One of the most confusing things that I have encountered is how to manage the aging Asian eyelid.  The reason for this is twofold.  First, if an Asian is born without an upper-eyelid crease where do you make the incision so that you don’t have a visible scar?  Second, when you remove skin from the upper eyelid of an Asian, you raise the position of the crease, which may look okay in a non-Asian (I would disagree) but it can look absolutely fake in an Asian because Asians typically are not born with high eyelid creases.

I have divided the management into three clinical scenarios:  Asians who are born with a natural crease, Asians who are born without a crease (or a very partial crease), and Asians who have had a surgically created crease made for them in the past. In the first clinical scenario, Asians who are born with a crease may be viewed just like a white person, i.e., one could simply remove skin.  And that is true.  However, the problem is, as mentioned, when skin is removed, the eyelid crease can ascend to the point that it looks unnatural.  In my opinion if I just put fat into the eyelid and brow in an Asian, I am able to make that individual appear much more youthful but at the same time maintain his or her eyelid crease height at a normal or natural position.  In an Asian that has a very low hanging skin that folds over the eyelash margin, I will remove skin from that person but almost always in conjunction with adding fat to the upper eyelid at the same time to maintain the crease position so that it does not artificially go too high.

In an Asian born without an eyelid crease, the biggest mistake is to try to remove skin, for two reasons.  First, since there is no natural position where the skin creases over, there is no place to make the cut.  When you arbitrarily define a line for incision, you can see the scar and if you try to take fat out, you can create a partial crease adhesion so that the person develops a partial crease.  That is a bad thing because it can change the person’s appearance and at the same time still the individual does not have a definable crease.  If you try to make the incision very long along the eyelash margin, the problem is unpredictable scarring, as the incision should never be placed there in the first place.  Interestingly, because one has a narrower eyelid opening that one has when one does not have a crease even removing skin from the upper eyelid does not help to make the eyelid position really look more open, which disappoints patients.  There are two ways then to manage this situation of an Asian without a crease.  First, one can make a crease, which can truly make the eyelid appear more youthful.  The problem with this approach is that it does change the way an eyelid appears from when that person was youthful (if that is ok with the patient).  Furthermore, there can be a long recovery period when creating an upper-eyelid crease, and the patient must know that.  The second way to rejuvenate an Asian eyelid without a crease is simply to add fat or fillers, which can plump up the eyelid to make it more youthful in appearance without any incisions.

The final scenario is an Asian who had a crease made in the past.  If the crease were made only a few years ago, then typically the creases made during the period from the 2000s forward were quite natural.  In the 1980s however the creases made were quite artificial in nature since a lot of skin and fat were removed and the creases were made artificially too high.  Interestingly, over time many of these eyelids start to descend and the crease can actually look low again.  The problem of removing eyelid skin at this point is that one can then unmask the previously bad result and at times even make the result look more unnatural in appearance.  The reason for this is that in fact when one is removing the upper-eyelid skin one is actually just removing brow skin, which is thicker and unnatural.  If the surgeon has a question as to whether it was an old-style Asian blepharoplasty or a new one, all one need to do is to lift up the eyelid skin to evaluate the height of the crease to determine if it was made unnaturally in the past or not.  This algorithm will hopefully help Asian patients seeking eyelid rejuvenation and also help surgeons seeking to help Asian patients with eyelid rejuvenation.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ plastic surgery procedures or to ask Dr Lam a question please visit his plastic surgery forum.

Why Asian Eyelids Can be More Easily Made Symmetrical

Symmetry is perhaps the hardest thing for me to fix.  I can improve one’s asymmetry but I can’t fix it.  In fact, in all my consent forms I state “the two sides of the body are not the same and can never be made the same,” a point that I typically try to underscore to every prospective patient who is considering a procedure no matter how big or small.  Curiously, when it comes to Asian eyelid surgery, i.e., creating a crease in the upper eyelid, in most cases I can actually make the eyelids more symmetric even if one was born with a slight or gross asymmetry.  The reason for this is that the asymmetry results from a partial crease on one side and an absent crease on the other side that when I create symmetric creases surgically the asymmetry disappears. Let me explain it another way.  When one has a partial crease on one side and a non-existent crease on the other side, the side that has the partial crease typically has an eyelid opening that is wider or bigger than the side with a non-existent crease.  The reason for this is that the side without a crease has more fat that slides downward since the levator muscle does not insert into the skin crease causing the eyelid opening to be smaller on that side.  The side with a partial crease has less fat that slides down over the eyelid and therefore that side the eye opening is bigger.  When the surgery is performed and there is a much more durable and defined crease, then both eyelids open even more and look less “sleepy eyed” but typically also in a symmetric fashion.

