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.