Written by Dr. Julian De Silva
In many parts of Asia, double eyelid surgery, also known as Asian Blepharoplasty is the most popular cosmetic procedure. London as an exciting multicultural city, has a relatively high demand for Asian Blepharoplasty. Although there are a variety of reasons why Asians seek eyelid cosmetic surgery, a common reason to improve the appearance of their eyes, to “open-up” the eyes. The procedure has become increasingly popular with teenagers and young adults undergoing the procedure with their parents consent in some Asian countries. Although the popularity of double eyelid surgery has grown rapidly in the last decade, the presence of a defined eyelid crease has long been valued because it is seen as an attractive and expressive appearance.
Dr. De Silva has found that there is large natural variation in the appearance of Asian eyelids and that is key that patients expectations are clarified before surgery as the position of the double eyelid can be customised according to patient’s wishes. “I prefer to use the patient’s natural facial aesthetics in shaping and designing a double eyelid fold, for it to be both natural and in harmony with a patient’s face. Asian blepharoplasty is a surgery of finesse and detail, even 1mm difference between the two eyelids can be readily seen.” The variability in appearance of the Asian eyelid has underlying anatomical and cultural differences that need to be considered with Asian blepharoplasty. Dr. De Silva believes that eyelid reshaping requires a balance in considering the natural shape of the eyelid, consideration of a crease if present, tapering of the natural crease and the presence of an epicanthic fold. Asian blepharoplasty encompasses a large number of very different shaped eyelids such as Chinese, Japanese, Korean, Malaysian all with relatively unique anatomy that requires specialist techniques to achieve a natural looking result.
Dr. De Silva is a facial cosmetic surgeon specializing in the face only, he does not perform body plastic surgery. He is known for natural looking results and uses the most innovative and contemporary techniques from Beverley Hills and Manhattan. Blepharoplasty is the most common cosmetic surgery he performs, Asian blepharoplasty is considered to be technically a difficult procedure, which is why some cosmetic and plastic surgeons do not perform asian blepharoplasty. The most common reasons people seek Asian blepharoplasty is for opening up the eyelids and improving their aesthetic appearance. Patients may also describe of functional difficulty in seeing if in combination with facial ageing the extra soft tissue in the upper eyelid obscures the person’s vision. Dr. De Silva specializes in the fine detail of facial cosmetic surgery, having trained in microscopic surgery where fractions of millimeters define success. He worked in the NHS for over 10-years before working in Beverley Hills and New York, bringing the most innovative techniques to his practice in London. Dr. De Silva has presented at international meetings, won prizes and led teaching programs on surgical practice and quality of care.
Asian blepharoplasty is usually an outpatient procedure performed under local anaesthesia with or without sedation. The procedure may be performed as a skin-incision method (small skin crease incision) or stitch method (virtually scar-less incisions with fast recovery). The procedure takes between 1-2 hours and afterwards stitches are placed in the eyelid and the patient is reviewed after 1-week. Shaping the eyelid is a challenging procedure as every Asian eyelid is unique in skin type and thickness, epicanthic fold and relative fullness. Dr. De Silva uses both skin-incision method and stitch method depending on a patient’s specific anatomy and expectations from surgery. Dr. De Silva uses suture and micro-refinement techniques to maximise the result, uses the most innovative facial plastic surgery techniques to maintain a natural appearance. Dr. De Silva is previous written book chapters on Asian blepharoplasty technique and is currently writing a facial cosmetic and plastic surgery book that features Asian blepharoplasty techniques.
What is Asian blepharoplasty?
The Asian eyelid has a different anatomy to the Caucasian eyelid, and approximately 50% of Asians have no defined eyelid crease. The eyelid crease divides the upper eyelid into two segments known as a double eyelid shape. The majority of Asian patients who seek cosmetic Asian blepharoplasty do not want to look “Westernized,” they would like to keep their ethnicity and look like other Asians who have more open eyes and a natural looking eyelid crease.
The images below are taken from Dr. Julian De Silva’s book on Facial Cosmetic & Plastic Surgery, showing the difference between Asian and Caucasian eyelids.
In comparison with a Caucasian shaped eyelid, where characteristically there is a well-defined eyelid crease resulting in a more open and larger eye appearance.
What is a double eyelid crease?
The eyelid crease is a naturally occurring fold in the upper eyelid skin that dived the upper eyelid into two parts. Although half of the Asian population have a crease it is often poorly defined. Double eyelid crease surgery is another name for Asian blepharoplasty.
