eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery

Facial Plastic Surgery in Asian Patients

Author: Carlo P Honrado, MD, Assistant Professsor, Department of Otolaryngology-Head and Neck Surgery; Consulting Staff, ENT Faculty Practice, LLP, Dermage Aesthetic Center and Spa and Westchester Laser Associates
Coauthor(s): Anthony Labruna, MD, Assistant Professor, Department of Otolaryngology, Department of Surgery and Plastic Surgery, Cornell University Medical Center; Edward Kwak, MD, Staff Physician, Department of Otolaryngology-Head and Neck Surgery, New York Eye and Ear Infirmary and Affiliated Hospitals; Melin Tan, MD, Staff Physician, Department of Otolaryngology-Head and Neck Surgery, New York Eye and Ear Infirmary
Contributor Information and Disclosures

Updated: Jan 8, 2008

Introduction

Asians are stereotypically described as having straight black hair, yellow skin pigmentation, puffy slitlike eyes with a medial epicanthal fold, a broad flat nasal dorsum with thick lobular skin that is yellow or brown in coloring, and a flat face with high cheekbones. This description consistently appears in books, television, and movies; however, these characteristics only apply to a small subgroup of individuals.

Because of geographic diffusion and interracial breeding, the physical characteristics of people of Asian descent show tremendous variation. For example, the skin of Asians living in southern latitudes tends to be darker and thicker than the milky skin pigmentation found in other Asian populations. The standard of beauty also varies among societies. Many people, especially whites, believe that a perfectly bronzed tan body suggests healthiness, whereas some Asian women preserve their milky skin, choosing to shade themselves from the sun with hats or umbrellas. The facial plastic surgeon should be aware of the anatomic and cultural differences among individuals of Asian descent when cosmetic surgery is being considered.

The facial plastic surgeon can offer several cosmetic surgeries unique to Asian individuals. The 2 most common invasive aesthetic procedures performed on Asian individuals are the double-eyelid procedure and the augmentation rhinoplasty. The double-eyelid procedure is the most common aesthetic procedure performed on Asian individuals and involves the creation of a superior palpebral fold from a single eyelid (a characteristic of approximately 50% of Asian people). Augmentation rhinoplasty, as opposed to nasal reduction, is also frequently performed, usually with the use of an alloplastic implant. Rhytidectomy can offer a reduction in rhytides; however, rhytidectomy is not performed as frequently as the previous 2 procedures because of the increased dermal thickness observed in Asian people.

Less-invasive procedures are becoming more popular in facial plastic surgery as well. Botulinum toxin (BOTOX®), dermabrasion, and chemical peeling are being used in increasing numbers for cosmetic purposes in patients who do not wish to undergo surgery. With the advent of laser surgery in the 1980s, lasers and light-based treatments offer another option for addressing surface cosmetic imperfections. Although wrinkling is an issue in the aging face in general, classic clinical features of photoaging in Asians are primarily discrete pigmentary changes. These include actinic lentigines, flat pigmented seborrheic keratoses, and mottled hyperpigmentation. The laser and light-based therapies are becoming more popular options for addressing these skin changes. In Asian patients, special consideration is required because ethnic skin has the potential for more complications than the skin of the general white population. 

This article focuses on the double-eyelid procedure, the nasal augmentation procedure, and the use of laser-based and light-based therapies in Asian patients, since these cosmetic procedures require special considerations that are unique to Asian patients.

History of the Procedure

Blepharoplasty techniques have been described as early as the 19th century, with some possible references to even earlier dates. However, popularization of the double-eyelid procedure in the Asian population did not occur until after World War II. Since the 1960s, various techniques have been described to create a double eyelid in individuals lacking a supratarsal fold. The basic premise is to create a firm adherence between pretarsal skin and the tarsal plate. When creating a supratarsal fold, different techniques have been incorporated to address the epicanthal fold that may also be present.

The goal in rhinoplasty surgery is to enhance the aesthetics of the nose and create a harmonious appearance with regard to the patient's other facial features. Although most rhinoplasty techniques in the white patient focus on nasal reduction, the anatomy of the Asian nose often requires augmentation. Although the best material for augmentation remains controversial, apparently most Western surgeons prefer autogenous material, whereas alloplastic material is favored in Asia.

