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

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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 ARCH OPHTHALMOL / VOL 117, JULY 1999 907 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 A SUBJECTS, MATERIALS, AND METHODS Two groups of anatomical specimens were studied and compared. Special attention was given to differ- ences in the structure and its relation to the upper eyelid crease. Five formalin-preserved Caucasian ca- davers (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 struc- ture was bilaterally symmetric in all specimens. Dissection findings were recorded photographi- cally. The upper eyelid specimens were cut into lat- eral 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 eye- lid 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. ARCH OPHTHALMOL / VOL 117, JULY 1999 908 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 A A O L B B O S 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 apo- neurosis 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).
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