The Asian Upper Eyelid an Anatomical Study with Comparison to the Caucasian Eyelid

CLINICAL SCIENCES The Asian Upper Eyelid An Anatomical Study With Comparison to the Caucasian Eyelid

Sangki Jeong, MD; Bradley N. Lemke, MD; Richard K. Dortzbach, MD; Yeoung Geol Park, MD; Heoung Keun Kang, MD

Objective: To evaluate the differences between Asian in Caucasians. The preaponeurotic fat pad descends an- and Caucasian upper eyelid anatomy through cadaver dis- teriorly to the tarsal plate in the Asian single eyelid, but section, histopathological study, and magnetic reso- not in the Caucasian eyelid. A pretarsal fat pad is iden- nance imaging. tified in the Asian single eyelids.

Materials and Methods: Upper eyelids of 9 Korean Conclusions: The causes of absent or lower crease in and 5 Caucasian cadavers were dissected, and then were the Asian upper eyelid are as follows: (1) the orbital sep- studied microscopically with hematoxylin-eosin, Mas- tum fuses to the levator aponeurosis at variable dis- son trichrome, and elastin stains. Four healthy young Ko- tances below the superior tarsal border; (2) preaponeu- rean men were studied by dynamic high-resolution mag- rotic fat pad protusion and a thick subcutaneous fat layer netic resonance imaging with regard to demonstration prevent levator fibers from extending toward the skin near of upper eyelid structure. the superior tarsal border; and (3) the primary insertion of the levator aponeurosis into the orbicularis muscle and Results: More subcutaneous and suborbicularis fat, with into the upper eyelid skin occurs closer to the eyelid mar- a pretarsal fat component, is present in Asian eyelids. The gin in Asians. Structural differences relating to in- Asian double eyelids showed an amount of fat interme- creased fat in the Asian upper eyelid include the pres- diate between Asian single eyelids and Caucasian eye- ence of a pretarsal fat pad and a moderate fat increase in lids. Asian single eyelids showed fusion of the orbital sep- the double Asian eyelid. tum to the levator aponeurosis below the superior tarsal border, while fusion is above the superior tarsal border Arch Ophthalmol. 1999;117:907-912

HE UNITED STATES is a melt- We have studied the Asian eyelid in ing pot with people of dif- the cadaver to demonstrate any anatomi- ferent races living together. cal differences between Asians and Cau- Presently there are approxi- casians. Noninvasive techniques for study- mately 7.5 million Asian ing the eye structures were used to obtain American people in the United States, in- additional anatomical information and dy- T 1 cluding 0.8 million Korean Americans. In- namic images of structure. Recent ad- creasingly, the North American surgeon en- vances in magnetic resonance imaging counters an Asian patient requesting eyelid (MRI) techniques have made it possible for surgery and thus encounters problems of us to study noninvasively the Asian up- anatomical and cultural differences. There per eyelid’s dynamical anatomical im- has been a lack of information concerning ages.3,4 We additionally report dynamic the terminology and the anatomical char- high-resolution MRI study findings in acteristics of the Asian eyelid. Asian single, low, and double upper eye- From the Departments of A clinically known anatomical ra- lids in staged movement. Ophthalomology (Drs Jeong cial difference in the upper eyelid be- and Park) and Radiology tween Asians and Caucasians is apparent RESULTS (Dr Kang), Chonnam in the upper eyelid crease. Most Western- University Hospital, Chonnam ers regard the Asian upper eyelid as a single CADAVER GROSS DISSECTION University Medical School and eyelid (without visible lid crease). How- Chonnam Research Institute of ever, there are 3 morphologic types of Dissection of the Caucasian cadaver up- Medical Science, Kwangju, Korea; and Department of Asian upper eyelids: single eyelid: no lid per eyelid revealed a well-demarcated up- Ophthalmology and Visual crease with puffiness; low eyelid crease: per eyelid crease area at the preseptal/ Sciences, University of low-seated, nasally tapered, inside-fold pretarsal orbicularis muscle junction at the Wisconsin, Madison type of crease; and double eyelid: lid crease superior tarsal border. Asian cadavers with (Drs Lemke and Dortzbach). parallel to the lid margin.2 a single eyelid crease showed diffuse fat