Lasers were first developed in the 1980s and, since that time, laser treatments have been increasingly indicated, including for scar revision and the removal of skin lesions. For cosmetic purposes, lasers are used for skin resurfacing and can be effective for exfoliating the surface of the skin as well as restoring the skin's elasticity by tightening the skin's collagen fibers. Laser pulses target the surface layer of the skin, vaporizing water and the skin's surface without affecting the deep layers. A new surface layer then grows back as a soft and younger-looking layer. Additionally, photorejuvenation, which is a light-based treatment for photoaged skin, is available.¹ These options afford minimal risk and less downtime for the patient, and are therefore becoming more popular globally, regardless of ethnicity. With the increasing demand, the properties unique to Asian skin must be carefully considered.

Problem

The Asian upper eyelid is characterized by lack of a superior palpebral fold, laxity of pretarsal skin, excessive fat, and the presence of an epicanthal fold. The typical Asian nose can be described as having a flat and broad dorsum, deficient tip projection, a wide lobule, thick lobular skin, abundant subcutaneous fatty tissue, alar flaring, and a retracted columella.

Etiology

Most patients who undergo cosmetic procedures in Asia are women, although cosmetic surgery is gaining popularity among men. Since the end of World War II, Asian women have become liberated from traditional habits, allowing them to explore and accept ways to make themselves look younger. As a result, the number of procedures for facial rejuvenation or alteration has increased.

Some people believe that the Asian person seeking cosmetic surgery wishes to look like a westerner. Although this may hold true for a small minority of patients, most Asian persons wish to preserve their heritage and undergo changes to make themselves more attractive. In fact, creation of westernized features may produce unsatisfactory results and complications that may disrupt the harmony and balance of the facial features of the patient. As in all facial plastic surgery procedures, the physician should clearly understand the wishes and desires of the patient and discuss realistic alterations that create an aesthetically pleasing face.

Presentation

A thorough history is important in evaluating any patient who desires cosmetic surgery. Carefully ascertain from the patient specific desires regarding the procedure, which helps to foster a relationship between the patient and physician. Unrealistic expectations only lead to disappointment for both the patient and the surgeon. Westernization of the Asian upper eyelid or nose may be desired by a few individuals; however, most patients only desire to enhance their features and preserve their ethnic identity.

Also include in the patient assessment any significant past medical or surgical history. Knowledge of systemic disease is imperative, as laser-based or light-based treatments may exacerbate inflammatory conditions such as psoriasis, rosacea, and contact dermatitis. Determine if any prior procedures were performed to the eyes or nose, especially cosmetic procedures, and make every effort to ascertain the details of such procedures. Make note of any history of hypertrophic scar formation or of hyperpigmentation after surgery or injury to skin. Record medications and smoking or alcohol history, which may affect postoperative wound healing.

The physical examination focuses on the characteristics of the eyes and/or nose; however, these areas also need to be examined in relation to the rest of the patient's facial features, such as the width and contour of the face. The facial plastic surgeon must also acknowledge the anthropometric differences of Asian faces and white faces. Applying Western ideals of facial beauty to an Asian face can result in a loss of ethnic identity along with a dissatisfied patient.

The presence of wrinkles and the laxity of skin or notable skin imperfections can also help dictate if any other ancillary procedures need to be performed.

Indications

Consider for surgery any individual of Asian descent who wishes to undergo a surgical procedure to enhance aesthetic appearance. Excessively thick upper eyelids with redundant skin that overhangs the eyelashes can make a person less attractive. Also, a single eyelid makes the eye look small, with the overall effect of making the patient look tired. Creation of a double eyelid everts the eyelid, making it more attractive. The double-eyelid procedure also makes the eye appear larger and more relaxed.

Patients who wish to undergo rhinoplasty usually seek to increase the height of the nose, while also refining the lobule/tip area. They may also wish to decrease the width of the nostrils.

Surgical corrections are the hallmark for cosmetic correction; however, surface skin abnormalities can be addressed with nonsurgical interventions. For patients who desire a more youthful appearance or to remove skin imperfections such as actinic lentigines, pigmented seborrheic keratoses, and mottled hyperpigmentation, laser skin resurfacing and photorejuvenation are available.² They are both minimally invasive, requiring minimal downtime for the patient. These can also be performed as adjunctive therapies to the more invasive procedures.

