skin excess or men whose only concern is ‘‘bags’’ resulting from fat protrusion. Lower blepharoplasty is an imperfect operation that has inherent limitations; the results are rarely as dramatic as those of upper blepharoplasty, except perhaps in the occasional patient who exhibits massive ‘‘bagginess.’’ Residual wrinkling is often a nagging concern, especially in Asian patients, and the surgeon walks a tightrope between residual rhytids and lower lid malposition secondary to overzealous tissue removal. Skin resurfacing procedures that often placate white patients are generally problematic in the Asian because of intolerance to prolonged discoloration. I have described my technique for lower blepharoplasty in detail elsewhere [2]. The most important consideration in this operation is preservation and reinforcement of the anatomic support of the lower eyelid. This is accomplished by preserving the pretarsal orbicularis adherence to the tarsal plate and placement of a permanent suspension suture of 5-0 nylon between the deep surface of orbicularis muscle and lateral orbital periosteum. The interested surgeon may wish to review my
conceptualization the dynamics of lower lid support, the cause of postoperative lower lid malposition, and the rationale for using the five-point operative program in each and every patient [2].
Asian rhinoplasty The goal of aesthetic rhinoplasty in the Asian nose is similar to that of Occidental rhinoplasty: creation of a strong, smooth dorsum exhibiting a prominent origin at the nasion but not competing with the tip as the leading point of the nasal profile. A delicate, well-defined lobule with definite columellar ‘‘show’’ and an oblique anteroposterior orientation of the nares contributes an equally important but seldom emphasized goal of surgery. The characteristic anatomy of the Asian nose generally requires an augmentation procedure rather than reduction. Although it might be assumed that the popularity of this operation reflects a desire for westernization, it should be noted that in many Asian cultures the high, narrow nasal bridge is an aesthetically desirable feature. In contrast, patients from the northern and central latitudes of eastern Asia may benefit from the classic techniques in reduction rhinoplasty. These patients may specifically request reduction and refinement of the lobule or alar base reduction. Because the lower lateral cartilages may be poorly supported in such individuals, techniques to increase tip support and projections may be indicated. Few procedures in facial plastic surgery elicit the controversy that surrounds augmentation rhinoplasty in the Asian nose. Historically, many materials have been used to augment the nose. At the present time, Western surgeons prefer autogenous material, whereas in Asia, use of silicone implants predominates. Evolution in the technology of silicone implants has continued as softer-grade silicone elastomers have become available for implant fabrication. Softer implants translate into increased flexibility, resulting in reduced tension at the implant-tissue interface. The incidence of infection, displacement, or extrusion is substantially lower than the experience with augmentation of the non- Asian nose using solid alloplastic implants. The reason for this greater tolerance is unknown but may be related to a greater thickness of skin and subcutaneous tissue. Complications are most commonly caused by technical error or occasionally infection rather than an inherent problem with the operation itself. Although autogenous material, when available, is preferable to alloplastic implants, many Asian patients are unhappy with the results of nasal augmentation using autogenous cartilage and bone because satisfactory
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sculpturing of the lobule is often not achieved. Techniques of tip rhinoplasty that are highly successful in the white nose are frequently unsatisfactory in the Asian nose because the attenuated lower lateral cartilages are not strong enough to accentuate tip projection and support, and the lobular skin and subcutaneous tissue is too thick to transmit sculpturing of the delicate cartilage. In some cases, only slight augmentation of the dorsum is required, and in such cases autogenous cartilage is an excellent choice. Mersaline mesh, Gortex, or homograft materials constitute alternatives to silicone implants for these patients. The decision to use autogenous or alloplastic material is individualized according to the desires of each patient with regard to the extent of lobular sculpturing and dorsal augmentation. Anatomic factors, such as skin thickness and configuration of the lower level cartilages, are factors in determining the type of procedure to be followed. I prefer silicone implants in most patients who request lobular definition or tip projection in addition to dorsal augmentation. Thin lobular skin or substantial fibrosis resulting from previous surgery constitutes a relative contraindication to the use of silicone
implants. Given the current social and medical legal environment, the feelings of each individual patient regarding use of alloplastic materials must be considered in the final decision of which material to use. Some surgeons use alloplastic material only for augmentation of the dorsum and use only autogenous material for the tip and lobule. In such operations, discontinuity between the dorsum and lobule is a risk, frequently being unapparent until final resolution of postoperative edema. In my experience, the use of L-shaped silicone prostheses provides the advantage of preserving continuity between the dorsum and lobule (Fig. 5). Results achieved using autogenous cartilage and alloplastic materials for dorsal augmentation in conjunction with standard tip plasty techniques are often suboptimal because of the failure of the standard techniques of lobular surgery to improve tip aesthetics in the Asian nose. The ability of an L-shaped implant to sculpture the lobule and augment the dorsum in continuity with the lobule is the reason for improved aesthetic results, and focusing on augmentation of the dorsum in the Asian nose rather than on improved lobular aesthetics
Fig. 5. (A, B) Preoperative and postoperative result of augmentation rhinoplasty using an L-shaped silicone implant.
Considerations in Asian Cosmetic Surgery
led to inferior results. Use of an L- shaped prosthesis allowed for a shift of my primary focus in augmentation rhinoplasty to enhancement of the lobule, just as in white reduction rhinoplasty, relegating dorsal augmentation as a component of the procedure that must complement, not overwhelm, lobular enhancement. Safeguards for successful augmentation rhinoplasty with L-shaped silicone prostheses are presented in Box 1.