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Two groups of anatomical specimens were studied and compared. Special attention was given to differences in the structure and its relation to the upper eyelid crease. Five formalin-preserved Caucasian cadavers (supplied by the Department of Anatomy, Uni- versity of Wisconsin Medical School, Madison) and 9 formalin-preserved (6 single and 3 double eyelid) Korean cadavers (supplied by the Department of Anatomy, Chonnam National University Medical School, Kwangju, Korea) were studied. One orbit of each cadaver was used for anatomi- B cal dissection while the contralateral orbit was sec- tioned for histological analysis. Eyelid crease structure was bilaterally symmetric in all specimens. Dissection findings were recorded photographi- cally. The upper eyelid specimens were cut into lateral and medial portions to study the central por- tion. The specimens were fixed in 10% formalin, S decalcified, and then processed for routine paraffin L embedding. Multiple 5-µm sections were then pre- pared and stained with hematoxylin-eosin, Masson trichrome, and elastin stains. Four healthy young (25- to 30-year-old) Asian men were studied by MRI following proper in- formed consent procedures. The subjects were scanned after 0.5% tetracaine ophthalmic solution in- stillation with the eyelids open, half-closed, and closed C with instruction to stare at a point. All MRI experi- ments were performed with a 1.5-T scanner (Gen- eral Electric, Milwaukee, Wis). Five series of sagit- tal images of the upper eyelid were obtained with a 7.6-cm (3-in) surface coil by means of conventional T1-weighted spin echo images and spoiled gradient echo images. Closed eyelid images of T1-weighted spin echo image were done by an echo time of 20 milli- S seconds and a repetition time of 450 milliseconds. L Opened eyelid images were performed with an echo time of 14 milliseconds and a repetition time of 400 milliseconds. Opened, half-opened, and closed eyelid spoiled gradient echo were done by 4.2- millisecond echo time, 68-millisecond repetition time, and 30° flip angle. Figure 1. A, Caucasian cadaver upper eyelid demonstrating well-demarcated upper eyelid crease area at the preseptal and pretarsal orbicularis muscle junction (arrow). B, Orbital septum (S) in the Caucasian specimen fuses above the supratarsal border with levator aponeurosis (L). C, Orbital septum (S) fuses with the levator aponeurosis (L) below the supratarsal border in a single upper deposits on the anterior and posterior surfaces of the eyelid (without a lid crease) from a Korean cadaver. preseptal/ pretarsal orbicularis muscle with no identifi- able trace of a lid crease as seen in the Caucasian ca- vator aponeurosis. The orbital septum of the Asian single daver eyelid (Figure 1). With dissection of the orbicu- eyelid fuses with the levator aponeurosis below the su- laris muscle posterior surface from the eyelid margin to pratarsal border, sometimes close to the eyelid margin the orbital rim, firm connections were observed be- (Figure 1). The levator aponeurosis is noted to attach to tween the levator aponeurosis and the orbicularis the tarsal plate 3 to 4 mm above the upper eyelid margin muscle at the lid crease area in Caucasians. In contrast, in Caucasians and 2 to 4 mm above the upper eyelid mar- a loose fibroadipose layer was interposed between the gin in Asians. orbicularis muscle and the orbital septum with fat de- In cases of Asian double eyelid specimens, the ana- posits on the anterior surface of the tarsal plate in the tomical dissection findings were similar to Caucasian eye- Asian single eyelid (Figure 2). lid, except more subcutaneous and suborbicularis muscle After complete orbicularis oculi muscle extirpa- fat was found. The fusion level of the orbital septum with tion in the Caucasian specimens, the orbital septum was the levator aponeurosis in the Asian double eyelid is higher noted to fuse above the supratarsal border with the le- than in the Asian single eyelid.

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B B

Figure 2. A, Firm connection (arrow) between the orbicularis oculi muscle (O) and the levator aponeurosis (L) at the lid crease area in a Caucasian cadaver. B, Loose filmy attachment (arrow) is noted in the corresponding area between the orbicularis oculi muscle (O) and the orbital septum (S) in a Korean single eyelid specimen.

