Because the fundamental difference between Asian and Occidental blepharoplasty revolves around the creation or enhancement of the upper eyelid crease, the subject of Asian eyelid surgery to lessen lower skin folding and fat bulging is commonly neglected.

Some eyelid surgeons even discourage Asian patients from pursing lower lid rejuvenation with disparaging remarks about the effectiveness and safety of lower blepharoplasty in the Asian eyelid. In our experience, this is unjustified and indicates either misunderstanding, inexperience, or an unwillingness to master the finer points of such surgery.

In fact, the same basic principles and techniques employed in Occidental eyelid surgery are applicable to the Asian lower lid, and the potential for a significant and safe outcome is equally high in both groups.

Just as there are subtle but important differences in the way the layers of the upper eyelid interact in the two groups, there are likewise similar differences between Asian and Occidental lower lid anatomy. None, however, interfere with successful execution of blepharoplasty as long as they are understood and recognized and certain caveats are observed.

• Basic anatomical differences: In all groups of people, the anatomy of the lower eyelid tends to mirror the anatomy of the upper eyelid. For instance, there is typically more fat present in the Asian lower eyelid and the tissue layers enclosing this fat compartment (the orbital septum and lower eyelid retractors) relate and connect differently than in the Occidental lid. If the surgeon is aware of such differences, the "standard" Occidental operation can be modified very slightly and yield equally effective outcomes in those as Asian descent.

• Fat: As noted, the amount of orbital fat extending into the lower eyelid is increased, and the fibroadipose layer is more developed (see diagrams). One common error is that some doctors confuse fat and muscle when evaluating the lid and thus draw erroneous conclusions with respect to the selection of the appropriate surgical procedure.

• Skin quality: Asian lower eyelid skin tends to be more resistant to wrinkling at a young age. The skin is, however, more "reactive," which means that the scars from skin incisions may seem thicker at first and take a longer period of time to soften and mature to a final state. The most common Asian olive skin tone is graded as Fitzpatrick IV, a designation important in skin resurfacing procedures (see below).

• Eyelid crease: Because the normal lower eyelid does not possess a defined crease in either Asian or Occidental adults, the concept of a "double eyelid" has no relevance in lower eyelid surgery.

• Shape of the eyelid opening: The Asian eyelid opening (that is, the space between the upper and lower eyelids) tends to be more almond shaped (that is, less rounded). In most Asian and Occidental patients, the lateral canthus (the junction of upper and lower eyelids closest the ear) sits slightly higher relative to the medial canthus (the similar junction closest the nose). This normal upward canthal tilt is intensified in some Asian eyelids. Surgery must be designed to respect such anatomical starting points.

The primary goal of Asian lower blepharoplasty in most younger and middle-aged patients is a reduction in the noticeable bulging of orbital fat.

Skin excess and/or wrinkling are usually minimal until advanced age, and so lower skin removal is seldom needed in such patients.

Young male before and after upper double eyelid surgery and lower transconjunctival blepharoplasty
(Surgery by Dr. Frank Meronk)

The preferred surgical approach is an appropriately modified transconjunctival blepharoplasty because:

• There is no skin incision, and so external scarring is not a concern. Better skin elasticity allows the skin to reshape following thinning of underlying bulging lower fat.

• The risks of lower eyelid distortion and rounding of the eyelid opening are greatly diminished compared to that seen with the older transcutaneous blepharoplasty used to approach the orbital fat.

Chemical peels and laser resurfacing are undertaken very cautiously if at all because of the higher risk of pigmentary loss and/or irregular splotchy coloration seen in patients with olive (Type IV) or darker skin tones.

Other anatomical and surgical nuances are technical in nature and beyond the scope of this overview.