Rejuvenation of the aging face Successful rejuvenation of the aging face and neck demands a careful assessment of various factors that may contribute to the deformity manifested by each individual patient. I have found that there are two keys to successful surgical rejuvenation: adequate management of midfacial ptosis (ie, the nasolabial fold); and management of deformities related to the anatomic configuration of the anterior platysma muscle. Cervical lipectomy with liposuction and anterior platysma approximation, if indicated, enables dramatic and lasting rejuvenation of the neck. Understanding the mechanisms of midfacial ptosis and the methods of its correction using subperiosteal midfacial dissection or other methods of malar fat pad elevation accompanied by debulking of the nasolabial mound using microliposuction and injection of filler materials into the nasolabial fold generally enables a successful attack on this problem.
Box 1: Safeguards for successful augmentation rhinoplasty with L-shaped silicone prostheses 1. Do not thrust the nasal tip anteriorly with a columellar strut. 2. Remember that the columella strut has two primary functions a. Proximal stabilization of the implant in the midline b. Columellar sculpturing 3. Carve each implant individually according to the nasal anatomy anesthetic desires of each patient. 4. Ensure that there are no sharp surfaces on the implant. 5. Dissect an adequate pocket precisely in the midline, ensuring that there is no tension whatsoever on the implant. 6. Be conservative in selection of prosthesis size. 7. Use soft silicone elastomer for all components of the prosthesis.
Anatomic differences between the Asian and white face and neck are manifested in skin thickness and texture, patterns of fat accumulation, and skeletal structure. In general, Asian skin tends to be thicker and the face and neck tend to accumulatemore fat during the aging process than the white face and neck. This fat accumulation tends to concentrate in the jowl, nasolabial mound, and buccal regions. The clinical significance of fat accumulation in these areas is accentuated by the skeletal structure of the Asian face (ie, prominent malar eminences associated with relative deficiency of the premaxillary region that results in shallowness of the midface and deepening of the nasolabial folds). Wide, prominent mandibular angles are often present contributing to a square, flat face. Although the goals for rejuvenation of the aging face and neck are the same in Asian as in white patients, variations in anatomy dictate greater emphasis on management of fat accumulation particularly in the nasolabial mound and jowl and management of the nasolabial fold. The anatomy of the Asian face does not otherwise necessitate substantial modification of surgical techniques for successful facial rejuvenation. A detailed description of the evolution of techniques for facial rejuvenation and my reasons for favoring certain techniques are presented elsewhere [2]. The technique that I now use, anterior superficial musculo-aponeurotic system (SMAS) plication [5], a procedure designed to enhance effacement of the nasolabial folds, has yielded improved results with postoperative edema of duration similar to that of subcutaneous procedures. I regard the primary cause of facial aging to be ptosis of the skin and subcutaneous fat and that the most direct and probably most effective technique of restoring this tissue to a more youthful position involves direct mobilization and plication (or actual debulking of adipose tissue) rather than attempting to elevate these tissues by traction on deeper structures located more posteriorly. This is reinforced by a study using MRI techniques confirming that the primary problem in nasolabial fold development is ptosis of the skin and subcutaneous tissue, rather than sagging of the musculofascial structures [6]. Even if the surgeon chooses to elevate the malar fat pad, aesthetic results in the midface are enhanced in most Asian patients by debulking the nasolabial mound using syringe microliposuction (Fig. 6A) or a suitable alternative (Fig. 7). Although surgeons whose primary patient population is white may dispute this contention in favor of elevating all ptotic facial fat to replace it into a more youthful position because removal of midfacial fat results in postoperative hollowness, Asian patients
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Fig. 6. (A) Microliposuction of the nasolabial mound. (B) Microliposuction of the jowl.
seem to accumulate extra fat during the aging process. An additional benefit of microliposuction is induction of some skin shrinkage over the treated area that follows this technique. Because deficiency of facial fat is rarely associated with aging of the Asian face (except in those who exhibit fat atrophy in the buccal and temporal regions), I believe that there is seldom an indication for volume restoration in facial rejuvenation of this population, as is the current trend in whites. I also use microliposuction of the jowl, and virtually all Asians face this procedure (Fig. 6B).
Summary Cosmetic surgery of the Asian face is a challenging and fascinating endeavor. In large part, the challenge relates to understanding cultural and psychologic differences that often translate into behavior that may be unfamiliar to the surgeon. Continuing efforts to understand the Asian psyche are mandatory if communication is to be effective. Any surgeon is wise to remember that there are usually several equally satisfactory surgical approaches to any problem, and the specialty is best
Fig. 7. (A, B) Preoperative and postoperative results of cervicofacial rhytidectomy with anterior SMAS plication and microliposuction of the nasolabial mound and jowl.
Considerations in Asian Cosmetic Surgery
served by keeping an open mind regarding various techniques recommended by colleagues. Most certainly, evolution and refinement of surgical techniques will impact the practice of cosmetic surgery for the Asian patient.
References [1] McCurdy JA. Upper blepharoplasty in the Asian eyelid. Facial Plast Surg Clin North Am 1996;4:7–24. [2] McCurdy JA, Lam SM. Cosmetic surgery of the Asian face. New York: Thieme; 2005. [3] Park JI, Toriumi DM, editors. Asian facial cosmetic surgey. Philadelphia: Saunders Elsevier; 2007. p. 145–51.
