REVIEW http://dx.doi.org/10.14730/aaps.2014.20.3.129 aaps Arch Aesthetic Plast Surg 2014;20(3):129-139 Archives of ARTICLE pISSN: 2234-0831 eISSN: 2288-9337 Aesthetic Plastic Surgery Comprehensive Review of Asian Cosmetic Upper Eyelid Oculoplastic Surgery: Asian Blepharoplasty and the Like Suzie H. Chang1, William P. Chen2, Background Asian Aesthetic Oculoplastic Surgery is a fast-growing field, both within In Chang Cho3, Tae Joo Ahn4 the United States and abroad. With growing interest, there have also been multiple terminologies used for the same concepts. This has created redundant and confusing 1Department of Plastic Surgery, language - prone to errors in patient-physician communication. In addition, there has University of Texas Southwestern Medical Center and Veterans Affairs North Texas been an upsurge of various techniques or variations to existing techniques that has Health Care System, Dallas, Texas; created unnecessary confusion among plastic surgeons. The objective of this article is 2Harbor-UCLA Medical Center, Torrance, to provide organization and simplification to the terminology and to the techniques California, USA; 3BIO Plastic Surgery used in what some broadly refer to as “Asian Blepharoplasty” or perhaps more cor- 4 Clinic, Seoul; Gyalumhan Plastic Surgery, rectly termed Asian Aesthetic Oculoplastic Surgery. Seoul, Korea Methods Unified terminology, aesthetic goal and detailed operative technique of com- monly conducted Asian blepharoplasty were suggested by experienced oculoplastic surgeons. Results The main procedures of Asian Aesthetic Oculoplastic Surgery including supra- tarsal crease surgery and medial epicanthoplasty were presented with figure and video in this paper. We also have provided author’s preferred selection of the major tech- niques with evaluation of its advantages and disadvantages. Conclusions The most important element in patient satisfaction is clear communica- tion of surgical expectations. Then, proper selection of the most suitable pre-operative design, type of surgery performed, and specific crease configuration based on the indi- vidual’s anatomic and physiological characteristics can be achieved. None of the authors has a financial interest in any of the products, devices, or drugs men- Keywords Asian blepharoplasty, Asian oculoplastic surgery, Epicanthoplasty, Supratar- tioned in this manuscript. sal crease, Double eyelidplasty INTRODUCTION reorganization to the surgical procedures of this topic, namely su- pratarsal crease surgery and epicanthoplasty techniques. In addition, The field of Asian Aesthetic Oculoplastic Surgery is a rapidly grow- a recommendation for unified terminology and an enhanced expla- ing area – with upper eyelid blepharoplasty ranking as the most nation of the aesthetic goals of the procedures will be offered. This commonly performed procedure in Asian aesthetic surgery. paper will also evaluate some of the advantages and disadvantages of The main objective of this article is to provide simplification and various surgical approaches in an objective fashion, based on ana- tomic and physiological criteria of the individual patient at hand. The imprecise use of terminologies in Asian Aesthetic Oculo- Received: Oct 21, 2014 Revised: Oct 25, 2014 Accepted: Oct 26, 2014 plastic Surgery has always been a problem with doctor/patient in- Correspondence: Suzie H. Chang Department of Plastic Surgery, University of Texas Southwestern Medical Center, Veterans Affairs North Texas Health teraction. This leads to miscommunication, unrealized expecta- Care System, VISN 17, 1801 Inwood Rd., Dallas, TX 75390, USA. tions, and suboptimal results. Because the Asian languages inher- E-mail: [email protected] ently have the capacity to hold multiple meanings even within the Copyright © 2014 The Korean Society for Aesthetic Plastic Surgery. same word, there is an even greater importance in using unified This is an Open Access article distributed under the terms of the Creative Commons At- language to optimize doctor/patient communication (Table 1). tribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any Too often, complications occur due to faulty primary surgery medium, provided the original work is properly cited. www.e-aaps.org based on incorrect concepts and choices. Although the choice in 129 Archives of aaps Aesthetic Plastic Surgery VOLUME 20. NUMBER 3. OCTOBER 2014 Table 1. Terminology in Asian aesthetic oculoplastic surgery Identity Current common terms Proposed term – Term used in this manuscript Supratarsal crease creation surgery Asian blepharoplasty, double eyelid surgery, lid crease Supratarsal crease surgery surgery, Asian upper lid procedure Parallel oriented supratarsal crease “Outfold”, “outer-oriented” crease, parallel crease Parallel crease Nasally tapered supratarsal crease “Infold”, “inner-oriented” crease, “unfolded fan” fold Nasally tapered crease Epicanthal fold “Mongolian fold” Epicanthal fold Hypertrophic orbicularis roll along lower lash line “Love-roll” Microincisional buried suture technique Non-incisional, suture technique Minimal incision supratarsal crease surgery terminology may seem to be a minor detail, these are challenging issues when handling patient complaints and suboptimal results in revisional cases. Therefore, it is critical to surgical success to clearly communicate expectations and desires of the patient at the first op- portunity. ANATOMICAL BASIS OF ASIAN AESTHETIC OCULOPLASTIC SURGERY The anatomical basis of Asian Aesthetic Oculoplastic Surgery re- volves around two unique entities, the supratarsal crease and the epicanthal fold. The absence and presence of these two entities dis- tinguishes the aesthetics of the Asian eye from other ethnicities. Anatomy and etiology of supratarsal crease Fig. 1. Skin tension vectors. Historically, the most commonly used explanation on the etiology of the supratarsal crease is commonly explained by the Levator Ex- the composition of the epicanthal fold [5]. It is located nasally be- pansion Theory - where the levator aponeurosis sends distal inser- tween the upper and lower eyelid, at an epicenter of opposing skin tions into the overlying dermis of the upper eyelid skin approximate- tension vectors. When the upper eyelid opens through the action ly at the level of the superior border of the tarsal plate [1]. of the levator muscle and aponeurosis, it is noted that the medial However, there have been more recent microanatomic studies skin of the upper eyelid moves in a superolateral direction and the that demonstrate how the levator sends distal insertions to overly- lateral upper eyelid skin moves in a superomedial direction [10]. ing orbicularis oculi muscle and subcutaneous tissues, not into the (Fig. 1). These vectors of upper eyelid skin tension are more pro- dermis itself [2]. In addition, the general consensus of updated thou- nounced when the eyelid is open rather than when closed. Addi- ght is that the contributing factors to the upper lid without a supra- tionally, it is prudent to perform an epicanthoplasty procedure con- tarsal crease are the increased thickness of skin, the increase in sub- comitantly with a supratarsal crease surgery in order to eliminate orbicularis adipose tissue, the variance in fusional height of the or- and disperse these deterring forces from blunting the supratarsal bital septum and levator aponeurosis, the existence of a pretarsal crease formation. fat pad, and the increase in preaponeurotic adipose tissues [3-6]. SUPRATRASAL CREASE SURGERY Anatomy and etiology of epicanthal fold Most Asian epicanthal folds can be categorized as the epicanthus The first known published account of the Asian supratarsal crease tarsalis variant [7,8]. It is a normal anatomic entity unique to the procedure is in the Japanese literature. In 1896, Mikamo published Asian patient population and is not considered a deformity. The a suture technique to creating the supratarsal crease [11]. In 1929, epicanthal fold is comprised of redundant skin, subcutaneous tis- Maruo reported the first incisional method [12]. Since then, there sue, and a portion of the preseptal orbicularis oculi muscle. When have been numerous publications on variations and combinations the epicanthal fold is eliminated in the case of epicanthoplasty pro- of these two techniques [13-18], including laser application [19] and cedures, there have been no functional deficits found [9]. the use of microsurgical mini-flaps [20]. There have been several anatomical studies published showing There are distinct advantages and disadvantages to each tech- 130 Archives of Chang SH et al. Asian Blepharoplasty aaps Aesthetic Plastic Surgery Table 2. Incisional vs minimal incision techniques in supratarsal crease surgery Incisional Minimal incision Ideal patient All patients, especially useful in revision cases, thick-lid cases, Thin-lid patient or patients with dermatochalasis Advantages Direct visualization, can perform ptosis correction concomitantly, Minimal external scarring, shorter recovery time ability to perform selective tissue debulking, Better ability to control for hemostasis, Previse preservation/repositioning of preapoenurotic fat Disadvantages Longer recovery time, possibly greater learning curve Decreased visualization of tissues, more difficulty in creating a parallel-oriented crease (with disappearance of medial crease), permanent buried sutures placed, potential Faden Effect [30] Complications