Relevant Anatomy

The Asian upper eyelid is characterized by a lack of a superior palpebral fold, laxity of pretarsal skin, excessive fat, and the presence of an epicanthal fold. Of note, approximately 50% of the Asian population lacks a superior palpebral fold, and 90% of Asian people demonstrate an epicanthal fold. The epicanthal fold is a semilunar fold of skin that extends from the upper eyelid across the medial canthal area to the lower eyelid. Although the double-eyelid operation is the most common cosmetic procedure performed in the Asian patient, debate still surrounds the anatomic reasoning for the lack of the superior palpebral fold. Two leading explanations for the variation between the folds exist, but one must first understand the structures of the upper eyelid.

A cross-section of the upper eyelid reveals 7 layers. From superficial to deep, these layers are the skin, loose subcutaneous tissue, the orbicularis muscle, a submuscular/areolar layer, a fascial layer, the tarsus, and the conjunctiva. The fascial layer consists of the orbital septum, which forms the anterior wall of the supraorbital fat compartment and extends from all of the edges of the orbital rim. The expansion of the levator palpebrae muscle lies deep to the supraorbital fat and forms the posterior wall of the compartment. Although it has not been demonstrated histologically or grossly, the consensus is that the formation of a double eyelid results from penetration of the expansion of the levator palpebrae muscle through the septum and orbicularis muscle to the overlying dermis.

Others believe that fibrous septa that extends from the tarsal plate, which causes a firm adherence between the pretarsal skin and tarsus, is absent in Asians. In whites, this adherence allows the pretarsal tissue to move as a unit with the mobile preseptal eyelid segment, which results in the supratarsal fold on lid retraction. Proponents of this theory believe emphasis should be placed on the removal of soft tissue between the dermis and tarsus, as opposed to levator fixation, to allow for a successful double-eyelid surgery. In either respect, creating a firm fixation and/or excising pretarsal tissue is important in creating the supratarsal fold in double-eyelid surgery.

Another important finding in the Asian upper eyelid is the presence or absence of an epicanthal fold. The exact anatomy of the epicanthal fold is unclear, but several possibilities are proposed. The epicanthal fold is widely believed to be a result of an underdevelopment of the nasal root and excess horizontal medial canthal skin. However, anatomic studies suggest that the epicanthal fold results from insertion of superficial fibers from the medial canthal ligament and orbicularis oculi muscle through the fold. These studies also suggest that differences in thickness between the nasal and eyelid skin may contribute to the epicanthal fold.

Certain characteristics of the Asian nose often create the basis for surgical alteration. The typical nose is described as one with a flat and broad dorsum, deficient tip projection, a wide lobule, thick lobular skin, abundant subcutaneous fatty tissue, alar flaring, and a retracted columella. The thick lobular skin causes the bulbous appearance of the nose, which can be exacerbated further by separation at the dome of the alar cartilages. The lower lateral cartilages also may not be strong enough, resulting in decreased projection of the nose. The medial crura of the lower lateral cartilage are much longer in Asians than in whites. Variations exist, and any one patient can present with one or more of these features. The aesthetic desires of the patient and the limits of what is technically feasible dictate the operative course of action.

Skin is typically grouped into the Fitzpatrick classification, which describes the propensity for sun reactivity. In general, all skin types are susceptible to photoaging. However, those who fall into higher Fitzpatrick phototypes are less susceptible, likely due to the protective role of melanin. Asians generally fall into categories IV-VI. Although no differences are evident in the number of melanocytes per unit area of skin when comparing lighter and darker skin, darker skin has a higher amount of melanin. Melanin, along with water and hemoglobin, is the target chromophore in skin for lasers and light devices. This is an important consideration because laser energy intended for deeper targets can be absorbed by melanin in the basal layer of the epidermis and can cause unintended epidermal damage, risking blistering, permanent dyspigmentation, textural changes, focal atrophy, and scarring. Therefore, the use of lasers in patients with darker skin, who have a higher melanin content, can result inmore complications.

Contraindications

Any person who has a medical condition that would not allow them to undergo elective surgery contraindicates blepharoplasty or rhinoplasty. Patients with dry eye syndrome also should not undergo blepharoplasty.

Patients with an impaired immune system, scleroderma, extensive radiation therapy, burns in the treatment area, or poor healing in the treatment area should not undergo laser skin procedures. Additionally, use of isotretinoin in the past 12 months is a contraindication for laser-based or light-based therapy.

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