[4] McCurdy JA. A simplified approach to subperiosteal dissection of the midfacial region: preliminary observations. American Journal of Cosmetic Surgery 1995;12:12–6. [5] Robbins L, Brothers D, Marshall D. Anterior SMAS plication for the treatment of prominent nasolabial folds and restoration of normal cheek contour. Plast Reconstr Surg 1995;96: 1279–84. [6] Gosain A, Amarante M, Hyde J, et al. Dynamic analysis of the changes in the nasolabial fold using magnetic resonance imaging: implications for facial rejuvenation and facial animation surgery. Plast Reconstr Surg 1996;98: 622–31.
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FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 15 (2007) 387–397
Considerations in Asian Cosmetic Surgery John A. McCurdy, Jr, -
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MD, FACS
Anatomic considerations Preoperative considerations Observations on common surgical procedures Upper blepharoplasty: the double eyelid operation Preoperative considerations
I have had the privilege and good fortune of practicing facial plastic surgery in Hawaii for 30 years. The composition of my surgical practice has reflected the ethnic makeup of Hawaii, the population approximating 70% Asian and 30% white, and my experience with cosmetic surgery of the Asian face has been extensive, ongoing, and evolving. As every surgeon who has experience in Asian cosmetic surgery recognizes, there are considerable differences when compared with aesthetic surgery for white patients. These differences are not only anatomic. In actuality, psychologic aspects of Asian cosmetic surgery often provide a greater challenge than mastery of anatomy and surgical techniques themselves. Coincident with the explosion in demand for Asian facial cosmetic surgery is a dramatic metamorphosis in the desires of the average patient who requests surgical intervention. When I began performing Asian surgery in 1976, most patients desired the relatively radical alterations described as ‘‘westernization.’’ Over the past 30 years, the number of requests for westernization has steadily
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Postoperative course Management of the epicanthus Lower blepharoplasty Asian rhinoplasty Rejuvenation of the aging face Summary References
declined, and in contemporary practice most patients desire relatively conservative changes that improve facial balance and harmony while maintaining ethnic identity. The operative term in the previous statement is ‘‘relatively conservative changes.’’ It is my distinct impression that patient dissatisfaction following procedures performed by Western surgeons is often related to overly aggressive surgery, whereas unhappiness following surgery performed by Asian surgeons is more likely to be related to an overly conservative approach. This article provides a general outline encompassing the following subjects: anatomic and psychologic considerations; preoperative and postoperative considerations; and points I consider to be the most important aspects (or highlights) of the common surgical procedures performed for the Asian face.
Anatomic considerations The Mongoloid race is the largest of Homo sapiens and because of a wide geographic diffusion,
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physical characteristics show considerable variation. At this juncture it is important to recognize that much of Asia is populated by white (Western Asia) and mixtures of white and mongoloid races (Central Asia), whereas individuals of pure mongoloid descent originate from East Asia, a region also known as the Orient. It is incorrect to use the term ‘‘Asian’’ synonymously with individuals of mongoloid descent; correctly, they should be termed ‘‘East Asians.’’ By convention, however, the term ‘‘Asian’’ is synonymous with East Asians and is used in this communication. Westerners tend to possess a stereotyped conception of the physical traits of East Asians: yellow skin pigmentation; straight, coarse black hair; a flat face with high malar eminences; a broad, flat nose; and narrow, slit-like eyes with a rudimentary or absent palpebral furrow and epicanthal fold. Although this stereotype may be loosely applied to East Asians (ie, Chinese, Koreans, and Japanese), the facial plastic surgeon must appreciate that considerable variation exists in all of these physical traits. For example, approximately 40% of East Asians originating from more northerly latitudes has a straight or convex nasal dorsum, and presence of a relatively defined superior palpebral fold increases from north to south. From the point of view of the facial plastic surgeon, the physical diversity of the Asian population not withstanding, certain facial features do necessitate formulation of unique surgical approaches for aesthetic modification and justify specialized study of surgical techniques that are consistent and reliable in producing good aesthetic results in the Asian face. The most notable of these features are the following: 1. The upper eyelid, characterized by an absent or poorly defined superior palpebral fold, abundant periorbital and preseptal fat, and an epicanthal fold of varying size and configuration. 2. A small, flat nose (deficient projection of both lobule and pyramid) with poor lobular definition exhibiting relatively thick, sebaceous skin. Additionally, the columella is often retracted and alar base may be somewhat widened. 3. Prominent, wide malar eminences, zygomatic prominence often being associated with relative hollowness of the temporal fossa, particularly in the aging patient. Prominent mandibular angles (often associated with masseteric hypertrophy) are concerns for some patients, particularly those of Korean ancestry. 4. A tendency toward hypoplasia of the midfacial skeleton with maxillary retrusion and anterior inclination of the maxillary incisors.
