Asian Eyelid Research Articles

Asian Blepharoplasty

One of the defining features between an individual of Asian descent and someone of Western descent is the presence of an upper eyelid crease. Approximately 50% of Asians do not have an upper eyelid crease. The double eyelid operation, or creation of a supratarsal crease, is the most common cosmetic procedure requested in Asia and the third most common procedure requested by Asian Americans. In this comprehensive article, we explore the art of creating an eyelid crease in the individual who either does not have a crease or has an indistinct crease. We will review the history of the development of Asian blepharoplasty, explain the anatomy of the Asian eyelid and how it differs from the Caucasian eyelid, and clarify how this anatomy then translates to differences in external appearance. The two main schools of surgical techniques will be discussed along with pearls, pitfalls, and personal observations.

The Levator Aponeurosis Contains Smooth Muscle Fibers: New Findings in Caucasians

To examine the microscopic structure of the upper eyelid of Caucasians, in particular looking for evidence of the presence of smooth muscle fibers and the microscopic nature of the levator aponeurosis. Full-thickness sagittal sections of central upper eyelids from 11 postmortem upper eyelids of 7 Caucasians (age range 78-101 years at death; mean age 87.7 years) were examined. The samples were stained with Masson trichrome and were microscopically examined for the presence of smooth muscle fibers and to determine whether the levator aponeurosis comprised one or more layers. All of the samples contained smooth muscle fibers, which were located posteriorly. Evidence of a clear double-layer structure was found in only 1 sample; the other 10 samples demonstrated a single monolayer, which was not reflected to the orbital septum but continued distally. In this series of upper eyelid specimens of Caucasians, all aponeuroses contained smooth muscle fibers, the distribution of which was more concentrated posteriorly, identical to previous findings in Asian eyelids and suggestive of a possible common mechanism of eyelid tension regulation between races. Most of the levator aponeuroses examined had evidence of a single monolayer only; this represents a further absolute difference in the microanatomical structure of the upper eyelids between Caucasians and Asians.

Long-term Functional and Cosmetic Outcomes after Frontalis Suspension Using Autogenous Fascia Lata for Pediatric Congenital Ptosis

To assess long-term functional and cosmetic outcomes after frontalis suspension using fascia lata autografts for congenital ptosis in Asian children. Retrospective, observational case series. Two hundred thirty-nine patients who underwent frontalis suspension using fascia lata autografts from 1998 through 2006 with a minimum of 6 months of follow-up. Functional success was assessed by review of photographs and medical charts. Cosmetic success was scored by objective analysis of photographs. Functional success was defined as improvement of eyelid position above the pupillary margin without serious complications. Cosmetic outcomes were assessed in terms of lid contour, symmetry of height bilaterally, and lid crease and were categorized as excellent, good, or poor at 1 month and at 6 months after surgery. The follow-up time ranged from 6 to 144 months (median, 18 months). The functional success rates were 100% at 1 month after surgery and 94% at the last follow-up. In the early postoperative period, 96.7%, 91.6%, and 97.5% of patients showed excellent cosmetic success rates regarding lid contour, symmetry, and lid crease, respectively. However, these rates decreased to 85.4%, 65.7%, and 66.9% at 6 months after surgery, respectively (P<0.001). Similarly, the mean grades for lid contour, symmetry, and crease were lower at 6 months compared with early after surgery (P<0.001). The only cosmetic parameter that differed between unilateral and bilateral patients was symmetry of height at 6 months after surgery. The occurrence of medial eyelash inversion increased from 0.8% at 1 month to 11% during the postoperative follow-up, and these cases required medial suspension release and strong double lid crease formation. The use of fascia lata autografts for pediatric congenital ptosis resulted in high functional success rates in both the short-term and long-term. In contrast, whereas cosmetic success rates were high in the short-term, they decreased by 6 months after surgery. This deterioration in cosmetic outcome was the result of gradual elevation of lid height, medial inversion of eyelashes, and poor lid creases, possibly resulting from contracture of the grafted fascia lata and the anatomic characteristics of Asian eyelids.

