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Asian Blepharoplasty

  • Author: Charles S Lee, MD, FACS; Chief Editor: Zubin J Panthaki, MD, CM, FACS, FRCSC  more...
Updated: May 11, 2015


Asian blepharoplasty, commonly termed double-eyelid surgery, refers to surgery designed to place a pretarsal crease in Asian eyes that are absent a fold. Patients typically desire to look more bright-eyed and want to make applying eyeliner easier. Patients also seek to remove the puffy and tired look associated with a fatty upper lid. In current American society, Asian patients almost never seek to westernize their appearance, and surgeons should be wary of modifying a patient's ethnic appearance, even in the rare case when it is requested.


History of the Procedure

The earliest reference to upper lid fold creation appears in the Japanese literature in the late 1800s. The case involves a surgeon who created a fold in the second eye of a patient born with a fold in only 1 eye.

In the English literature, Sayoc and Millard furnished early descriptions of the procedure.[1, 2] In addition to securing the aponeurosis to the skin, Millard, a plastic surgeon, relied on orbital lipectomy to create the fold. This technique was specifically to westernize the eyelid at the patient's request (D. R. Millard, verbal communication, August 1993).

Leabert Fernandez, also a plastic surgeon trained by James Barrett Brown, developed the technique of suturing pretarsal skin to the levator aponeurosis expansion.[3] Fernandez's technique remains the hallmark of the modern double eyelid operation and remains probably the most common technique of incisional double eyelid surgery. Plastic surgeon Robert Flowers' anchor blepharoplasty (described below) expanded the artistic possibilities of the Fernandez procedure by emphasizing the creation of a crisp line and smooth pretarsal skin by securing the fold to the tarsal plate in addition to the levator aponeurosis.[4]



Asian patients with a puffy upper lid and an absent crease may dislike such an appearance. The patient may report difficulty applying eyeliner because of the overhanging fat and may wish to have a crease similar in appearance to Asian friends who were born with such a crease. Patients generally do not want to change their ethnic appearance.




Approximately 50% of people of Pacific Asian descent (eg, Korean, Japanese, Chinese) have a pretarsal crease.



Traditional theory states that the pretarsal fold represents the insertion of the levator aponeurosis expansion into the dermis. Presumably, Asians have a lower insertion point than white persons, leading to smaller or absent folds. An alternative theory is that the fold corresponds to the level of the septoaponeurotic sling. Lower height of the sling in Asians allows the fat to sit lower in the eyelid, leading to a smaller fold.



Traditional approaches to placing a pretarsal crease involve suturing the dermis to the levator expansion at the appropriate height. Alternative approaches attempt to create a septoaponeurotic sling at the desired lid height.



Most commonly, the patient for this procedure is female and presents in mid adolescence with her mother or is female and is in her early 20s. Male patients, seen occasionally, tend to be slightly older, aged in the late 20s to early 30s. Female patients may report difficulty applying eyeliner. Not infrequently, females may apply cellophane tape to create a fold as part of the daily makeup ritual; the patient desires surgery to spare herself this inconvenience.

Occasionally, an older patient presents to report problems related to the aging upper eyelid and/or periorbital area. The patient may have had prior pretarsal crease placement.



Surgeons should consider the maturity of patients when they request such surgery. Occasionally, a mother brings a young teenaged daughter in for surgery. Patients should be mature enough to participate in oral or intravenous sedation for surgery and should understand and accept the risk of complications.


Relevant Anatomy

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. Nasally, it begins close to the lash line and then reaches a maximum height at mid pupil. It stays at this height, extending to the orbital rim laterally. In contrast, folds in non-Asians tend to be larger and have less orbitopalpebral fat.

The primary difference between the non-Asian versus Asian eyelids is that the prelevator fat lies in a more inferior level; ie, the septo-aponeurotic sling hangs lower. In non-Asians, the supratarsal fold marks the inferior limit of the prelevator 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 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 nonincision suture method of eyelid surgery creates the fold by recreating this dermal attachment using nonabsorbable 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. 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. The incisional method and semi-open method are described in Surgical therapy. 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.

The height of the proposed crease is determined by using a height of 7-10 mm from the lid margin (see Surgical therapy), which corresponds to the height of the tarsal plate. Because the tarsus shape varies in its configuration[5] , the point of maximum height is used.

The nasal area of the fold bears a variable relationship to the medial epicanthus. A fold may begin on the undersurface of the epicanthal fold or on the visible outer surface. These are referred to as an "inside" fold or an "outside" fold, respectively. When the fold is set relatively high, the crease usually folds on the outside.

The medial epicanthal fold can be variable in configuration. The Flowers classification is based on the how much of the caruncle is visible. In type I, the caruncle is visible and resembles a white person's anatomy. In type II, the caruncle is partially obstructed, while in type III, the fold is prominent and has an inversus component. Type IV resembles type I, except that the medial epicanthal fold is thick. A medial epicanthoplasty is recommended for patients with type III or IV and is optional for patients with type II.



Consider the maturity level of the patient, especially if he or she is young. At age 15-16 years, many teenagers do not have adequate coping mechanisms for potential complications. For these patients, consider the simplest and least morbid procedure.