5. Experience suggests that small degrees of microgenia are somewhat more common in Asians than in whites. Skin texture and pigmentation exhibit substantial individual variation. In general, those Asians originating from more southerly latitudes exhibit darker pigmentation. Approximately 75% of individuals who originate from the northern and central latitudes of eastern Asia (Northern Chinese, Koreans, and Japanese) have a lightly colored somewhat milky skin pigmentation, the remainder exhibiting various degrees of brownish coloration. The yellowish tint of Asian skin is largely consequence of the number and distribution of melanin granules rather than variations in skin or other biochemical components. Regardless of the extent of skin pigmentation, Asians generally exhibit a thicker dermis than equivalently pigmented whites. This greater collagen density is manifested in a tendency toward a more vigorous fibroplastic response during wound healing, which results in hypertrophic scarring and prolonged erythema during scar maturation even in lightly pigmented Asians. Clinically, hypertrophic scarring is most common in the epicanthal region and the postauricular (and occasionally temporal) incisions for rhytidectomy. For unknown reasons, hypertrophic scarring rarely occurs on the lower eyelids or following alar base excision. Despite the fact that hypertrophic scarring may occur in the previously noted areas, frank keloid formation is rare, being noted most commonly in the ear lobule after piercing. Increased dermal thickness may account for substantially lower incidence of fine facial rhytids in both darker and fair complexion Asians compared with whites of the equivalent age. This may account for the myth that the Asian face ages more slowly than the white face. In actuality, a considerable number fair-skinned Asians do develop fine wrinkles as aging progresses, but Asian skin tends to respond to sun exposure and the aging process with an accelerated development of pigmented dermatoses (lentiges, actinic keratoses, seborrheic keratoses, and so forth) compared with white skin. Skin malignancies of all types are markedly less common in Asians than in whites. There is a tendency for the aging process in the Asian patient to be characterized by an accumulation or ptosis of fat, particularly in the jowls, nasolabial mound, buccal area, and submental region to a greater extent than noted in whites of comparable age. This necessitates special attention in planning facial rejuvenation procedures. In other patients, particularly Koreans, facial aging is often accompanied by atrophy of fat in the buccal region and temporal fossa.
Considerations in Asian Cosmetic Surgery
Preoperative considerations In general there are three prerequisites that a patient should meet before acceptance for cosmetic surgery: 1. A treatable aesthetic concern that is within the technical skills of the surgeon to correct with a reasonable expectation of a good result. 2. Motivation for surgical correction that is reasonable and comes from within rather than being the desire of a loved one, parent, or other individual. 3. Realistic expectations and an understanding that the goal of cosmetic surgery is improvement, not perfection. During the preoperative interview with an Asian patient, it should be understood that, generally speaking, requests for cosmetic surgery are seldom requests for ‘‘westernization.’’ Rather, contemporary Asian patients generally request improvement that ‘‘matches my Asian face,’’ not conversion of ethnicity. The surgeon must be aware of the fact that effective communication may be impaired by several factors including language barriers, respect for the physician that may stifle patient comments and questions, and an assumption on the part of the patient that a learned and competent surgeon knows exactly what is best for each face. I have found that use of actual preoperative and postoperative photographs in preoperative consultation is by far the most effective means of accurate and precise communication regarding patient desires for cosmetic transformation. Because asymmetry is the most common cause of postoperative dissatisfaction in Asian patients (especially of the eyelids and nares-alae), it is critically important to point out and document pre-existing asymmetries that may not be entirely correctable surgically. The surgeon must stress the limitations of cosmetic surgery and carefully discuss the required healing period. Expect price sensitivity during the preoperative consultation. Remember that as with all patients, Asians hope for and may expect perfection (ie, perfect symmetry, no residual wrinkles, and rapid convalescence with minimal edema or ecchymosis). The surgeon must anticipate the difficulty of conveying some aspects of these preoperative discussions and ensure that all the essentials are well documented.
Observations on common surgical procedures Operative details of these procedures are discussed elsewhere in this issue. In the following sections,
considerations related to planning and communication with Asian patients are reviewed.
Upper blepharoplasty: the double eyelid operation Upper blepharoplasty is the most commonly requested cosmetic operation by Asian patients, and because of the large Asian population now residing in the West, it is important that facial plastic surgeons have a working knowledge of techniques available for this procedure. Although, upper blepharoplasty in the Asian is a variation of standard upper blepharoplasty as performed in the white patient, important anatomic differences that characterize the Asian eyelid warrant intensive study of possible surgical options. This is a challenging procedure that requires focused planning and meticulous intraoperative technique if consistent and reliable aesthetic results are to be achieved. One of the major differences between Asian blepharoplasty and standard upper blepharoplasty in whites is the variability in sculpturing the upper eyelid configuration offered by relatively subtle modifications in surgical technique. Differences in the level of the palpebral fold and depth of the palpebral sulcus produce substantial effects on the appearance of the eyelid. Surgeons who wish to become expert in this operation must possess a clear understanding of the interactions between the various factors that allow construction of upper eyelids and vary in size, shape, and palpebral sulcus depth. It is of paramount importance to emphasize that most patients do not request ‘‘westernization’’ of the eye. Most contemporary Asian patients, particularly those born in Western countries, wish to maintain the character of the upper lid while enhancing its natural beauty. Westernization requires reduction of lid fullness and creation of a large, deep upper lid by removing large amounts skin and fat and effacement of the epicanthal fold. In contrast, modern double eyelid surgery is characterized by placement of incisions closer to the ciliary margin, resection of smaller amounts of skin and fat, and conservative manipulation of the epicanthus. This type of procedure is the choice for most young Asians whether living in the United States or in Asia. In my experience, westernization procedures have been requested with markedly decreased frequency during the past 30 years and are sought primarily by recent immigrants to the West or patients who have an existing small double eyelid. In fact, patients who have undergone westernization procedures years ago often request surgery to create a more natural look that matches their face. Because such revision surgery is difficult it is incumbent on
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the surgeon to understand the desires of each primary patient regarding postsurgical eyelid appearance to avoid patient unhappiness by production of a result that may be difficult or impossible to modify. Gone are the days in which a surgeon could perform the same operation on every Asian upper eyelid; the ability to individualize each and every operation is essential to success in contemporary practice. All surgeons owe their patients an opportunity to choose the type of eyelid transformation that they desire; patients should not be condemned to construction of a classic ‘‘westernized’’ eyelid that was the sine qua non of this procedure in earlier years. As a group, approximately 50% of Asians exhibit a ‘‘single eyelid,’’ so-called because in the absence of a superior palpebral fold, the lid hangs like a curtain from the supraorbital ridge. Creation of a palpebral sulcus divides the lid into well-defined pretarsal and preseptal segments. The incidence of the single eyelid is higher in Asian populations that have remained homogeneous (ie, Japanese, Koreans), whereas double eyelids are more common in heterogeneous populations and those originating from more southerly latitudes, and Southeast Asia where Malay and Mongoloid influences have combined. Most Asians with natural double eyelids, however, exhibit a small fold accompanied by abundant periorbital and submuscular fat and excess skin with considerable pretarsal laxity.
