Plastic Surgery & Cosmetic Surgery in Dallas

These learning modules were written by Dr. Lam for the expressed purpose of providing more systematic and comprehensive knowledge about a particular topic in facial plastic surgery that reflects Dr. Lam’s philosophical and surgical approach. These tutorials are not meant to convey any kind of objectivity about plastic surgery (if such objectivity even exists) but instead to explain Dr. Lam’s perspective on each topic culled through his extensive clinical experience and critical thinking.

The Asian face is uniquely different from other races and requires special methods to enhance one’s appearance without creating an unnatural result that does not fit one’s ethnicity and/or gender.  There are many minor and salient differences that divide the various nationalities, e.g., Chinese, Korean, Vietnamese, Japanese, Cambodian, etc.  However, a discussion of all the many nuances lies beyond the scope of this learning module.  Further, the soft-tissue and skeletal differences between the Occidental and the Oriental face will also not be a topic of discussion.  Instead, the focus will be almost entirely on the two most popular areas of the face for enhancement, the eyelid and the nose.

The first documented report of Asian eyelid enhancement came in the latter half of the nineteenth century by a Japanese surgeon named Mikamo.  (For more information about Mikamo and his accomplishments, you can ( read Dr. Lam’s article)   Although Mikamo flourished during an era of intense Westernization known as the Meiji Restoration, most of his references to the creation of the double eyelid were self-referential to his own race and stated that the single eyelid led to a “monotonous and impassive” countenance that ran counter to what “writers and painters have regarded as an indicator of beauty.”

The efforts at creation of an eyelid crease that span the past half-century have referenced the idea that the procedure was principally designed to “Westernize” the eyelid.  Fortunately, the popularity of true “Westernization” procedures that dominated the 1980s has faded over time.  Today, most individuals seeking eyelid enhancement want to create a very natural result that features a non-hollowed out eyelid shape and a relatively low-crease height.

Dr. Lam believes that there has truly been a convergence in what we consider a beautiful eyelid.  Unfortunately, traditional blepharoplasty for the aging Caucasian eyelid has also made older Caucasians look very unnatural.  Today, a very conservative amount of skin removal (if at all) combined with fat grafting to restore the lost fullness of the upper eyelid creates a result that is more youthful and truly matches the aesthetic of younger Caucasians.  That same aesthetic can be applied in many respects to the Asian eyelid:  a very high crease and an empty appearing eye are both unnatural and aged in appearance.

The full convexity and relatively low crease height is considered a new ideal of youthful beauty across all races.  Although Caucasians can tolerate a slightly higher crease height the convexity of the brow and upper eyelid is a sign of youth and beauty that should not be taken away.

The following example shows an individual before and after traditional blepharoplasty.  As you can see, the upper eyelid is tremendously hollowed that makes the person look radically different from before.  This is not a youthful look, even for a Caucasian.

As the following example demonstrates, the natural evolution of the aging process leads to completely hollowed and sunken eyes that is not attractive in any race.

The following example shows how even in a Hispanic woman seeking eyelid rejuvenation, Dr. Lam’s method to create a youthful convexity is simply to fat graft the upper eyelid.  You will also notice that the upper eyelid crease is actually lowered.  This is a principal method that Dr. Lam uses in correcting over hollowed Asian eyelids and to restore and maintain a natural crease height (to be discussed).

For more examples of a youthful, framed eye (the new aesthetic) and Dr. Lam’s corrective work for traditional blepharoplasty, please review the Facial Rejuvenation Tutorial. 

Whether the “double eyelid” procedure constitutes a Westernized look or a betrayal of one’s own ethnicity can be long debated and perhaps never resolved.  However, Dr. Lam believes that the objective in Asian blepharoplasty is to create a seamlessly natural result that matches the ideal examples of beauty in one’s own race.  It is rare that an individual seeking eyelid enhancement today would bring in examples of Western celebrities.  Instead, more commonly, the person seeking to find an ideal eyelid shape will look at models and other attractive examples of men and women from East Asian descent.

