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.

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 .