Preoperative considerations The major goal of blepharoplasty in the Asian upper lid is creation (or enhancement if the patient exhibits a small or poorly defined fold) of a crisp, well-defined palpebral fold. Because of the many possible surgical variations in achieving this goal (ie, the level of the palpebral fold, the depth of the palpebral sulcus, and the appearance of the epicanthal region that can be controlled by variations in technique), careful preoperative evaluation and counseling of each prospective patient are mandatory in planning this operation. Many patients desire only the creation of a palpebral fold and wish to retain the other characteristics of the Asian eyelid. Others, however, prefer a more radical westernization that requires modification of the epicanthal fold and reduction of lid fullness by removal of redundant skin and fat. Several methods assist the surgeon and patient in selecting the type of eyelid transformation desired. In my practice, patients are advised that three basic decisions are necessary: (1) size of the new eyelid, (2) the shape of the eyelid, and (3) the disposition of the epicanthal fold.
For planning purposes, double eyelids are arbitrarily divided into small, medium, and large sizes, depending on the amount of visible pretarsal skin and the depth of the palpebral sulcus. Likewise, eyelids are classified as either round or oval in shape. In discussing the epicanthal region, differences between the so-called ‘‘inside’’ and ‘‘outside’’ folds are demonstrated with preoperative and postoperative photographs, enabling a more rational discussion of possible variations (Fig. 1). Patients are then shown preoperative and postoperative photographs illustrating the various sizes and shapes of eyelids (Figs. 2–4). In many patients, it is possible to demonstrate the approximate size and shape of the lid by manipulating the eyelid skin with a bent paper clip, forceps, or a special instrument produced in Asia that is designed for this purpose. Some patients bring pictures of magazine models to the consultations, and although it must be stressed to the patient that a surgeon cannot construct an eyelid to the patient’s exact specifications, examining these pictures in conjunction with preoperative and postoperative photographs allows the surgeon to determine the general size and shape of the eyelid that each individual desires. My general surgical approach to Asian upper blepharoplasty is an external excisional technique to gain access to the levator system and create suture fixation of the skin to the levator or tarsus at the desired crease location. Variations in the height and shape of the incision, amount of tissue excised (skin, muscle, periorbital fat), the point of fixation, and modification of the epicanthal fold allow for tremendous variation in the postoperative appearance [1].
Postoperative course The early postblepharoplasty period is characterized by marked edema of the pretarsal portion of the lid and by variable degrees of blepharoptosis. Blepharoptosis is generally not objectionable
Fig. 1. The left eye exhibits an outside fold (epicanthal effacement), whereas the right eye exhibits an inside fold (no epicanthal effacement). Both eyelids are medium in size and oval in shape.
Considerations in Asian Cosmetic Surgery
Fig. 2. (A, B) Surgical creation of a small, round double eyelid with an inside fold. The incision was placed 6 mm above the ciliary margin, and 3 mm of skin was excised.
following removal of fixation sutures on the seventh postoperative day but may occasionally cause persistent concern because of resultant asymmetry. Slowly resulting asymmetric ptosis is often related to hematoma or edema of Mu¨ller’s muscle. Occasionally, residual pretarsal edema may be detectable for up to 6 months, but is usually satisfactorily camouflaged by cosmetics following suture removal. Lid edema and size is generally greater in the morning than in the evening because of postrecumbency edema. I tell patients that this serves as a guide to determine the progress of healing. Healing is complete when intraday differentials in pretarsal edema are no longer apparent. For small double eyelids, edema is generally undetectable 3 to 4 weeks postoperatively, whereas following the creation of a medium-sized eyelid, slight edema may persist for 6 weeks or more. Following westernization procedures, residual edema may be detectable for 3 and as long as 6 months postoperatively. Undoubtedly the most common source of dissatisfaction in Asian patients undergoing upper blepharoplasty is postoperative asymmetry of the lid folds. This deformity occasionally occurs even in the hands of the most experienced surgeon. Postoperative asymmetry is more likely to occur when lid or brow asymmetry exists preoperatively, and each prospective candidate for upper
blepharoplasty must be carefully evaluated in this regard. Minimal ptosis also predisposes postoperative asymmetry. If preoperative asymmetry exists, it must be carefully pointed out to the patient, explaining that exact postoperative symmetry is more difficult to achieve. Such asymmetry must be carefully documented in the medical record by preoperative photographs. Meticulous preoperative marking with the skin tensed, detailed measurements, and repeated comparison of the two sides as fixation sutures are placed before skin closure is critical to minimizing the development of postoperative asymmetry. Slight asymmetry in the early postoperative period is very common because of differential swelling of the eyelids and the slight degree of ptosis that may temporarily follow fixation procedures. Although patients are concerned about this asymmetry, my approach is carefully to explain this problem and defer any consideration of revision until edema has resolved. Occasionally, more marked lid asymmetry caused by obvious failure of one or more fixation sutures deserves earlier correction, repair being easily accomplished by replacement of the failed sutures as described elsewhere [1–4]. The keys to a happy patient are clear communication of goals related to eyelid appearance;
Fig. 3. (A, B) Surgical creation of a medium, oval double eyelid with an inside fold. The incision was placed 8 mm above the ciliary margin, and 50% of the maximum amount of skin that could be removed (as determined by forceps pinching) was actually removed.