This Taiwanese model/actress exemplifies the current standard of beauty characterized by a relatively full upper eyelid contour, a low crease height and a more open eye appearance.

There are three major ways to create a crease in the upper eyelid:  the suture method, the partial-incision method, and the full-incision method.  Each method has its own benefits and limitations.  The suture method is very popular in Japan and involves passing a suture through the eyelid in order to create the upper-eyelid crease.  Although this procedure is attractive in its simplicity, the real problem with this method is the very high rate of failure over a period of 1 to 5 years following the procedure, requiring revision surgery.  Further, if excess skin should be removed as the person ages, the skin fold may be entirely lost with this procedure.  Accordingly, Dr. Lam has preferred not to use this method of Asian blepharoplasty.

The partial incision method, popular in South Korea, was a method that Dr. Lam preferred in the past for its short incision line and relatively quick recovery time.  However, Dr. Lam has stopped using this method altogether for several reasons.  Over time, the fold may be lost like in the suture method but less commonly so.  The incision line may be visible since the point at where it starts and stops can be visible.  The sutures used to hold the crease in place are permanent and can come out or become irritated, which can also cause a loss in the skin fold.

For all of these reasons, Dr. Lam uses almost exclusively a full-incision method that permits several advantages.  First, a very tenacious crease fold that does not require any permanent sutures to maintain.  In fact, at the end of the first week, all sutures are removed so there is no need for any permanent buried sutures.  Second, the shape and style of the upper eyelid crease (discussed below) can be modified much more precisely.  As one becomes older, if excessive skin needs to be removed, there is virtually no risk in losing the crease with a standard blepharoplasty.  The major drawback with the full-incision method is the greater recovery time that is required.

Prior to Asian blepharoplasty	One week following full-incision blepharoplasty prior to suture removal
Two weeks following full-incision blepharoplasty	One month following full-incision blepharoplasty

At times there can be more swelling than the example shown above that may require several months for almost all of the swelling to entirely dissipate. 

Let’s take a step back and review exactly what the difference is between an eyelid that has no crease and one that does have a crease.  An eyelid with a crease or skin fold exhibits the crease by virtue of the attachment of the levator muscle (the muscle that opens the eyelid) to the skin.

The Asian eyelid that has no crease has the levator muscle insert either very low (for partial or low creases) or not at all into the skin so that no crease is visible.  The reason that the Asian eyelid appears narrower than the Occidental eye is that the fat (postseptal fat) hangs lower over the eyelid to make the eyelid appear both fatter and the eyelid opening narrower.  In the past, a lot of this puffiness was reduced by removal of fat that would lead to a hollow appearing eye after the procedure or many years down the road.  Removal of excessive fat is oftentimes not necessary to “open the eye”.  Creation of the crease moves the fat out of the way and creates the same degree of opening in the eyelid aperture.  Only about 30% of the time, Dr. Lam encounters excessive fat that needs to be conservatively removed to reduce the puffy appearance of the eyelid. Let’s now review the same anatomy from a different perspective, i.e., from the vantage of what the surgeon encounters during the procedure.  After the initial skin incision, the orbicularis muscle is encountered and moved out of the way to visualize a structure known as the orbital septum.  The orbital septum holds back the fat that we discussed before and needs to be opened to expose the underlying fat.  Immediately below the fat pad lies the glistening white levator muscle (shown as gray in the following illustration).  The levator is the structure that is fixated to the skin with sutures to create the levator-to-skin crease that is desired.  As mentioned, these sutures are removed after one week when the levator to skin fixation is already durably created during the healing process.