Lower Eyelid Retractors in Caucasians

To examine the microscopic anatomic features of lower eyelid retractors in Caucasians, specifically looking for an anatomic division of the retractors into 2 layers, as is present in the Asian eyelid. Experimental anatomic study. Seven Caucasian cadavers (13 lower eyelids: 7 right and 6 left). Sagittal full-thickness sections of the cadaveric lower eyelids were prepared and stained with Masson's trichrome. The specimens were examined microscopically to discern the configuration of the lower eyelid retractors. Micrographs were obtained with a digital camera system attached to the microscope. Histologic findings of the lower eyelid retractors in Caucasians. Although 2 specimens were excluded because anatomic details were severely disrupted during slide preparation, all the other samples demonstrated clear double layers of the lower eyelid retractors. The lower eyelid retractors in Caucasians consist of clear double layers. In this regard, no differences were detected between Caucasian and Asian eyelid anatomic features.

Anthropometry of Asian Eyelids by Age

The normal morphologic and functional values of eyelids and orbits vary according to race, sex, and age. Unfortunately, there is a paucity of information related to these values in Asians, leading Asian surgeons to use statistical data from Caucasians. The authors quantified and statistically analyzed nine morphologic and functional values in 234 Asian male and 264 Asian female subjects. Among adults, the mean value for the palpebral fissure was 27.0 +/- 1.8 mm in males and 26.8 +/- 1.7 mm in females in the horizontal dimension and 8.0 +/- 1.0 mm in males and 8.2 +/- 1.1 mm in females in the vertical dimension. The average slant of the palpebral fissure was 7.9 +/- 2.4 degrees in males and 8.8 +/- 2.3 degrees in females, and the average height of the opened upper eyelid was 12.4 +/- 2.4 mm in males and 12.0 +/- 1.9 mm in females. The average height of the double fold in the closed eye was 6.6 mm in males and 6.5 mm in females, and the average intercanthal distance was 38.4 +/- 3.0 mm in males and 38.2 +/- 2.8 mm in females. The average interpupillary distance was 64.6 +/- 2.9 mm in males and 63.6 +/- 2.9 mm in females. The peak level of growth in the vertical dimension of the palpebral fissure was reached between ages 10 and 13 years, that of the intercanthal distance between ages 14 and 16 years, and that of the horizontal dimension of the palpebral fissure between ages 17 and 19 years.

Lid margin split in the surgical correction of epiblepharon

To describe the technique of splitting the lid margin combined with the excision of redundant skin and muscle during the surgical correction of epiblepharon and to report its clinical outcome. A combined procedure that included splitting the lid margin to repair lower eyelid epiblepharon was performed on 31 eyes of 19 consecutive patients. Lid margin splitting was performed along the grey line on the medial third or half of the lower eyelid by making a 1 mm-deep incision. Having made a transverse subciliary skin incision and a dissection between the tarsus and the orbicularis oculi muscle, the subcutaneous tissue of the superior edge of the incision was secured to the tarsus with interrupted sutures to evert the cilia. An excision of the redundant skin and orbicularis tissue was made and the skin was closed. The patients were followed for direct inspection of the wound, the split lid margin, the direction of the lashes and the status of the cornea. The mean postoperative follow-up period was 29.4 weeks. Symptoms disappeared in all patients. In 30 eyelids of 19 patients the cilia did not touch the cornea, even in the down-gaze. In one eyelid the cilium touched the medial conjunctiva, but not the cornea. The cosmetic outcome of the lower lid was satisfactory in all cases and the wounds of the split lid margin healed without scarring. To date, there have been no complications such as wound dehiscence, ectropion or eyelid retraction. The lamellar splitting of the lid margin is a beneficial addition to the repair of prominent lower lid epiblepharon, especially on the medial aspect of the eyelid. This simple technique ensures easier eversion of the cilia in epiblepharon repair, without disturbing the posterior lamella or causing unfavourable results.

Asian upper blepharoplasty double-fold procedure

The author describes how to create a double eyelid in Asians by use of three different techniques, noting advantages and disadvantages related to postoperative swelling and recovery time, wrinkle removal, scarring, and longevity of results. Technique selection is based on patient preference and careful evaluation of patient skin and upper eyelid fat tissue.