HISTOPATHOLOGIC STUDY

The fusion of the orbital septum with the levator aponeurosis above the supratarsal border in the Caucasian and the Asian double eyelid specimens prevents the preaponeurotic fat pad from extending toward the lid crease area; the levator aponeurosis is inserted into the subdermal eyelid tissue. In contrast, the preaponeurotic fat pad in the Asian single eyelid specimens extends closer to the eyelid margin, inferiorly limited by the low Figure 3. A, Caucasian orbital septum fuses with the levator aponeurosis above the supratarsal border (white arrow) at the black arrow fusion between the orbital septum and the levator apo- (hematoxylin-eosin stain). B, Korean single eyelid orbital septum joins with the neurosis. Additionally, subcutaneous and suborbicu- levator below the superior tarsal border (white arrow), shown by the black laris muscle fat layers with pretarsal fat are noted in arrow (hematoxylin-eosin stain). Note the pretarsal fat pad (open arrow). Asian specimens that inhibit the levator insertion into the subdermal skin of the Asian single eyelid (Figure 3 showed a lesser amount of subcutaneous fat than the single and Figure 4). eyelid, with a similar low orbital septum fusion with the levator aponeurosis below the superior tarsal border MRI IMAGING STUDY (Figure 6). The Asian double eyelid demonstrated a moderate subcutaneous fat layer, orbital septum fusion to the Comparison of Asian single, low, and double upper eye- levator aponeurosis above the superior tarsal border, and lid anatomical structural differences were evaluated by absent downward prolapse of the preaponeurotic fat pad dynamic high-resolution MRI study. The Asian single eye- (Figure 6). lid showed a remarkable amount of subcutaneous fat. The fusion of the orbital septum to the levator aponeurosis COMMENT below the superior tarsal border with interposed preaponeurotic fat was noted during eyelid closure: when open, Until recently, for several reasons little has been written the orbital septum folded and the preaponeurotic fat pad in the American literature regarding the Asian upper eye- retracted posteriorly (Figure 5). The Asian low eyelid lid anatomical characteristics, especially with regard to lid

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 crease and the aesthetic features. First, most studies on the nation in Asian countries considerably limit materials avail- subject are written in Asian-language journals.5-8 Unfor- able for anatomical study. tunately, English-language surgeons have little access to By the eighth century BC, Mongoloid tribes living this knowledge. Second, until the number of emigrated in the forested areas of North Asia had moved to the Kam- Asian people reached higher proportions in North America, chatka peninsula along the eastern side of Asia. Mongol- there had been less interest here in Asian anatomical stud- oid groups, including Korean, Mongolian, Turk, Japa- ies. Third, religious and cultural inhibitions to cadaver do- nese, Chinese, and Indo-Chinese, have similiarities in their physical stature and language. For our purposes of com- A B parison and discussion, Korean eyelid anatomical characteristics have been grouped with those of the Japa- nese and Chinese because of cultural, religious, and geographic similarity. To our knowledge, this is the first report of Korean eyelid cadaver anatomy study in the En- glish-language literature. Many Americans misunderstand the importance of upper eyelid crease variations in Asian people. Asian people who want to have an eyelid crease think of an upper eyelid crease not as a westernization but as a form of beauty. Eyelid crease formation surgery was performed in Asia before the occurrence of notable western influence. Some Asian individuals with a single eyelid perceive their eyes as puffy, small, and drowsy, and Figure 4. Illustration of Korean (A) and Caucasian (B) single eyelid then want blepharoplasty to create the appearance of a anatomical characteristics. bigger eye.9

A B

Figure 5. A, Korean single eyelid (25-year-old man) showing extension of the orbital septum (arrow) during eyelid closure. B, Open eyelid with folding of the orbital septum (arrow) and retraction of the preaponeurotic fat pad (F) posteriorly. The levator aponeurosis fuses with the orbital septum below the superior tarsal border (open arrow).

A B

S F

Figure 6. A, Korean low eyelid (27-year-old man) showing a lesser amount of fat than the single eyelid. The orbital septum fuses (white arrow) with the levator aponeurosis below the supratarsal border (open arrow). Note the inferiorly prolapsed preaponeurotic fat pad. B, Korean double eyelid (30-year-old man) exhibiting a moderate subcutaneous fat layer (S). Orbital septum (black arrow) fusion to the levator aponeurosis (white arrow) above the supratarsal border (open arrow) prevents the downward prolapse of the preaponeurotic fat pad (F).