Let’s now review the same anatomy from a different perspective, i.e., from the vantage of what the surgeon encounters during the procedure.  After the initial skin incision, the orbicularis muscle is encountered and moved out of the way to visualize a structure known as the orbital septum.  The orbital septum holds back the fat that we discussed before and needs to be opened to expose the underlying fat.  Immediately below the fat pad lies the glistening white levator muscle (shown as gray in the following illustration).  The levator is the structure that is fixated to the skin with sutures to create the levator-to-skin crease that is desired.  As mentioned, these sutures are removed after one week when the levator to skin fixation is already durably created during the healing process. With the full incision method, the precise shape of the eyelid crease can be accurately created.  An inside fold refers to how the fold closes downward to touch the epicanthus (the inner part of the eyelid).  The inside fold is a more common occurrence in the Asian population and may be considered slightly more “ethnic”.  It is commonly paired with a slightly flared crease known as an oval eyelid shape.  An outside fold ends further inside the epicanthus and does not touch close down to touch the epicanthus.  It is oftentimes paired with a round eyelid configuration in which the crease remains parallel throughout the entire distance of the eyelid.  Any of these combinations however are possible and are shown above.

The following photograph demonstrates a very low crease that is especially important in an Asian male so that a natural result is ensured.  In this case, an inside fold is paired with a round eyelid configuration.

The following photograph demonstrates an outside fold paired with an oval eyelid configuration.

Besides the actual eyelid shape, the inner and outer part of the eyelid known as the epicanthus and lateral canthus, respectively, can also be modified.  More commonly, the inner part of the eye can be opened up to expose the pink caruncle, as known as the lacrimal lake.  Dr. Lam uses a method that requires no external skin incision and thereby minimizes recovery time and risk of scarring.

The following photographs show a mild to moderate epicanthus and resulting epicanthoplasty.

The following photographs show a more prominent epicanthus and resulting epicanthoplasty.

The lateral canthoplasty is a procedure that is designed to increase the diameter of the eye rather than the actual shape in most cases.  The actual procedure only facilitates a very small change in the overall size of the diameter of the eye, and Dr. Lam rarely performs it nowadays given the limited benefit.

The procedures for Asian blepharoplasty described above mainly relate to the younger Asian patient seeking eyelid enhancement.  Although the same technique can be applied to the older individual as well, other considerations must be entertained when evaluating the older Asian patient seeking upper eyelid rejuvenation.  Dr. Lam has devised a unique strategy for approaching the aging Asian eyelid that he lectures on regularly and on which he has written extensively and that ensures an optimal aesthetic and natural result.

Dr. Lam has classified the aging Asian eyelid into three types:  the aging Asian eyelid with a natural crease, the aging Asian eyelid without a natural crease, and the aging Asian eyelid that has a previously surgically made crease.  Each scenario requires a different approach to attain the best results.

The aging Asian eyelid with a natural crease may be thought of as very similar to a standard Occidental eyelid.  However, there is one major distinction.  If the extra skin is simply removed from the upper eyelid for the aging Asian eyelid, the crease will oftentimes be made too high, which will appear unnatural.  As mentioned, Dr. Lam believes that this higher crease also looks bad on the Caucasian patient but looks exceptionally unnatural in the Asian patient.  Accordingly, if Dr. Lam needs to remove some extra skin for the individual with a natural crease, he will almost always perform fat grafting simultaneously to create the natural convexity of a youthful eyelid shape but also to maintain the eyelid crease height.  Phrased another way, fat grafting permits maintenance of the eyelid crease height by pushing the eyelid crease back down to a natural height after skin removal alone raises the crease unnaturally.

The following example shows a woman who underwent simultaneous removal of upper eyelid skin and fat grafting to rejuvenate the upper eyelid and to maintain the natural upper-eyelid crease height.

The aging Asian eyelid without a crease poses a unique challenge.  The individual without a crease may not want a crease because he or she may feel that a crease may change the way he or she looks.  Alternatively, removal of skin alone can lead to a visible incision line since there is no skin that folds over the incision line.  Further, skin removal alone is oftentimes simply unsatisfactory in individuals without a crease, as the eyelid opening still appears very small afterward (even though it was always this way).  Removal of the puffiness, i.e., the fat, without a crease fixation, can cause an accidental, unintended crease to form to a variable degree, which is also a significant problem.  Accordingly, Dr. Lam offers two options to improve the aging Asian eyelid without a natural crease.  For optimal opening of the eyelid shape, he recommends a formal full-incision Asian blepharoplasty with or without simultaneous fat grafting.  For the patient who desires to maintain the same look as he or she had in youth, fat grafting alone provides the safest and most appealing result.