Medial Epicanthoplasty Using the Skin Redraping Method

Background:The presence of epicanthal folds and the absence of supratarsal folds are unique features in the eyelids of Asians. The resulting appearance leads many to seek cosmetic improvement in the medial canthal area. Although many techniques have been described for the elimination of epicanthal f

Simple Epicanthoplasty with Minimal Scar

This article makes for interesting reading about a technique that is easy to follow and perform. However, I am not sure that the concept is entirely original. I have performed a similar technique for the past 5 years, taught to me by a Japanese doctor, Dr Keizo Fukuta of Nagoya [1]. The sole difference is that with Dr. Fukuta s technique (Fig. 1a and b), the tiny triangular skin flap is taken from the terminal part of the epicanthic fold below the level of the horizontal limb and rotated 90 horizontally, whereas with the reported technique, the flap is derived from the skin above the level of the horizontal limb. This is a useful modification because it attempts to blend the vertical limb of the scar into the double-eyelid fold. However, judging from the photographs provided, it may not confer as powerful a correction of the epicanthic fold as the Fukuta technique. With the latter technique, the vertical limb may sometimes be visible as a scar over the medial aspect of the lower lid, but the correction is significant and lasting (Fig. 2a d). Whatever the case, both procedures are cosmetic improvements over the traditional techniques used for epicanthal correction, for which visible scarring has always been a problem. However, I believe the article perpetuates some stereotyping and conceptual misperceptions of the Asian eyelid that need to be corrected because westernization of the Asian eye is not a uniform goal of those seeking cosmetic improvement of the upper lid. Not all Asian eyelids are characterized by thick upper eyelid skin and orbicularis oculi muscle, excessive fat distributed between the orbicularis oculi muscle and the levator palpebrae muscle, laxity of the pretarsal fold and absence of supratarsal folds due to lack of levator palpebrae attachments to supratarsal skin, and the presence of a medial epicanthal fold (Fig. 3). Almost all Asians have some form of epicanthic fold whether there is an accompanying double-eyelid crease or not. When present, the double-eyelid crease or palpebral fold exists in two forms: an ‘‘innie’’ (in which the crease blends medially with the epicanthic fold; Fig. 4a and b) or an ‘‘outie’’ (in which the fold runs parallel with the lid margin; Fig. 5a and b). Some individuals may have an ‘‘innie’’ on one side and an ‘‘outie’’ on the other side (Fig. 6). This palpebral fold in the Asian upper eyelid is a true ‘‘double’’ eyelid because it is a pretarsal crease caused by folding of the pretarsal skin and not just a supraorbital hollow or sulcus (Fig. 7a), which characterizes many Caucasian lids. This latter Correspondence to W. Wu, M.D.; email: woffles@ woffleswu.com Fig. 1. (a) Fukuta technique, preoperative markings. (b) Fukuta technique, postoperative diagram of flap rotation. Aesth. Plast. Surg. 31:354 357, 2007 DOI: 10.1007/s00266-006-0205-6

Simple Epicanthoplasty with Minimal Scar

Asian eyelids are characterized by the presence of an epicanthal fold and the absence of a supratarsal fold. Because many Asians desire wide, open, large eyes, elimination of the medial epicanthal fold along with double-eyelid operation frequently are performed for cosmetic improvement. Medial epicanthoplasty enhances the aesthetic result by lengthening the palpebral fissure horizontally, thus producing larger-looking, open eyes. This study describes the author's method for correcting the medial epicanthal fold. Simple epicanthoplasty with minimal scar, the author's method, was performed to correct the epicanthal folds of 52 patients from December 2001 to August 2005 at the Catholic University of Korea Kangnam St. Mary's Hospital. This technique yielded excellent results in terms of inconspicuous scar and long-lasting open medial canthal area during a 3-year follow-up period. Of the 52 patients, 2 showed a depressed scar on the lower eyelid, which was corrected satisfactorily. Many procedures have been introduced to correct the epicanthal fold, but scarring or undercorrection remains as a dilemma for surgeons to overcome. Simple epicanthoplasty with minimal scar is a simple, easy-to-follow, and effective method that can be applied to various cases of medial epicanthal fold.

