On Creases, Folds, Hollows, and More
Asian double eyelid surgery
and procedures on the upper crease,
lower eyelid, brow, canthus, and more.
Eyelid plastic surgery has become the most popular of all facial cosmetic surgery procedures selected by patients of Asian descent in the East and the West. However, it is not, as many people assume, merely a single operation on the upper eyelid.
More accurately a group of related operations (see 26 Ways of Altering the East Asian Eye), the most well-known procedure is double eyelid surgery designed to create or enhance the eyelid crease. Still, there are many other procedures available, all tied together by a common primary objective, to make the Asian eye appear bigger, more open, more expressive, and sometimes more Western.
While the various anatomic layers that comprise the Asian eyelid are the same as those found in the non-Asian lid, their arrangement, connections, and thicknesses differ in many respects, some obvious, some subtle. Such variations and distinctions make surgery on the Eastern lid so different from that on the Western lid that modern Asian double eyelid surgery bears only scant resemblance to European blepharoplasty.
Single eyelids ("monolids") and epicanthal folds are not unique to those of East Asian ancestry and can be found in other distant groups, such as the indigenous Indian populations of North and South America, a result of nomadic migrations many centuries ago across the Bering Strait separating what is now Russia and Alaska. What's more, many people of northern, southern, and western Asian descent share few of what are often considered "characteristic" East Asian traits, especially around the eyes.
In other words, "Asian eyelid surgery" is not just one thing, and one size does not fit all. It's much more complex.
Many plastic surgeons consider eyelid surgery to be the least forgiving of all cosmetic procedures. Results can vary tremendously with the training, skill, and experience of the doctor, and preexisting limitations such as skin thickness, asymmetry, misdirected eyelashes, accessory skin folds, hollowness, crease variability, and so on are by no means rare.
Less than full patient satisfaction with the final result is surprisingly common, a reflection of both the difficulty in performing these operations as well as what are often unrealistic expectations with respect to surgical precision. If all one ever views on the Internet are a surgeon's finest results, it's hard to appreciate that perfection after surgery is not really the norm.
Double Eyelid Surgery: What is It?
Asian double eyelid surgery, also known by the misnomer Asian blepharoplasty, is an operation designed to create or enhance a crease in the upper eyelid. While there are two main approaches for achieving this goal, there are many variations within each group depending upon a surgeon's experience and skill.
The suture technique, sometimes mislabeled as a non-incisional approach, is an operation first described in the late 1800s and modified countless times since right up to the present day. The operation requires placement of permanent sutures knotted internally to compress the eyelid's anatomy. A crease is always present (static crease) whether the eyes are opened or closed. Because skin is not removed, the technique allows for minimal customization of the double eyelid and is not the most appropriate approach in other than some very young patients. Sooner or later, the buried sutures break or untie. Once internal compression is lost, the crease either weakens, disappears, or is lost in an irregular or spotty fashion on either one side or both.
While still popular in some parts of Japan because of quick execution, short recovery times, and reduced cost, suture techniques are not the favored approach in most Asian or Western countries. Despite modifications said to increase durability, there are too many limitations.
The incisional technique for double eyelid surgery is a more modern approach that incorporates both some advances in non-Asian "European" blepharoplasty with a vastly improved understanding of the normal anatomic mechanism of natural crease formation in the Asian eyelid. In contrast to the static crease created by the suture technique, the new crease forms only when the eyes are opened (dynamic crease). Because skin and sometimes fat and muscle may be removed as indicated, the technique allows for a high level of customization. The crease is permanent because it depends on internal anatomic rearrangement rather than retained suture knots.
Incisional double eyelid surgery is a difficult operation that requires a high level of surgical expertise, experience, and precision; it shares almost nothing in common with older suture techniques. Incisional surgery is not well-suited for the casual eyelid surgeon or in a setting where surgery is performed without an in-depth preoperative analysis and consultation with the surgeon.
