Asian Blepharoplasty – Double Fold Surgery

This is Dr David W Kim and tonight this video blog is about Asian Blepharoplasty which is the common name for the procedure which is used to create a crease in the upper eyelid, usually in an Asian individual. It is also sometimes known as double fold surgery. It is a very common operation that I perform but conceptually it is complicated for someone not acquainted with the anatomy of the eyelid. I created this video blog to educate folks interested in this procedure. The first thing to remember is that the eyelid anatomy is complicated and vary even among Asian patients. If you read the literature it says that anywhere from 20-50% of Asians either have an underdeveloped crease or no crease at all. This individual at the top has no crease and therefore has a single fold. This patient in the middle has an underdeveloped low crease and therefore the fold is very low and close to the eyelash margin. And in this last individual (which happens to be me) does have a crease in a normal position and therefore a higher fold. When we look at the anatomy of the eyelid, we look at the layers beneath the skin. The first layer we see is the obuicularois muscle which is important to allow us to close our eyes. Beneath that we have a couple of facial layers, we have the orbital septum and very importantly we have this levator aponeurosis. This is a continuation of the levator muscle and this muscle is important cause this muscle allows us to open our eyes. When we look at the levator aponeurosis in its deeper claim, it is attached to the tarsus which is the fibrous portion of the eyelid which gives substance to the eyelid. So the levator attachment to the tarsus is what allows us to open our eyes. When you look at the side view of the anatomy, the levator muscle which is show in red typically goes down next to the tarsus but sends some fibers to the skin. The location in which the levator muscle is attached to the skin signifies where the creases are formed. Only in a minority of Asian patients is this connection lacking. IN this situation the levator muscle still maintains its function and allows the eyelid to open but because its lacking in connection to the skin, there is no apparent crease and therefore only a single fold.
When we perform surgery, I typically make an incision in the exact position of the desired crease. That allows me to place some very precise, strategic sutures between the lower aspect of the incision and the actual levator muscle. These stitches eventually dissolve but scar tissue forms between these structures restoring the normal anatomy in that area. In some cases, surgeons will use a different technique where they flip the eyelid and evert it and just place some sutures that wave back and forth like a baseball style manner avoiding incision. This is tempting for some surgeons because it can be done more rapidly with less down time, however, I found that this technique to not lead to uniform, precise results and more importantly the results tend to go away over time. Therefore, I prefer to use this open method. This is a patient who this operation. Preoperatively, you can see that he has no crease, therefore a single fold. This is him less than a week after surgery. He still has a little bit of bruising and because the swelling hasn’t settled the fold is at a higher position that where it will eventually settle. The last picture is about three weeks after surgery. It still hasn’t completely settled but this is approaching the final result.
In summary, Asian blepharoplasty or upper lid crease formation is an intriguing and very satisfying operation. It demands an intimate knowledge of the complicated anatomy of the upper eyelid. It is a fairly simple, technical procedure but it is one that requires a very meticulous, technical approach. This is an operation I enjoy doing and my patients have had great results.