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Several previous studies have identified differences scribed thicker upper eyelid skin in association with the of anatomical characteristics between Caucasian and Asian presence of a thicker subcutaneous areolar layer in Asian people.10-15 Doxanas and Anderson11 identified the or- eyelids. Wang and Bian18 dissected Chinese eyelids and bital septum variations in the Asian eyelid. They noted found that the fusion level of the orbital septum with the that the levator aponeurosis fuses with the orbital sep- levator aponeurosis in single eyelids is lower than in tum below the level of the superior tarsal border. Preapo- double eyelids. Our findings agree with these reports. Ad- neurotic fat anterior to the tarsus prevents the insertion ditionally, our Korean eyelid dissections and findings from of the levator aponeurosis from extending to the subcu- histological studies have identified a pretarsal fat layer. taneous tissue and thus prevents the normal eyelid crease This pretarsal fat layer is not inferior orbital fat pro- formation. Asian authors have found the location of the lapse, but a separate entity. orbital septum fusion site with levator aponeurosis to be Single eyelid anatomy and the inner upper eyelid a main factor in eyelid crease formation.2-5 In our Cau- crease anatomy have been characterized by a lower pri- casian and Asian double eyelid specimens, these struc- mary insertion of the levator aponeurosis just above the tures were found to fuse above the superior tarsal bor- upper eyelid margin,19 thicker fat and hypertrophic or- der, but below the superior tarsal border in the Asian single bicularis oculi muscle and upper eyelid skin,20 and a lower and low eyelid types. primary insertion of the levator aponeurosis through a We found more prominent subcutaneous, subor- relatively thin orbicularis oculi and skin at the level of bicularis, and pretarsal fat tissue in the Asian upper eye- the middle or lower upper tarsal plate.5 In our current lid specimens. This is in agreement with Uchida’s16 study, study, the Asian single or low eyelid crease is affected by wherein he first described the presence of 4 areas of fat 3 factors: lower orbital septum-levator fusion site with pads in Asian eyelids: the subcutaneous, the pretarsal, preaponeurotic fat prolapse over the tarsal plate; thicker submuscular or preseptal, and the preaponeurotic fat pads. subcutaneous, subdermal, suborbicularis, and pretarsal He identified pretarsal fat as an entity different from a fat layers; and lower primary insertion of the levator apo- herniated preaponeurotic fat pad. In this study, we con- neurosis toward the upper eyelid skin. firmed the presence of pretarsal fat in Asian single and In summary, it is evident that the location of the or- low eyelid specimens. We consider the more prominent bital septum fusion with the levator aponeurosis plays a subcutaneous and preseptal fat tissue in Asians as spac- major role in forming the upper eyelid crease. However, ers that act to prevent the levator aponeurosis from ex- there are more considerations in the formation of the up- tending to the subdermal tissue. per eyelid crease. They are the amount of soft tissue (sub- Western authors may think the Japanese, Chinese, cutaneous fat, suborbicularis fat, pretarsal fat, and preapo- and Koreans have the same Asian characteristics of up- neurotic fat) and the characteristics of the skin and per eyelid anatomy; however, the configuration of the orbicularis oculi muscle of the upper eyelid, especially in crease in the upper eyelids of Asians varies greatly. The the lid crease area. Structural differences relating to increase may be absent or exhibit variable shape. There has creased fat in the Asian upper eyelid include the presence been a report in young Korean women of the prevalence of a pretarsal fat pad and a moderate fat increase in the of upper eyelid crease variations: apparent outer upper double Asian eyelid. Any facial plastic surgeon requested eyelid fold (49%), inner or incomplete upper eyelid fold by Asians to perform eyelid surgery should consider their (31%), and no upper eyelid crease (20%).2 Liu and Hsu12 personal and cultural characteristics. An understanding of estimated the prevalence of upper eyelid crease varia- the profound anatomical differences is required to achieve tions in the Chinese: outer upper eyelid fold (67.2%), in- the results desired by the patient. ner and unilateral upper eyelid crease (9.6%), and no upper eyelid crease (23.2%). About 40% of Japanese have Accepted for publication February 3, 1999. a double eyelid crease.17 Comparison between articles is Presented as a poster at the American Society of Oph- difficult, as there are differences in study groups and in thalmic Plastic and Reconstructive Surgery Scientific Sym- methods. We have not identified an Asian study com- posium, San Francisco, Calif, October 25, 1997. paring the Korean with other population groups. This study was Curins No. 95-0075 at the Chonnam Chen13 classified Asian people who have an inner Research Institute of Medical Science, Kwangju, Korea. or incomplete upper eyelid crease by their upper eyelid Reprints: Sangki Jeong, MD, Department of Ophthal- crease shape. One of us (S. J.) collected upper eyelid crease mology, Chonnam University Hospital, 8 Hakdong Dongku data from young Koreans and found that about 30% of Kwangju, Korea 501-757. young Korean people have an apparent upper eyelid crease. Most of them want to have an upper eyelid crease REFERENCES inferiorly that tapers medially with a gentle lateral flar- ing (unpublished data, 1998) 7 1. National Statistical Office. Population and Housing Census Reports. 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