While serious complications such as infection and vision loss are rare, all double eyelid surgery procedures, can, as is true for any type of facial plastic surgery, create aesthetic issues such as an unnatural appearance, too high a crease, ethnic imbalance, or "Westernization."
Why Do It?
Men and women of Asian lineage seek eyelid plastic surgery for the same fundamental reason as their Occidental counterparts, namely, to feel better about themselves. While enhancing the existing eyelid structure so that it better conforms to generally-accepted norms of aesthetics and balance is indeed a major goal, feeling happier and more confident is yet another.
While approximately half of East Asian people are born with an upper eyelid crease, that crease is different from an Occidental crease in important ways, most notably in height, shape, and depth. Some natural Asian creases are almost rudimentary and may be highly variable in their expression day to day.
Of those born without a crease or with a very low or weak crease who later seek double eyelid surgery, very few are trying to look Western.
Rather, the vast majority desire the creation of a defined and stable platform of skin above the lashes that is harmonious with their other facial features and consistent with that occurring naturally in the Asian population. Some patients want only a "thinning" of excess skin or fat from fuller eyelids.Interestingly, the first medical description of an operation designed to establish a crease in the Asian single eyelid was published in Japan in the late 1800s, long before the intense intermingling of Eastern and Western cultures.
Although the popularity of double eyelid surgery has grown rapidly in the last fifty years, the presence of a defined eyelid crease has long been valued because it is seen by many as allowing for a more accurate and intense expression of emotion.
While the ethical "baggage" associated with undergoing cosmetic eye plastic surgery has all but disappeared from contemporary thought, a few people still insist on investing the topic of Asian blepharoplasty with overtones of cultural rejection.
Critics expressing such sentiments are far too narrowly focused, but so also are those who categorically reject the obvious influence of one culture upon another in today's highly interconnected world.
Electing to undergo any type of cosmetic surgery is an intensely personal decision, and each individual's motivations are different, multiple, and complex. For whatever reasons, double eyelid surgery has become the most requested cosmetic operation among those of Asian descent in both the United States and the Orient.
Double Eyelid Surgery Is Not A Blepharoplasty
Despite common use of the term "Asian blepharoplasty," double eyelid surgery is not a blepharoplasty. Both operations are indeed performed on the upper eyelid. Beyond that, their differences are so fundamental that they are best thought of as unique rather than closely related procedures.
Nomenclature aside, why might this matter to a potential patient?
"Blepharoplasty" is an older operation developed on and for patients of European and Occidental descent, while "double eyelid surgery" is a more recent operation developed on and for patients of Asian lineage. Many cosmetic surgeons who can perform a blepharoplasty with skill have little or almost no experience with double eyelid surgery.
The most prominent differences between the two operations relate to intended goals, ages of the patient population, and surgical techniques.
• Most Occidental patients requesting blepharoplasty are in their forties, fifties, and sixties, while the vast majority of Asian patients requesting surgery are in their teens, twenties, and thirties.
• In the Occidental eyelid, the primary goal of surgery is rejuvenation of the aging upper lid. For the most part, the operation is subtractive (that is, removal of stretched, weakened, or poorly positioned skin and fat). Typically, minimal attention is devoted to reshaping the already-present crease.
• In the Asian eyelid, the primary goal of surgery is creation of a new crease or enhancement of an inadequately defined, asymmetrical, or unstable crease. Skin and fat removal are minimal, and, in many cases, no fat is removed at all. Instead, the procedure is focused on the realignment of youthful internal eyelid structure.
• Trying to compare minimal-incision "suture techniques" for crease creation with blepharoplasty becomes even more tenuous. The two operations share no common features.
• If a young Asian patient is approached surgically in a manner similar to that used in an aging Occidental patient, the result can appear unnatural and surgical.
All animals are not birds
Appending the modifier "Asian" to the classical operation known as "blepharoplasty" is not unlike calling cosmetic eyelid surgery in a patient of European descent by the name "European double eyelid surgery."
Why does this matter? If you happen to need one operation but instead get the other, you may not be very pleased.
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