Medial Epicanthoplasty Using the Skin Redraping Method

The presence of epicanthal folds and the absence of supratarsal folds are unique features in the eyelids of Asians. The resulting appearance leads many to seek cosmetic improvement in the medial canthal area. Although many techniques have been described for the elimination of epicanthal folds, scarring and design complexity are barriers that must still be overcome by surgeons. From December of 2002 to December of 2004, the authors performed medial epicanthoplasties using the skin redraping method (tension-free epicanthoplasty) to correct epicanthal folds in the eyelids of 215 Asian patients. The authors' method is very simple to design and easy to perform. The procedure requires only the elevation of skin, eliminating volume of muscle, and trimming of skin. Other ancillary procedures, such as flap design, anchoring, plication, or subdermal fixation, are not required. Most of the patients obtained satisfactory results. No patients complained about visible scarring and none required revision surgery. Scarring can be avoided on the noticeable medial canthal region because the only incisions needed are supratarsal and subciliary incisions. The ability to avoid tension resulting from skin redraping is another important factor contributing to the minimization of scarring. The skin redraping method is simple to design and easy to perform. It does not create tension or visible scars on the medial canthal region.

Modified Split V-W Plasty for Entropion with an Epicanthal Fold in Asian Eyelids

The epicanthal fold, which is peculiar to East Asians, forms an arch across the medial canthus in parallel with the nose. It is often accompanied by entropion of the medial eyelid. Although many surgical procedures have been described for correction of the epicanthal fold, none has reported a procedure to treat the epicanthal fold and entropion at the same time. The authors have performed a modified split V-W plasty to simultaneously correct entropion and to modify the epicanthal fold. From January of 1998 to December of 2002, we have performed a modified split V-W plasty in 20 cases. The preoperative and postoperative medial canthal distances and palpebral fissure width were measured, and the extent of postoperative scarring and improvement of the epicanthal fold and entropion were reviewed. This method provided good results, including an inconspicuous scar, release of the epicanthal fold, and improvement of entropion. The authors believe that the modified split V-W plasty is available to eliminate entropion with an epicanthal fold in Asian eyelids.

P92: Upper Blepharoplasty for Asian Eyelid Is Not a Westernizing Procedure

P92: Upper Blepharoplasty for Asian Eyelid Is Not a Westernizing Procedure

Lower Lid Epiblepharon as the Presenting Feature of Spontaneous Dural Carotid Cavernous Fistula in an Asian Patient

Lower lid epiblepharon is a relatively common problem among young Asian patients. Occasionally, it may be secondary to underlying orbital pathology. We report a 33-year-old Chinese patient with a dural carotid cavernous fistula who presented with an ipsilateral lower lid epiblepharon in the absence of any other significant signs. After a recurrence following primary corrective lid surgery, she was investigated further because of mild ipsilateral proptosis. CT-scans of the orbit revealed an enlarged superior ophthalmic vein and a dural carotid cavernous fistula was confirmed on angiography. Subsequent embolisation of the fistula led to resolution of the proptosis as well as the epiblepharon. We believe that extension of orbital fat to the inferior tarsal border in Asian eyelids together with a poorly fixed anterior lamella contributes to the occurrence of epiblepharon when the Asian orbit becomes congested. The new onset of such features in the Asian patient should lead one to suspect underlying orbital pathology, even in the absence of other, more classic signs.

Microscopic anatomy of the lower eyelid in asians.

To study the microscopic anatomic relation of the capsulopalpebral fascia, orbital septum, and tarsus of the lower eyelid in Asians. The anatomic differences between the Asian and non-Asian upper eyelid have been well described by various authors, but the differences of the lower eyelid have not been well characterized microscopically. The microscopic anatomy of the lower eyelid in non-Asians was well studied, but in Asians, despite the presence of gross differences, there were very limited studies on the microscopic anatomy. A thorough knowledge of the Asian lower eyelid anatomy is essential for surgical exploration of the eyelid. It may also explain the higher prevalence of eyelid disorders such as epiblepharon and entropion in Asians. Ten normal Asian lower eyelids from 10 formalin-fixed cadavers (mean age, 67.5 years) were harvested and studied with light microscopy after staining with Masson trichrome. There was no fusion of the orbital septum and the capsulopalpebral fascia at the lower border of the tarsal plate in 7 specimens and a very limited fusion of these tissues in 3 specimens. The average distance from the inferior tarsal border to the first observable smooth muscle nuclei of the inferior retractors was 1.44 mm. The average tarsal plate thickness was 1.36 mm and the average tarsal plate height was 4.12 mm. The Asian lower eyelid anatomy differs from its non-Asian counterpart. There was no consistent fusion between the capsulopalpebral fascia and the orbital septum inferior to the inferior tarsal border. No extension of the capsulopalpebral fascia to the skin was observed. The average distance between the inferior retractors and the inferior tarsal plate was 1.44 mm in the normal Asian lower eyelid.