The following patient underwent a full-incision Asian blepharoplasty with a very conservative amount of skin removal to achieve the desired rejuvenation.

The aging Asian eyelid that has had a previous surgically created crease can also pose a unique problem.  If the crease created in the past was natural, i.e., very little fat removed and a low crease configuration fashioned, then the eyelid can practically be treated the same as an eyelid with a natural pre-existing crease.  However, oftentimes, the Asian patient had an aggressive “Westernization” procedure performed many years ago that appeared very unnatural at the time but somehow over time has become increasingly more natural in appearance.  The reason for this change is that the loss of fat in the upper eyelid, increase in skin laxity, and brow descent have camouflaged the previously very high crease that was present years ago.

In order to determine whether this is the case, you can simply lift up the eyelid to see where the crease was placed.  If the crease appears very deep and high when lifting the eyelid up, most likely the previously made crease is very unnatural.  Also, even though the crease has fallen over time, it can still look a bit unnatural because the thickened brow skin that descends downward still does not resemble the thin eyelid skin of a natural, lower crease.

Here is the problem:  if the surgeon simply removes upper-eyelid skin without paying attention to the patient’s prior surgery, the result can unmask the previously very high eyelid crease and return the patient to an unnatural result.  A browlift can also create the same problem since the elevated brow can expose the former unnatural crease height.  A combination of a browlift and upper-eyelid skin removal can be a disaster.  Accordingly, there are very few options for such a patient.  Fat grafting alone can provide limited but safe rejuvenation of the upper eyelid without causing the problem mentioned above.

Asian Nose

The Asian nose is very different from the Caucasian nose in many respects.  First, the overlying skin is typically quite a bit thicker than that of the Occidental individual.  Secondly, the underlying cartilage tends to be thinner and less firm.  These two attributes are the two most important anatomic features that impact the technique that should be selected for Asian rhinoplasty.  These attributes can also be found in some Caucasians, African-Americans, Hispanics, and in Middle Eastern races but to a lesser extent.  Skin and cartilage thickness and rigidity directly affect the method for refinement of the nasal tip.  In individuals with relatively thinner skin and thicker cartilages, the cartilages can be refined and the thinner overlying skin will show the improvement as it redrapes over the new framework.  However, this is not the case with the typical Asian nose.

As the following illustration demonstrates, narrowing the cartilages under thick skin will lead to a worsening of the condition rather than an improvement.  After the cartilage is refined and narrowed through traditional Western techniques, the thicker skin will not redrape over the narrowed framework.  Accordingly, there is a dead space that develops between the narrowed cartilage and the unyielding thicker skin.  Over time, scar tissue develops in this dead space leading to a rounder, more bulbous tip.  The end result is that the tip will look actually bigger and less refined.  Instead a cartilage tip graft is used (taken typically from the septum inside the nose) to project the nose forward and thereby create a narrower appearance by pushing the thicker skin forward.  This technique is actually unacceptable in the thinner-skinned patient, where the graft can become visible over time.  Therefore, a careful physical examination (see the Rhinoplasty Tutorial for more information) is mandatory to determine which method or methods would be appropriate in your case.

In the following diagram, Dr. Lam demonstrates various types of cartilage tip grafts that increase tip structure, support, and appearance.  He does not always use all of these grafts but will do so depending on your individual anatomic requirements.

In some instances based on cartilage and skin thickness, Dr. Lam may find that narrowing of the cartilages will provide the best results at a more refined nasal tip.  In the following case, the patient demonstrated medium thick skin but thicker cartilages and Dr. Lam undertook narrowing of the cartilage framework to achieve the desired narrowing of the nasal tip.  A Gore-Tex implant was used to raise the bridge at the same time to create a balanced result.  The patient previously had a silicone implant performed in Taiwan that had slid down to the bottom of the nose, which Dr. Lam had to remove first.

