Saudi Arabia (SA) Asian Blepharoplasty

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Asian blepharoplasty (double-eyelid surgery)

Eyelid surgery (technically called blepharoplasty) is a procedure to remove fat--usually along with excess skin and muscle from the upper and lower eyelids.

Asian blepharoplasty (double-eyelid surgery), is a surgery designed to place a pretarsal crease in Asian eyes that are absent a fold.

Patients are typically looking to remove the puffy and tired look associated with a fatty upper lid.
In America today, the majority of Asian patients do not seek to “westernize” their appearance. Plastic surgeons should be careful in modifying a patient`s ethnic appearance, even in the rare case when it is requested.

Asian patients with a puffy upper lid and an absent crease may wish to improve such an appearance. The patient may have difficulty in applying eyeliner (because of the overhanging fat), and may wish to have a crease similar in appearance to other Asian people who were born with such a crease.

Approximately 50% of Pacific Asians (Koreans, Japanese, Chinese) have a pretarsal crease.

The best candidates for eyelid surgery are men and women who are physically healthy, psychologically stable, and realistic in their expectations.

Most commonly, patients are female teenagers or in early 20s. Occasionally there are also male patients, aged late 20s to early 30s. Female patients may report difficulty applying eyeliner. There are many cases where females apply cellophane tape to create a fold as part of their daily makeup ritual.

In Asians with a fold, the height of the normal lid fold lies 8-10 mm from the lash line with the skin gently stretched. In contrast, folds in white individuals tend to be larger and have less orbitopalpebral fat.

The primary difference between white versus Asian eyelids is the inferior level of the fat. In whites, the supratarsal fold marks the inferior limit of the fat. This inferior limit is also the point at which the levator aponeurosis attaches to the dermis, creating an upper lid crease. In the Asian eyelid, this dermal attachment rests lower, resulting in a smaller crease, or it does not attach to the skin at all, resulting in an absent fold.

The Surgery
Eyelid surgery is usually performed under local anesthesia (which numbs the area around the eyes). The patient is awake during the surgery, but relaxed and insensitive to pain. However, the patient may feel some occasional discomfort.

Some surgeons prefer to use general anesthesia, where in such case the patients sleeps through the operation.

Blepharoplasty usually takes one to three hours, depending on the extent of the surgery.

After Surgery
The surgeon will probably lubricate the eyes with ointment and may apply a bandage. The eyelids may feel tight and sore as the anesthesia wears off, but it can be controlled with pain medication prescribed by the surgeon.

The patient will be instructed to keep the head elevated for several days, and to use cold compresses to reduce swelling and bruising.

The patient will be shown how to clean the eyes, which may be gummy for a week or so. Many doctors recommend eye-drops, since the eyelids may feel dry at first. For the first few weeks the patient may also experience excessive tearing, sensitivity to light, and temporary changes in eyesight, such as blurring or double vision.

The patient should be able to read or watch television after two or three days. However, a patient will not be able to wear contact lenses for about two weeks, and even then they may feel uncomfortable for a while.

Most patients feel ready to go out in public (back to work) in a week to 10 days. The patient may be sensitive to sunlight, wind, and other irritants for several weeks, so it is advised to wear sunglasses and a special sun-block made for eyelids when going out.

The patient will probably be told to keep activities to a minimum for three to five days, and to avoid more strenuous activities for about three weeks. As well, it will be recommended to avoid alcohol, since it causes fluid retention.

Healing after surgery
Healing is a gradual process, and scars may remain slightly pink for six months or more after surgery. Eventually, though, they`ll fade to a thin, nearly invisible white line.

The general categories of repair
The surgical strategy for creating an Asian eyelid fold is either to recreate the dermal attachment of the levator aponeurosis, or to prevent the fat from descending below the desired eyelid fold height.

• The non-incision suture method of eyelid surgery creates the fold by recreating dermal attachment using nylon sutures.

• The incisional method of Asian eyelid surgery recreates the fold by removing the inferior portion of the prelevator fat and sealing off this area. Prelevator fat is removed through a stab incision, effectively raising the septoaponeurotic sling. This procedure is best suited for younger patients with little forehead ptosis and no prior crease surgery. The upper eyelid skin should be relatively thin, with thin pretarsal orbicularis muscle. Surgeons less experienced in operating on Asians may prefer this procedure because of its potential reversibility.

• A hybrid version, the semi-open method, combines aspects of both techniques by using buried nylon sutures to recreate the fold but also removing a portion of the prelevator fat through a small incision.

In any case, the surgeon should not remove too much fat from the Asian eye because this results in a westernized appearance, which should be avoided.

Risks
A few medical conditions make blepharoplasty more risky. They include thyroid problems such as hypothyroidism and Graves` disease, dry eye or lack of sufficient tears, high blood pressure or other circulatory disorders, cardiovascular disease, and diabetes. A detached retina or glaucoma is also reason for caution.

Candidates must check with their ophthalmologist (eye doctor) before they have surgery.

Complications
The minor complications that occasionally follow blepharoplasty may include:
• Double or blurred vision for a few days;
• Temporary swelling at the corner of the eyelids; and
• A slight asymmetry in healing or scarring.
Tiny whiteheads may appear after the stitches are taken out. The surgeon can remove them easily with a very fine needle.

After surgery, some patients may have difficulty closing their eyes when they sleep. In rare cases this condition may be permanent.

Another very rare complication is ectropion, a pulling down of the lower lids. In this case, further surgery may be required.

Potential deformities
The most irreversible deformity that can occur with Asian eyelid surgery is overresection of prelevator fat. The suture or semiopen method precludes this complication.

Asymmetry: Apparent asymmetry resolves with time if markings were placed with care. Consider reoperation after 3-6 months. Asymmetric fat removal, especially if retro-orbicularis fat is removed from one side and prelevator fat from the other, can be avoided by careful attention to anatomy.

Loss of crease: This occurs less frequently with the semi-open method than with the pure suture method. Conversion to an open method such as the Flowers anchor blepharoplasty may be necessary.

Ptosis: The most common cause of postoperative ptosis is failure to recognize a preexisting ptotic condition. In the Asian eyelid, this can sometimes be difficult to assess because of overhanging skin that created a pseudoptosis. The lid margin must be carefully assessed preoperatively. In the Asian eyelid, ptosis is defined as a lid margin that is lower than halfway between the limbus and the pupil. This is approximately 1 mm lower than in a white person`s eyelid.

For a natural looking fold, the ideal amount of pretarsal show with the eyes open and at straight gaze is 2-3 mm. The rest of the pretarsal skin should be hidden behind the overhanging upper lid skin. This height is usually obtained by creating an incision at 7-10 mm above the lash line with the skin slightly stretched. Although this is a general guideline, a patient with brow ptosis should have the incision set slightly higher because the brow will drop in the postoperative period, decreasing the amount of pretarsal show. On the other hand, patients who are slightly exophthalmic should have the crease set slightly lower, closer to 6 or 7 mm.

The preferred height of the incision has already been determined with the patient in the upright position, taking into account the patient`s forehead anatomy (larger, around 10 mm or more, if the patient has brow ptosis) and globe position (smaller than 6 mm, if the patient is exophthalmic).

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