Why have Asian blepharoplasty?
Common reasons for undergoing double eyelid crease surgery are to have a more open looking eye that is regarded as more attractive. Motivations for surgery are specific to each person and other reasons include ability to apply make-up without smudging, improve symmetry, reduce fullness of upper eyelid and to replace the need for eyelid taping.
What are the different types of Asian eyelid creases?
There are a variety of naturally occurring shapes to the Upper Eyelid Crease in Asians. Dr. De Silva tailors his surgery to the patients’ own anatomy and their preference. The goal of the surgery is to achieve the patients’ expectations which commonly involves the creation of a natural Asian crease or a more open Caucasian crease.
- Parallel crease- The eyelid crease is in parallel to upper eyelid
- Temporal flare crease- The eyelid crease has an increased height from the eyelid towards the ear
- Nasal slant crease- The eyelid crease has increased height from the eyelid towards the nose
What does Asian Blepharoplasty surgery involve?
There are over twenty differently reported techniques on Asian Eyelid Blepharoplasty which can be divided into three principal methods: the suture method, the partial-incision method and the skin-incision method.
- The Skin-incision Method (Trans-Cutaneous Approach)
This method of Asian Blepharoplasty is the most effective long term, it involves making a skin incision in the natural crease of the skin, which is usually invisible in a few months. Eyelid surgery can result in swelling and bruising that takes several weeks to settle. The benefit of the skin-incision methods is that it enables a natural looking fold to be created that is long-lasting.
- The Suture Method
The suture or stitch method avoid any incisions in the skin, except for the passing of the stitches, and is very popular in the East particularly South Korea, China and Japan. The suture method is appealing as it avoid significant incisions in the skin and the stitches are buried underneath soft tissues and the recovery from surgery is fast. Dr. De Silva uses a customised suture method for asian blepharoplasty where the recovery is usually only a few hours. The limitation with this method is that the sutures have relatively short effect compared to the other methods as the effect is completely dependent on the stitches, which can weaken with time.
- The Partial-incision Method
The partial-incision method is a hybrid approach between the suture method and the full-incision method. Patients like this method as it has a relatively quick recovery of 1-2weeks with a small 1.5cm incision. The main disadvantage is that in some individuals their may be loss of the skin crease with time, that may be a few months to years depending on the person. The long-term effects are however better that the stitch technique alone.
In addition to the shape of the upper eyelid, the inner aspect of the eyelid can vary with the appearance of a fold of skin, termed an epicanthic fold, this may reduced the horizontal width of the eyelid. This can be improved with surgery however it not suitable for all patients. The epicanthic fold is on a more open part of the face and any incision to improve this area has more risk of scarring.
Out of the many different techniques for Asian blepharoplasty, which is best?
On reading about Asian blepharoplasty it may seem that there are many different ways in which the surgery can be completed. There are principally only three types of surgery, one that uses sutures to create the skin crease (this technique tends to be more temporary and requires repeating, although takes a shorter amount of time to complete) and skin-incision technique (through the eyelid skin, which is long-lasting). There is also a third type that is a hybrid version of the suture and skin incision method (tends to be short lasting) However there are many different types of suture techniques have been described in the surgical literature, they are all variations on the two principal methods. The preferred choice of asian blepharoplasty depends on the patient’s objectives from surgery, Dr. De Silva discusses this with patient individually to achieve a patient’s specific requirements. For patient’s looking for a rapid recovery and minimal downtime, Dr. De Silva uses his own customised technique that results in a rapid recovery of a few hours. For patients looking for a more a permanent change in the shape of their eyelid Dr. De Silva uses a customised skin incision method as this provides his patients with a natural looking and long lasting eyelid appearance.
What is suture Asian Blepharoplasty?
Dr. De Silva has customised his own suture Asian blepharoplasty technique that maximises the appearance of the open double eyelid while reducing down time and speeding up recovery. The recovery time for this procedure is usually several hours.
This figure is taken from Dr. De Silva’s forthcoming book on Facial Cosmetic & Plastic Surgery. Dr. De Silva uses fine microsurgical stitches to create a natural looking double eyelid crease.
What is the ideal height of your eyelid crease?
The height of the eyelid crease is determined by your eyelid anatomy, the height of the rigid plate in your upper eyelid that gives it its tensile strength, termed the tarsal plate. The tarsal plate has an important function in enabling the eyelid to be effective in blinking and protecting the eye. The height of they tarsal plate varies (on average is between 6.0 and 7.5 millimetres) and is unique to each person. Dr. De Silva measures the height of your eyelid tarsal plate during the procedure, and the final height of your eyelid crease is determined by the tarsal plate.