Another concern that is oftentimes expressed by the Asian or ethnic patient is the desire to narrow the base of the nose.  A flared nostril may contribute to an overly ethnic look and also create an unbalanced appearance.  Dr. Lam does not always narrow the base of the nose for two reasons.  First, it is oftentimes unnecessary and can also lead to a more unbalanced result in some cases.  For example, if the tip of the nose is very wide, narrowing the sides of the nose can actually make the tip appear even wider.  If you have a wider tip and you squeeze the sides of your nose, you will see that your tip will suddenly appear wider and bigger.  Understanding harmony and balance is important to attain the correct results.

In narrowing the nasal base for those individuals that should require it, Dr. Lam uses a combination of techniques.  In order to decrease the nostril width, he makes an isolated incision that remains for the most part inside the nose, known as a nasal sill reduction.  This unique strategy ensures three benefits.  First, the incision is kept in a place that tends not to prolong recovery time, like the incision that circumscribes the outer part of the nose.  This technique truly reduces the size of the nostril in those individuals that need it.  Finally, reducing the nostril in this way helps prevent over reduction of the outer part of the nostril that can lead to a loss in natural curvature and shape of the nostril itself.

If your nostril is not too wide but too flared (too round), then a Sheen flap reduction can be beneficial to achieve less of a flared nostril.  The Sheen flap preserves a very small island of skin so that the natural curvature of the nostril is not violated.  If you look at Michael and Janet Jackson’s noses you will see two major problems:  a loss in natural curvature of the sides of the nose as well as a notched appearance at the base of the nose.  By using the nostril sill reduction to reduce the width of the nose and the Sheen flap to reduce the flare of the nose, Dr. Lam can truly tailor a very customized solution in every case.

A wide reduction of the nostril base that extends all the way into the nostril is a bad technique that can lead to the aforementioned flattening of the natural nostril curvature and a notched appearance that is unnatural as well.

If you look at Janet Jackson’s nose, you can see the flattening of the outer nostril as well as the notched appearance along the nasal sill that is very unnatural looking.

A major concern of most Asian patients seeking rhinoplasty is whether the bridge of the nose will be made too high or if it will look like a Popsicle stick shoved inside the nose.  The older solid silicone implants that Dr. Lam used to use unfortunately led to these types of problems.  Here are the reasons why Dr. Lam no longer uses silicone as his implant of choice for Asian rhinoplasty.  First, solid silicone tends to cause a shrink-wrapping of the skin around the implant, which leads to a visibility of the implant edges and thereby an unnatural result.  Second, silicone is very hard (even the softer versions) and can feel unnatural.  Third, silicone is very heavy and in some patients can tend to shift and slide downward to cause problems with the nasal-tip skin.  For all of these reasons, Dr. Lam prefers now to avoid using solid silicone in building Asian noses.

This woman had a silicone implant placed in Vietnam and is shown with the implant having slid downward to cause a hole at the tip of the nose.  Dr. Lam rebuilt the nose using a cartilage graft for the tip of the nose, Gore-Tex for the bridge of the nose, and performed a scar revision to improve the appearance of the bottom of her nose.

The concern of raising a nasal bridge too high is legitimate considering the number of individuals who exhibit a very fake looking bridge.  Dr. Lam does not use Western standards of beauty for raising the nasal bridge but tries to adjust the nasal bridge height to match your gender, ethnicity, and facial features.  In general, the top of the Asian nose should end approximately at the middle of the eye level, whereas in the Western nose the bridge should ideally terminate at the top of the eyelid crease.  The elevation of the nasal bridge to this level can look unnatural in many Asians and should be avoided in many cases.

The following patient demonstrates improvement in her nasal appearance by raising her nasal bridge to an appropriate height.  As part of an understanding of harmony, notice that the nasal tip appears smaller after raising the nasal bridge even without modification of the nasal tip itself.

For minor modification of the nasal bridge height after rhinoplasty, Dr. Lam can further raise the bridge height as desired using micro droplets of liquid silicone.  Although Dr. Lam does not like using solid silicone implants, he occasionally uses micro droplets of liquid silicone as needed to enhance the nose further when warranted.  Dr. Lam is very hands on with his patients after rhinoplasty to ensure that the result is as perfect as he can deliver every time.