East Asian eyelid anatomy and double eyelid surgery

How are East Asian eyelids different?

East Asian eyelids have anatomical features that distinguish them from Western eyelids. These features are described as giving East Asian eyes their distinctive look and serving as a basis for deciding which surgical method to use ^[1]. Double eyelid techniques have also been modified and refined as surgeons came to better understand the anatomical differences between the two groups ^[4].

From front to back, the upper eyelid is made up of layers: the skin, the muscle around the eye (orbicularis oculi), the orbital septum and the fat behind it, the tendon sheet of the muscle that opens the eye, and the tarsal plate (tarsus) and conjunctiva. The thickness and arrangement of these layers affect how a double eyelid crease forms.

Fat is often cited as a key difference. The East Asian upper eyelid has more prominent preseptal fat, which tends to make the eyelid look fuller ^[2]. However, the amount of fat and the thickness of the skin vary from person to person even among East Asian patients, so they need to be checked during an examination.

Why anatomy changes the surgical approach

The goal of double eyelid surgery in East Asian patients is described as creating an attractive, long-lasting upper eyelid crease ^[4]. Because East Asian eyelids have fullness from fat, the soft-tissue work needed to keep the crease in place is said to be more varied and more essential than in Western eyelid surgery ^[2]. For this reason, it is stressed that surgery should be tailored to the anatomy around East Asian eyes ^[2].

The methods fall broadly into incisional and non-incisional (suture) techniques. A review of the incisional method described in detail how incisions are used to create a natural crease in people with single eyelids ^[2]. The non-incisional method is described as simple and minimally invasive, and studies report that choosing the right patient and technique can give a natural result and reduce the chance of the crease coming undone ^[5].

How surgical goals change with age

In younger patients, the main goal is to create the crease commonly called a double eyelid while keeping the characteristic features of East Asian eyes ^[1]. In older eyelids, by contrast, the three conditions below are described as needing evaluation and, if necessary, treatment at the same time ^[1].

In particular, when the outer part of the brow sags considerably and skin hangs over the outer corner of the eye, the literature notes that an incision just below the brow can offer additional functional and cosmetic benefit ^[1]. Even when the sagging looks the same, the approach differs depending on whether it comes from the skin, the eyelid muscle, or the position of the brow, so it is important to identify the cause during the examination.

• Excess eyelid skin (dermatochalasis): upper eyelid skin that has stretched and hangs down
• Droopy eyelid (blepharoptosis): the upper eyelid itself sits too low
• Brow sagging (brow ptosis): the brow has dropped and presses down on the eyelid

How is a natural look judged?

A review of the incisional method describes the goal of East Asian double eyelid surgery as creating a crease that resembles one that looks natural on other East Asian people ^[2]. Another review of East Asian double eyelid surgery also treated how to define East Asian aesthetic standards and how to preserve a person's original look and ethnic identity as important topics ^[3].

Men have their own anatomical features and aesthetic considerations, and are sometimes discussed separately ^[6]. A crease of the same height and shape can look different depending on how it fits with the rest of the face, so it helps to describe the look you want in specific terms.

Recovery, risks, and what to ask during your consultation

A review that walked through the incisional method step by step also addressed preoperative planning and consultation, the course of recovery, and complications and revision surgery as key concerns before and after surgery ^[3]. With any method, recovery and risks vary from person to person, so it is best to have them fully explained before surgery.

• The amount of fat and the condition of the skin in your eyelids
• If there is sagging, whether it comes from the skin, the eyelid muscle, or the brow
• Whether the incisional or non-incisional method suits you, and why
• The crease shape you want and what looks natural to you
• Recovery time, complications, and the possibility of revision surgery