When can I return to social activities and work after Asian blepharoplasty?
The recovery from Asian Blepharoplasty is dependent on the method used for surgery. Most patients take one week off work and social activities. Approximately 80-90% of the swelling has resolved at this time. Residual bruising can be covered with cosmetics and mascara after ten days. As a result of normal swelling the upper eyelid may look to high immediately after the surgery, as the swelling reduced the skin crease height comes down. There are surgical measures that Dr. De Silva takes to minimise swelling and bruising, and there are steps that patients can take to improve the recovery period including avoiding medications and foods that encourage swelling and the use of cold compresses after surgery.
Dr. De Silva uses his own customised technique to achieve suture-method Asian Blepharoplasty, the advantage over are the methods include a rapid recovery with minimal swelling less 1-week after surgery. The customised technique is virtually scarless and gives a natural looking skin crease.
What are epicanthic folds and magic epicanthoplasty?
The epicanthic fold is the name given to the fold of skin that is on the inner aspect of the upper eyelid that drops down to the lower eyelid concealing the inner aspect of the eye in many Asians. Traditional surgery to open up this part of the eyelid resulted if the use of reconstructive plastic surgery flaps that could result in scary and an unnatural appearance. When indicated Dr. De Silva uses a newer and innovative hidden incision technique that hides the incisions along the natural eyelid lines, in Asia this technique has been described as “magic epicanthoplasty” or “upper epicanthoplasty”. The epicanthus surgery in Asian blepharoplasty is both delicate and refined and mill meters determine the final result. The magic epicanthoplasty technique does speed up recovery, reduce downtime and reduce the risk of scarring. Dr. De Silva uses this technique for specific patients to open up the eyes and enhance the double eyelid surgery while maintaining a natural enhancement.
What is lateral epicanthoplasty?
The lateral epicanthus is the outside corner of the eyelids where the upper eyelid meets the lower eyelid. In some Asian patients the outside of the eyelid is relatively narrow with marked up-slanting appearance, these patients may benefit from a procedure that modifies the position of the outside of the eyelid termed lateral epicanthoplasty. This procedure opens up the outside of the eyelid and reduces the up-slanging appearance. The lower eyelid anatomy is intricate as the eyelid has an important functional role in blinking and lubrication and lateral epicanthoplasty is not required for most Asian eyelids.
Why are Asian Eyelids Different?
In the figure below, in the Asian eyelid there is an absence of the levator muscle attachments resulting in no crease, the Asian post-septal fat is marked with a blue arrow, this results in making the eyelid appear fuller and the eye look smaller. Dr. De Silva blepharoplasty surgery is tailored to the individual as there can be marked anatomical differences in the Asian eyelid depending on ethnicity, age and environmental factors.
Will Asian blepharoplasty result in a scar?
Any incision into the skin to change the shape of the eyelid has the potential to cause a scar. Dr. De Silva hides the scar in the natural eyelid crease. The shape, contour and design of the eyelid crease is of paramount importance in hiding the scar from Asian blepharoplasty. Any scar in the skin maybe slightly red and elevated immediately after surgery then with normal healing the scar remodels to become flat and difficult to see. The eyelid scars are usually relatively hidden and difficult to see after surgery.
What are the risks of Asian blepharoplasty?
The risks are similar to upper blepharoplasty, described in a previous chapter. Key to a good outcome is relative symmetry of the eyelids, this requires meticulous attention to detail in the eyelid crease position, and volume of fat reduction in the upper eyelids. A conservative amount fat is reshaped in the upper Asian eyelid to reduce eyelid fullness. Key to a natural looking result is avoidance of over-removal of fat that results in a more hollow appearance of the upper eyelid. Asian blepharoplasty is technically more demanding that Caucasian blepharoplasty and revision rates have been reported between 5 to 20%.
Can the surgery be done under local anaesthesia?
Asian Blepharoplasty surgery takes between one to two hours and most eyelid surgery can be completed with local anaesthesia with or without sedation. The surgery can be completed under general anaesthesia, however it is not considered necessary as sedation (Monitored Anesthesia Care or MAC), is safer and a better experience for patients (faster recovery). Dr. De Silva prefers to do surgery that enables patient to have the best safety, quality and experience that is possible, with eyelid surgery this usually involves local anaesthesia with or without sedation.
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