Samuel M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a Asian eyelid consultation please call (972) 312-8188. To Learn more about Dr Lams’ Asian blepharoplasty surgery or to ask Dr Lam a question please visit his Asian plastic surgery forum.

My Thoughts on Medial and Lateral Canthoplasty for Asian Blepharoplasty

Besides creating a supratarsal crease in the upper eyelid for Asian blepharoplasty, there are two other modifications of the eyelid shape that can be performed, namely a medial and/or lateral epicanthoplasty.  The canthus describes the joining of the upper and lower eyelids so the medial canthus describes the inner corner of the eye near the nose and the lateral canthus describes the outer corner of the eye near the temple.  A modification of the shape of the canthus is thereby known as a canthoplasty.  The predominant medial canthoplasty performed is intended to change the shape of the eyelid from a closed shape to a more pointed appearance; whereas the lateral canthoplasty is intended to lengthen the eye and thereby have a larger eyelid aperture.

By far the most common procedure involves the medial canthus, or medial canthoplasty.  The method that I use I learned in South Korea and involves making my incision inside the curvature of the canthus itself, i.e., not on the naked skin between the eye and the nose.  I believe that the medial canthus is prone to scarring and any incision that is created on the skin can lead to unpredictable scar formation.  That is why I prefer to perform my procedures without a skin incision in this sensitive area that has a tendency toward webbing and scarring.  The key maneuver with a medial canthoplasty is to actually shorten the medial canthal ligament to create a durable change to the medial canthal shape.  The goal is to open up the canthus to show the pink portion of the eye known as the lacrimal lake.  When the ligament is shortened, the eyelid shape looks like a cat eye for 1 to 2 weeks, which then relaxes.  The goal for a good medial canthal procedure is that it is subtle and not overly sharp, which can look artificial.  With the method mentioned above, it can be performed in conjunction with a double-eyelid procedure or separately.  In my opinion, I prefer a slight medial canthal roundness that I think preserves ethnicity.  However, I am always open to discussing with a patient whether he or she would like to have the canthal procedure performed to achieve his or her aesthetic goals.

The lateral canthoplasty is a procedure that is far easier to perform but with far more limited gains.  I personally have stopped performing this procedure because I believe that the improvements are too modest to justify the procedure.  The goal for lateral canthoplasty again is to open up the canthal width simply to have a more open eye.  The technique involves cutting the canthus approximately 3 mm open and then removing a slight degree of redundancy and tacking the upper eyelid canthal skin to the upper eyelid canthal skin and the same for the lower canthal skin.  Even though the recovery for this procedure is very negligible, I have seen the 3 mm expansion return to only a mm or 2 of change, which to me is too slight to justify this procedure.  For those individuals who are willing to accept the limited gains of this procedure, I am still open to trying it, especially since the recovery and risk are both relatively low.  The type of lateral canthoplasty that I personally do not like is the z-plasty method to lower the outer canthus downward to make the eye less “slanted” in appearance.  The reason that I do not like it is that it violates my principle of trying to avoid cutting on exposed canthal skin, that can lead to visible scarring that is very hard if not impossible to fix.  I think if these modifications are understood in the context above then they can be safely performed as adjuncts to the standard double-eyelid blepharoplasty.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. Call (972) 312-8188 to schedule a consultation or to ask Dr Lam a question about Asian blepharoplasty please visit our Asian plastic surgery forum.

