The most natural appearing crease shape on the Asian face is tapered. If the epicanthal fold is especially well-developed, a tapered crease is usually the best choice. If a parallel shape is chosen, there will often be a slight discontinuity between the end of the new crease and the start of the epicanthal fold.
Since the parallel crease does not meet the epicanthal fold, a small area of "disconnect" between crease and fold may, in some patients, look slightly artificial. Still, this is a popular shape in females because it allows for a larger platform of exposed skin on which to apply cosmetics.
A semilunar crease peaks upward and looks unnatural on the Asian face. Its only application is in patients of mixed descent (part Asian, part Occidental) or those few Asian patients who have a large socket, high nasal bridge, and very high eyebrows.
While a lateral flare may be added to any of the above, it is rarely recommended or selected. The vast majority of inborn creases in Asian eyelids are tapered, and so a flare upward can appear unnatural.
Height: Patients requesting double eyelid surgery may be seeking the creation of a crease from scratch or a change in the height of an existing inborn crease. A typical Occidental crease may sit 7-11 mm above the margin of the lid, while most inborn Asian creases tend to sit lower, usually between 2-5 mm.
A patient with a thin eyelid (not much fat) and a high starting eyebrow position can, generally, support a higher crease than a patient with a thick lid and low brow position.
The following values may be useful for classification of crease heights:
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Low range
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Medium range
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High range
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<---- 2 to 3 mm---->
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<---- 4 to 6 mm ---->
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<---- 7 to 10 mm ---->
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In expressing a height preference, it is important to understand that even in the hands of an expert, surgery and subsequent healing are not such precise processes that a doctor can fully control the result. Thus, selecting a "low," "medium," or "high" range crease should be viewed more as an expression of a preference you would like the doctor to try to achieve.
"Splitting hairs" by requesting, for instance, a "low-medium" or "medium-high" crease assumes a level of surgical precision beyond what can usually be achieved.
Most Natural: The most natural appearing crease on the Asian face is a low tapered, while the most unnatural is the high semilunar, with high parallel a close second. (Note: A high crease cannot be tapered.)
Continuity: If a discontinuous or incomplete crease is present, it may be "completed" without changing the preexisting crease shape and/or height. Multiple poorly-defined creases may be converted into a single dominant crease.
Asymmetry: Significant eyelid, socket, or facial asymmetry will almost always "pass through" the operation and still be present to some degree after surgery. For instance:
If ptosis (a drooping eyelid caused by a deficiency of the internal eyelid lifting mechanism) is present, double eyelid surgery alone will not lift it to a better position.
If brow positions are unequal, this will impact on the final position of the creases.
If the eyes sit at different positions in the socket (higher vs. lower, or deep-set vs. bulging), such eye-orbital asymmetry will still cause a visible effect after surgery.
Other Considerations:
Just because one person desires to have his or her eyelids look like those of another (often, a model in a fashion magazine) does not mean that such a result is technically possible. While a photo may serve well as a starting point to communicate desires, no patient should ever realistically hope to look like somebody else.
