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Looking east: New approaches and attitudes enhance Asian blepharoplasty: The surgical subtleties of optimizing, but not obscuring, the ethnicity of the Eastern eye


Dr. Schiller
Staten Island, N.Y. One key to a successful outcome when performing blepharoplasty on Asian patients lies in understanding the ethnic anatomic differences of the Asian eye as well as the culturally diverse aesthetic variations.

26-year-old Asian patient with absence of a crease ("single eyelid").
But it is in combining that knowledge with an extreme degree of precision that consistent and predictable results are achieved, according to one expert.

"Precision is required in analysis of the patient's anatomy, in communicating with the patient about what can be achieved, in planning the procedure, and in execution," Jeffrey Schiller, M.D., tells Cosmetic Surgery Times.

Dr. Schiller is a clinical assistant professor of ophthalmology at the University of Medicine and Dentistry of New Jersey. He has taught surgical techniques in China, Singapore, Thailand and the Philippines, and in his private practice he focuses on cosmetic and reconstructive surgery of the eyelids, lacrimal system, orbit and face.

Same patient immediately after incisional double-eyelid surgery.
VISIBLE TRAITS The most identifiable trait of the Asian eyelid relates to the crease. Roughly half of all Asians lack a crease entirely, a variation described by the term "single eyelid." In contrast, the "double eyelid" describes a lid with a crease present. The crease may be shallow, interrupted, duplicated or parallel to the lid margin, or flared away from it.

Another major characteristic of the Asian eye is the epicanthic fold, or epicanthus. This vertical fold of skin on either side of the nose is prominent enough in some patients to cover the inner canthus and, in some cases, the epicanthus blends into an inner, or tapered, eyelid crease.

DISSECTING THE DIFFERENCES In recent years, magnetic resonance imaging (MRI), high-resolution ultrasound and scanning, and standard electron microscopy have been used to document anatomic differences between Asian and Western eyelids.


Same patient 10 days after CO2 laser-assisted double-eyelid surgery.
"We must understand the deep anatomy in detail if we are going to modify the surface anatomy reliably," Dr. Schiller says.

"The main anatomic difference is that the orbital septum inserts much lower on the levator aponeurosis in the Asian than in the Western eyelid," he explains. "In the Western eyelid there is a system of interconnected fibers which both attach the skin to the levator aponeurosis creating the lid crease, and hold the skin and orbicularis flat against the tarsus. In half of Asians, the lower insertion of the septum does not allow formation of these attachments. Hence the lack of a crease, and the absence of a flat platform of skin in front of the tarsus."

"Furthermore," Dr. Schiller continues, "the orbital preaponeurotic fat is both lower and more anterior in the eyelid, resulting in a fuller appearance."


Typical marking for double-eyelid incisional procedure in a young patient. Symmetry is verified with calipers.
OPENING THE EYE "Asian blepharoplasty" refers to the standard cosmetic techniques when they are applied to the special anatomy of the Asian eyelid to reverse signs of aging. However, the term can al so refer to the surgical creation or enhancement of a crease in the eyelid. This procedure is popularly called a "double eyelid" operation.

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