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Fig. 4. (A, B) Surgical creation of a large, round double eyelid with an outside fold. The incision was placed 9 mm above the ciliary margin, and the maximum amount of skin that could be removed as determined by forceps pinching, less 3 mm, was actually removed.
management of expectations (eg, possibility of asymmetry); and meticulous technique.
Management of the epicanthus Although approximately 90% of Asians exhibit an epicanthus of variable size, in most individuals the fold is relatively small. Aesthetically successful effacement only rarely requires complex procedures described for management of this condition in the white eyelid. A major reason for the relative ease in managing the Asian epicanthal fold is that, in contrast to the epicanthus encountered in whites, in which a vertical shortage of skin is problematic, the epicanthal fold in the Asian lid is usually associated with horizontal skin redundancy of the entire upper lid. This can be demonstrated by medial displacement of the skin with cotton-tipped applicator. Successful effacement of the fold can be conceptualized as an advancement procedure. The goal of this advancement, in addition to effacement of the fold itself, is to elongate the entire palpebral fold in the medial direction. Further benefits to this maneuver are the production of a longer-appearing eyelid in patients concerned with small eyes because of large epicanthal folds (effacement results in an apparent increase in the lateral dimension of the eye) and an apparent narrowing of the nasal dorsum, a wide dorsum being of concern to many individuals with prominent epicanthal folds. In many patients, no specific intervention in the epicanthal area is necessary. This group includes those who desire an inside fold and other patients with a small, almost rudimentary epicanthus in whom the surgical approach used to create the lid fold results in sufficient medial advancement of the epicanthus to achieve aesthetically beneficial effacement. A major advantage in minimizing surgery in that medial canthus region is reduction in the risk of hypertrophic scarring. This region exhibits
a biologic predisposition to hypertrophic scar formation, and even the most meticulously performed procedure in this area may be complicated by an aesthetically unpleasant scar. In keeping with the reduction in requests for westernization of the Asian eyelid, most patients who desire epicanthal modification can be treated by conservative procedures involving undermining, small excision of pretarsal orbicularis beneath the epicanthal fold, and medial advancement with fixation sutures. More extensive procedures for epicanthal modification are described in detail elsewhere [1,2]. Many surgeons, citing concerns about hypertrophic scarring, encourage patients not to undergo surgical modification of the epicanthus, further suggesting that such surgery invariably produces an unnatural look incompatible with the Asian face. Failure to modify the epicanthus deprives many eyes of their full aesthetic potential, however, and in many cases is a source of patient unhappiness with an otherwise successful blepharoplasty. The flexibility in a range of effacement possible using available procedures allows the aesthetic surgeon to select an operation that results in a modified epicanthus that blends harmoniously with the eyelid and face. To combat the tendency toward hypertrophic scar formation, inject 0.1 mL of triamcinolone (10 mg/mL) in each epicanthal region (regardless of the type of intervention) intraoperatively before closure. This technique markedly diminishes the incidence of hypertrophic scars and postoperative induration in this area. Postoperatively, massage of the epicanthal aspect of the incision with or without topical corticosteroid creams is of additional benefit in reducing scar formation. Occasionally, postoperative triamcinolone injection is indicated. Such treatment invariably results in satisfactory healing.
Considerations in Asian Cosmetic Surgery
Lower blepharoplasty As in the upper eyelid, the Asian lower lid characteristically exhibits a considerable volume of periorbital fat that frequently produces a puffy appearance even at an early age. In many patients, considerable fat is present in the submuscular plane (superficial to the orbital septum), accentuating fullness. Although a wide spectrum exists, Asian skin is generally thicker than white skin and deeply etched rhytids extending laterally occur less frequently. Eccrine syringomas occur on the lower eyelid skin in some individuals and such patients must understand that these blemishes are not eliminated by blepharoplasty. Pigmented lesions are also common on the lower eyelids. Frequently, hypertrophy of the orbicularis muscle is present. Such patients must be counseled regarding the differences between fullness caused by fat protrusion and orbicularis hypertrophy and the aesthetic and technical limitations of partial muscle resection. The fullness of the Asian lower lid may tempt the surgeon to recommend a transconjunctival approach. Most Asian patients, however, are firmly convinced that ‘‘too much skin’’ is a component of their problem, and dissatisfaction often follows an operation that does not remove skin. This observation, coupled with the fact that transconjunctival blepharoplasty does not allow modification of orbicularis hypertrophy, is the reason that the skin-muscle flap approach is my procedure of choice for all but the very young patient with no concern about skin excess or men whose only concern is ‘‘bags’’ resulting from fat protrusion. Lower blepharoplasty is an imperfect operation that has inherent limitations; the results are rarely as dramatic as those of upper blepharoplasty, except perhaps in the occasional patient who exhibits massive ‘‘bagginess.’’ Residual wrinkling is often a nagging concern, especially in Asian patients, and the surgeon walks a tightrope between residual rhytids and lower lid malposition secondary to overzealous tissue removal. Skin resurfacing procedures that often placate white patients are generally problematic in the Asian because of intolerance to prolonged discoloration. I have described my technique for lower blepharoplasty in detail elsewhere [2]. The most important consideration in this operation is preservation and reinforcement of the anatomic support of the lower eyelid. This is accomplished by preserving the pretarsal orbicularis adherence to the tarsal plate and placement of a permanent suspension suture of 5-0 nylon between the deep surface of orbicularis muscle and lateral orbital periosteum. The interested surgeon may wish to review my
conceptualization the dynamics of lower lid support, the cause of postoperative lower lid malposition, and the rationale for using the five-point operative program in each and every patient [2].
