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Because the fundamental difference between Asian and Occidental blepharoplasty revolves around the creation or enhancement of the upper eyelid crease, the subject of Asian lower eyelid surgery to lessen 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.
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