Contributor Information and Disclosures

Charles S Lee, MD, FACS Private Practice, Beverly Hills, CA

Charles S Lee, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, California Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Chief Editor

Zubin J Panthaki, MD, CM, FACS, FRCSC Professor of Clinical Surgery, Department of Surgery, Division of Plastic Surgery, Associate Professor Clinical Orthopedics, Department of Orthopedics, University of Miami, Leonard M Miller School of Medicine; Chief of Hand Surgery, University of Miami Hospital; Chief of Hand Surgery, Chief of Plastic Surgery, Miami Veterans Affairs Hospital

Zubin J Panthaki, MD, CM, FACS, FRCSC is a member of the following medical societies: American College of Surgeons, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, American Council of Academic Plastic Surgeons, Miami Society of Plastic Surgeons, Medical Council of Canada, Canadian Military Engineers Association

Disclosure: Nothing to disclose.

Additional Contributors

Neal R Reisman, MD, JD Chief of Plastic Surgery, St Luke's Episcopal Hospital; Clinical Professor of Plastic Surgery, Baylor College of Medicine

Neal R Reisman, MD, JD is a member of the following medical societies: American Society of Plastic Surgeons, American College of Surgeons, American Society for Aesthetic Plastic Surgery, Lipoplasty Society of North America, Texas Medical Association, Texas Society of Plastic Surgeons

Disclosure: Nothing to disclose.

  1. Sayoc BT. Plastic construction of the superior palpebral fold in slit eyes. Bull Phil Ophthal Otolaryngol Soc. 1953. 1:2.

  2. Millard DR Jr. Oriental peregrinations. Plast Reconstr Surg (1946). 1955 Nov. 16(5):319-36. [Medline].

  3. Fernandez LR. Double eyelid operation in the Oriental in Hawaii. Plast Reconstr Surg. 1960 Mar. 25:257-64. [Medline].

  4. Flowers RS. Upper blepharoplasty by eyelid invagination. Anchor blepharoplasty. Clin Plast Surg. 1993 Apr. 20(2):193-207. [Medline].

  5. Nagasao T, Shimizu Y, Ding W, Jiang H, Kishi K, Imanishi N. Morphological analysis of the upper eyelid tarsus in Asians. Ann Plast Surg. 2011 Feb. 66(2):196-201. [Medline].

  6. Chung S, Ahn B, Yang W, et al. Borderline to Moderate Blepharoptosis Correction Using Retrotarsal Tucking of Müller Muscle: Levator Aponeurosis in Asian Eyelids. Aesthetic Plast Surg. 2014 Dec 17. [Medline].

  7. Park DH, Park SU, Ji SY, et al. Combined epicanthoplasty and blepharoptosis correction in Asian patients. Plast Reconstr Surg. 2013 Oct. 132(4):510e-519e. [Medline].

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  9. Flowers RS. Surgical treatment of the epicanthal fold (invited essay). Plast Reconstr Surg. 1983. 73:571.

  10. McCurdy JA. Upper blepharoplasty in the Asian patient: the "double eyelid" operation. Facial Plast Surg Clin North Am. 2005 Feb. 13(1):47-64. [Medline].

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Measure the desired height of the fold. Typically, an 8-mm fold yields a medium-sized fold in young patients. If one brow lies lower, then mark the fold 1 mm higher on that side to compensate for the increased overhang of skin.
Perform the medial epicanthoplasty first. Mark the V-W plasty; each limb measures approximately 2 mm. Mark the W portion on the surface of the epicanthal fold. The tip of the central flap of the W sits at the edge of the epicanthal fold, and the V component lies on the undersurface of the epicanthal fold. The markings represent skin that will be resected.
Use 6-0 nylon to suture the apex of each flap, as well as one in between them, for a total of 7 sutures.
Remove thin slivers of tissue, going through orbicularis muscle, retro-orbicularis fat, and septum until reaching prelevator fat. Do not confuse the proper fat layer. Verify prelevator fat by the glistening levator aponeurosis underneath, which moves when the patient opens his or her eyelid.
Pass 6-0 nylon through the conjunctiva along the upper border of the tarsal plate.
Pass one arm of the needle through the full thickness of the eyelid.
Arm the free end of the suture with a free needle, and then pass it through to the other side of the eyelid using the same needle hole as the initial conjunctival bite.
Tie the suture and sink the knot deeply into the space previously created to accommodate it.
Close the skin and place a light compression dressing.
Preoperative (top) and 2-wk postoperative (bottom) photos of a patient who underwent semiopen procedure (without medial epicanthoplasty).
After the skin markings and incision, a sliver of orbicularis muscle is excised to expose the underlying orbital septum.
The prelevator fat is identified and used as an anatomical guide to open the entire septoaponeurotic sling.
After the lateral portion of the fat is excised, the pretarsal soft tissue "bursa" is cleared, exposing the relevant anatomy. The skin flap has been everted; the tarsal plate fully exposed; and the levator aponeurosis lies just cephalad to the tarsal plate, under the forceps.
Use 6-0 Vicryl to secure the dermis to the tarsal plate and levator aponeurosis.
The suture has been tied.
The sutures have been placed in 6 positions along the incision. Closure is with 6-0 Prolene.
Preoperative (top) and postoperative (bottom) photos of a 22-year-old patient after anchor blepharoplasty and medial epicanthoplasty.
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