Globalization of Beauty: Trends and Concepts

Globalization of Beauty

The traditional view on beauty has focused on the standard of the Caucasian, Nordic race.  In the past two decades the trend has been to incorporate many models of mixed heritage.  In fact, with the growing acceptance of marriage between races, racial lines have continued to blur in the United States; and racial barriers have diminished.  Reading an article in the New York Times recently stimulated this blog post.  Many students who are entering college today do not know how to respond when asked what race or ethnicity they belong to when they are perhaps part of several or at least two.  I think when I talk about “Asian beauty” or “Hispanic beauty” etc., I may be oversimplifying these terms for the sake of categorical purity.  However, the case is that these terms may already be outdated.  When I look at prospective patients’ faces I am always ethnically sensitive, especially growing up as an Asian kid in a primarily white Texas culture.  Travelling abroad and completing almost 6 months of training in Asia has made me more culturally aware of the effacement of racial lines.  In addition, I did all of my training in the East Coast, where there is truly a melting pot of cultures, identities, and ethnicities.  So forgive me if I tend to write in categorical ways on this Web site but take it that I am very sensitive to the composite of one’s ethnic persuasion when helping you achieve your desired aesthetic goals.

Samuel M. Lam, MD, FACS is a board certified plastic surgeon, specializing in facial plastic surgery. For more info, or to schedule a consultation please call (972) 312-8188. If you would like to ask Dr Lam a question please visit our Plastic Surgery Forum.

My Strategy for Asian Upper Eyelid Blepharoplasty

There are three principal methods for creating a so-called “double eyelid”, or upper eyelid crease in an Asian patient: the suture method, the partial-incision method and the full-incision method. I have tried all three over the years but have found that the full-incision method has been the most versatile, natural, and durable of all three.

I spent many months training in Asia with many prominent surgeons to learn the art and craft of Asian cosmetic surgery. The product of my travels was the book I produced, Cosmetic Surgery of the Asian Face (2nd Edition). I have concluded that as many practitioners of the art of Asian cosmetic surgery that exist so do the variations on techniques. However, by categorizing Asian blepharoplasty into three main categories, we can evaluate the pros and cons of each type of procedure despite these subtle variations that may exist.

The Suture Method
The suture method is the most popular one in Japan. It is very appealing because there is no incision except for a few stab entries with the crease held together by a suture that travels in and out of the skin to wind up buried as a permanent suture underneath. The major benefit of this method is the limited recovery time. Someone can be looking pretty good within a few days to a week following the procedure. The major limitation that I have encountered is that about 98% of results fall out or are at least partially lost over a period of one to two years following the procedure. For the reason of this limitation, I have chosen to abandon performing the procedure at all.

The Partial-incision Method
The partial-incision method held a great degree of appeal to me during the early years of my practice. It was a nice hybrid approach that was situated between the suture method and the full-incision method. It had relatively short downtime of only a week or two, sometimes for several weeks. It was also attractive selling someone that there would only be a very small incision of approximately 1.5 cm. The real problems with this method were twofold. First, I had a tremendous percentage of fold loss over a period of a year but less so than the suture method. Second, because the incision was short, when someone closed his or her eyes there was a good chance of seeing some puckering right at the incision line that gave away the unnaturalness of the result.

The Full-incision Method
I have been performing full-incision Asian “double eyelid” blepharoplasty for many years now and find it to be the best method in my hands to accomplish what I would like for a patient. The major limitation is the period of time of swelling. For the first week the swelling can be significant and the result very unnatural. Even for the first 3 to 6 weeks, there can be residual swelling that can make the result not appear 100% natural. It can take several months before the result looks excellent and one year for all the minor degree of swelling to resolve completely.

Despite this major limitation, it offers so many advantages that override this one limitation. First, it creates the most durable fixation with a very low incidence of fold loss. Second, it creates the most beautiful and natural looking fold that I have seen since the adhesion is uniform and across the entire length of the eyelid. Third, it is flexible allowing me to work with young and old patients and individuals with both thick and thin skin, excess or normal fat, and pre-existing folds or lack thereof, and the ability to design any shape and contoured fold that I please. Also, scarring has really not been an issue just as much it has not been one for my Western patients who have a standard upper-eyelid procedure. The reason for this is that I only take out 2 to 3 mm of skin so there is no tension on the incision hence no widening. This stands in contrast to the traditional upper-eyelid blepharoplasty in the Asian and the non-Asian in which a tremendous skin is removed. In the Asian, removal of slight skin is beneficial but the incision is more important for access and for creating the most uniform adhesion of levator to skin. For all of these reasons, I have relied on the full-incision method as my workhorse method for Asian “double eyelid” blepharoplasty.

Follow the links to learn more about Dr Lam’s , Asian blepharoplasty procedure, including before and after photos, videos, and FAQs, or call (972) 312-8188 to schedule a consultation .