Asian rhinoplasty The goal of aesthetic rhinoplasty in the Asian nose is similar to that of Occidental rhinoplasty: creation of a strong, smooth dorsum exhibiting a prominent origin at the nasion but not competing with the tip as the leading point of the nasal profile. A delicate, well-defined lobule with definite columellar ‘‘show’’ and an oblique anteroposterior orientation of the nares contributes an equally important but seldom emphasized goal of surgery. The characteristic anatomy of the Asian nose generally requires an augmentation procedure rather than reduction. Although it might be assumed that the popularity of this operation reflects a desire for westernization, it should be noted that in many Asian cultures the high, narrow nasal bridge is an aesthetically desirable feature. In contrast, patients from the northern and central latitudes of eastern Asia may benefit from the classic techniques in reduction rhinoplasty. These patients may specifically request reduction and refinement of the lobule or alar base reduction. Because the lower lateral cartilages may be poorly supported in such individuals, techniques to increase tip support and projections may be indicated. Few procedures in facial plastic surgery elicit the controversy that surrounds augmentation rhinoplasty in the Asian nose. Historically, many materials have been used to augment the nose. At the present time, Western surgeons prefer autogenous material, whereas in Asia, use of silicone implants predominates. Evolution in the technology of silicone implants has continued as softer-grade silicone elastomers have become available for implant fabrication. Softer implants translate into increased flexibility, resulting in reduced tension at the implant-tissue interface. The incidence of infection, displacement, or extrusion is substantially lower than the experience with augmentation of the non- Asian nose using solid alloplastic implants. The reason for this greater tolerance is unknown but may be related to a greater thickness of skin and subcutaneous tissue. Complications are most commonly caused by technical error or occasionally infection rather than an inherent problem with the operation itself. Although autogenous material, when available, is preferable to alloplastic implants, many Asian patients are unhappy with the results of nasal augmentation using autogenous cartilage and bone because satisfactory
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sculpturing of the lobule is often not achieved. Techniques of tip rhinoplasty that are highly successful in the white nose are frequently unsatisfactory in the Asian nose because the attenuated lower lateral cartilages are not strong enough to accentuate tip projection and support, and the lobular skin and subcutaneous tissue is too thick to transmit sculpturing of the delicate cartilage. In some cases, only slight augmentation of the dorsum is required, and in such cases autogenous cartilage is an excellent choice. Mersaline mesh, Gortex, or homograft materials constitute alternatives to silicone implants for these patients. The decision to use autogenous or alloplastic material is individualized according to the desires of each patient with regard to the extent of lobular sculpturing and dorsal augmentation. Anatomic factors, such as skin thickness and configuration of the lower level cartilages, are factors in determining the type of procedure to be followed. I prefer silicone implants in most patients who request lobular definition or tip projection in addition to dorsal augmentation. Thin lobular skin or substantial fibrosis resulting from previous surgery constitutes a relative contraindication to the use of silicone
implants. Given the current social and medical legal environment, the feelings of each individual patient regarding use of alloplastic materials must be considered in the final decision of which material to use. Some surgeons use alloplastic material only for augmentation of the dorsum and use only autogenous material for the tip and lobule. In such operations, discontinuity between the dorsum and lobule is a risk, frequently being unapparent until final resolution of postoperative edema. In my experience, the use of L-shaped silicone prostheses provides the advantage of preserving continuity between the dorsum and lobule (Fig. 5). Results achieved using autogenous cartilage and alloplastic materials for dorsal augmentation in conjunction with standard tip plasty techniques are often suboptimal because of the failure of the standard techniques of lobular surgery to improve tip aesthetics in the Asian nose. The ability of an L-shaped implant to sculpture the lobule and augment the dorsum in continuity with the lobule is the reason for improved aesthetic results, and focusing on augmentation of the dorsum in the Asian nose rather than on improved lobular aesthetics
Fig. 5. (A, B) Preoperative and postoperative result of augmentation rhinoplasty using an L-shaped silicone implant.
Considerations in Asian Cosmetic Surgery
led to inferior results. Use of an L- shaped prosthesis allowed for a shift of my primary focus in augmentation rhinoplasty to enhancement of the lobule, just as in white reduction rhinoplasty, relegating dorsal augmentation as a component of the procedure that must complement, not overwhelm, lobular enhancement. Safeguards for successful augmentation rhinoplasty with L-shaped silicone prostheses are presented in Box 1.
Rejuvenation of the aging face Successful rejuvenation of the aging face and neck demands a careful assessment of various factors that may contribute to the deformity manifested by each individual patient. I have found that there are two keys to successful surgical rejuvenation: adequate management of midfacial ptosis (ie, the nasolabial fold); and management of deformities related to the anatomic configuration of the anterior platysma muscle. Cervical lipectomy with liposuction and anterior platysma approximation, if indicated, enables dramatic and lasting rejuvenation of the neck. Understanding the mechanisms of midfacial ptosis and the methods of its correction using subperiosteal midfacial dissection or other methods of malar fat pad elevation accompanied by debulking of the nasolabial mound using microliposuction and injection of filler materials into the nasolabial fold generally enables a successful attack on this problem.