Racial and Ethnic Differences in Ocular Anatomy

Differences in eyelid structure are well described in the literature with respect to the Asian eyelid, but discussion of differences in eyelid structure between the other races is scarce. Most of the literature focuses on distinctions between “double” and “single” eyelids. Other clinical and surgical considerations are the presence of epicanthi and palpebral fissure slant. By understanding racial and ethnic anatomical differences, oculoplastic surgeons will be able to optimize function and aesthetics. Asians may have fuller, thicker-appearing upper eyelids with an absent or relatively lower upper lid (supratarsal) fold, making the distinction between the single and double eyelid (Figs 1, 2). The orbital septum of Asians fuses with the levator palpebrae aponeurosis at variable distances below the superior tarsal border, closer to the eyelid margin than in non-Asians. This hinders aponeurotic fibers from the levator palpebrae superioris from reaching the subcutaneous tissues, prohibiting the creating of a double eyelid crease. The fusion is above the superior tarsal

Medial Epicanthoplasty Combined with Plication of the Medial Canthal Tendon in Asian Eyelids

The authors present a new technique for the correction of the medial epicanthal fold using the Y-W-plasty or inverted Y-V-plasty combined with plication of the medial canthal tendon. From January of 1996 to April of 2001, 10 patients with epicanthal folds received a medial epicanthoplasty combined with plication of the medial canthal tendon. The patients ranged in age from 20 to 49 years (average, 27.3 years). Eight patients with epicanthal folds received the Y-W-plasty with plication of the medial canthal tendon. Two patients were operated by inverted Y-V-plasty. The follow-up period ranged from 5 months to 2 years. Neither injury of the lacrimal apparatus nor asymmetry of the eyes was noted. Fibrosis and redness of the operated scar was noted in the first 2 to 3 months. However, the scar maturated by 3 months in all patients, and the hypertrophic scar was unnoticeable in all patients. Two key modifications of this technique are plication of the outer leaflet of the medial canthal ligament and lateral advancement of the central triangular flap. These modifications remarkably reduce the tension along the skin suture line. This method is very effective for the correction of the moderate-to-severe epicanthal fold. In addition, these modifications can be applied in most other medial epicanthoplasty techniques.

Root z-epicanthoplasty in asian eyelids.

In the eyelids of Asians, the presence of epicanthal folds and the absence of supratarsal folds are a unique feature. The resulting appearance leads many to seek cosmetic improvement in the medial canthal area. Although many techniques have been described for the elimination of epicanthal folds, scarring and complexity in design are still barriers for surgeons to overcome. From July of 1998 to May of 2000, the authors used root Z-epicanthoplasty on the eyelids of 30 Asian patients to correct epicanthal folds. Results were satisfactory in all patients, with no complications. Root Z-epicanthoplasty, as performed by the authors, is a simple design and procedure; there is minimal scarring in the medial canthal area and no tension.

Root Z-Epicanthoplasty in Asian Eyelids by Won-Min Yoo, M.D. Sang-Hyeon Park, M.D. Dong-Rhyul Kwag, M.D.

Root Z-Epicanthoplasty in Asian Eyelids by Won-Min Yoo, M.D. Sang-Hyeon Park, M.D. Dong-Rhyul Kwag, M.D.

No-scar Asian epicanthoplasty: a subcutaneous approach.

The epicanthal fold is a normal finding in the medial portion of the upper eyelid in many Asians. We describe a simple technique of removing the excess muscle and softening or eliminating the epicanthal fold without making incisions in the medial canthal region, thus avoiding complications such as scarring or web formation Interventional case series. The subcutaneous epicanthoplasty was performed on all Asian patients undergoing concurrent upper eyelid blepharoplasty or aponeurotic ptosis repair. Thirty-eight Asian patients underwent epicanthal fold correction between January 1996 and December 2000. All patients had softening of the epicanthal fold; however, some cases of mild undercorrection were noted. Softening or elimination of the Asian epicanthal fold can be accomplished without making skin incisions in the medial canthal region. Our technique is a simple, graded procedure that can be performed in conjunction with upper blepharoplasty or ptosis repair.