Box 1: Safeguards for successful augmentation rhinoplasty with L-shaped silicone prostheses 1. Do not thrust the nasal tip anteriorly with a columellar strut. 2. Remember that the columella strut has two primary functions a. Proximal stabilization of the implant in the midline b. Columellar sculpturing 3. Carve each implant individually according to the nasal anatomy anesthetic desires of each patient. 4. Ensure that there are no sharp surfaces on the implant. 5. Dissect an adequate pocket precisely in the midline, ensuring that there is no tension whatsoever on the implant. 6. Be conservative in selection of prosthesis size. 7. Use soft silicone elastomer for all components of the prosthesis.
Anatomic differences between the Asian and white face and neck are manifested in skin thickness and texture, patterns of fat accumulation, and skeletal structure. In general, Asian skin tends to be thicker and the face and neck tend to accumulatemore fat during the aging process than the white face and neck. This fat accumulation tends to concentrate in the jowl, nasolabial mound, and buccal regions. The clinical significance of fat accumulation in these areas is accentuated by the skeletal structure of the Asian face (ie, prominent malar eminences associated with relative deficiency of the premaxillary region that results in shallowness of the midface and deepening of the nasolabial folds). Wide, prominent mandibular angles are often present contributing to a square, flat face. Although the goals for rejuvenation of the aging face and neck are the same in Asian as in white patients, variations in anatomy dictate greater emphasis on management of fat accumulation particularly in the nasolabial mound and jowl and management of the nasolabial fold. The anatomy of the Asian face does not otherwise necessitate substantial modification of surgical techniques for successful facial rejuvenation. A detailed description of the evolution of techniques for facial rejuvenation and my reasons for favoring certain techniques are presented elsewhere [2]. The technique that I now use, anterior superficial musculo-aponeurotic system (SMAS) plication [5], a procedure designed to enhance effacement of the nasolabial folds, has yielded improved results with postoperative edema of duration similar to that of subcutaneous procedures. I regard the primary cause of facial aging to be ptosis of the skin and subcutaneous fat and that the most direct and probably most effective technique of restoring this tissue to a more youthful position involves direct mobilization and plication (or actual debulking of adipose tissue) rather than attempting to elevate these tissues by traction on deeper structures located more posteriorly. This is reinforced by a study using MRI techniques confirming that the primary problem in nasolabial fold development is ptosis of the skin and subcutaneous tissue, rather than sagging of the musculofascial structures [6]. Even if the surgeon chooses to elevate the malar fat pad, aesthetic results in the midface are enhanced in most Asian patients by debulking the nasolabial mound using syringe microliposuction (Fig. 6A) or a suitable alternative (Fig. 7). Although surgeons whose primary patient population is white may dispute this contention in favor of elevating all ptotic facial fat to replace it into a more youthful position because removal of midfacial fat results in postoperative hollowness, Asian patients
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Fig. 6. (A) Microliposuction of the nasolabial mound. (B) Microliposuction of the jowl.
seem to accumulate extra fat during the aging process. An additional benefit of microliposuction is induction of some skin shrinkage over the treated area that follows this technique. Because deficiency of facial fat is rarely associated with aging of the Asian face (except in those who exhibit fat atrophy in the buccal and temporal regions), I believe that there is seldom an indication for volume restoration in facial rejuvenation of this population, as is the current trend in whites. I also use microliposuction of the jowl, and virtually all Asians face this procedure (Fig. 6B).
Summary Cosmetic surgery of the Asian face is a challenging and fascinating endeavor. In large part, the challenge relates to understanding cultural and psychologic differences that often translate into behavior that may be unfamiliar to the surgeon. Continuing efforts to understand the Asian psyche are mandatory if communication is to be effective. Any surgeon is wise to remember that there are usually several equally satisfactory surgical approaches to any problem, and the specialty is best
Fig. 7. (A, B) Preoperative and postoperative results of cervicofacial rhytidectomy with anterior SMAS plication and microliposuction of the nasolabial mound and jowl.
Considerations in Asian Cosmetic Surgery
served by keeping an open mind regarding various techniques recommended by colleagues. Most certainly, evolution and refinement of surgical techniques will impact the practice of cosmetic surgery for the Asian patient.
References [1] McCurdy JA. Upper blepharoplasty in the Asian eyelid. Facial Plast Surg Clin North Am 1996;4:7–24. [2] McCurdy JA, Lam SM. Cosmetic surgery of the Asian face. New York: Thieme; 2005. [3] Park JI, Toriumi DM, editors. Asian facial cosmetic surgey. Philadelphia: Saunders Elsevier; 2007. p. 145–51.
[4] McCurdy JA. A simplified approach to subperiosteal dissection of the midfacial region: preliminary observations. American Journal of Cosmetic Surgery 1995;12:12–6. [5] Robbins L, Brothers D, Marshall D. Anterior SMAS plication for the treatment of prominent nasolabial folds and restoration of normal cheek contour. Plast Reconstr Surg 1995;96: 1279–84. [6] Gosain A, Amarante M, Hyde J, et al. Dynamic analysis of the changes in the nasolabial fold using magnetic resonance imaging: implications for facial rejuvenation and facial animation surgery. Plast Reconstr Surg 1996;98: 622–31.
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