Asian blepharoplasty: creating or defining the upper eyelid crease

Anatomical characteristics of the East Asian eyelid

The upper eyelid of many East Asian people has a different anatomy from the European eyelid. The main differences include:

• Congenital absence of the supratarsal crease (the double eyelid).
• A lower insertion of the levator muscle into the eyelid skin.
• A thicker layer of preaponeurotic fatty tissue.
• Thicker, firmer skin.
• The inner corner of the eye partly covered by the epicanthal fold.

These characteristics produce an eyelid that looks smoother and more uniform, with no clear line dividing the fixed and the mobile parts. While many people regard it as a normal and attractive variation, others prefer to define that crease in order to achieve eyes that look more open and expressive and that take make-up more easily.

Why there is a crease or there is not: what the anatomy says

The explanation usually given — “in the East Asian eyelid the levator aponeurosis does not reach the skin” — is only part of the story, and anatomical studies have qualified it considerably.

A study of 26 upper eyelids from Japanese cadavers compared those with a crease against those without, and what best distinguished one from the other was not the aponeurosis: it was the thickness of the orbicularis muscle and of the skin right at the line of the crease. In eyelids with a double crease the orbicularis was significantly thinner at that point (p = 0.029), and the skin thinner too. In some cases the crease also coincided with the edge of a thick, folded orbicularis. The authors’ conclusion is explicit: the thickness of the orbicularis — or its folded shape — and the thickness of the skin are the main causative factors.

A more recent study adds another piece: the pretarsal fascia, which is distinct from the extension of the aponeurosis but receives its forces. According to its authors, the way the collagen bundles are distributed within that fascia cushions and transmits the pull of the levator, and that would explain why some eyelids have a crease and others do not, and why some creases are deep and stable while others fade.

The practical consequence is the one that matters at the consultation: creating a crease is not “putting in a stitch” but changing how those layers behave. That is why the result depends on the actual thickness of each person’s eyelid, and why two patients having the same procedure can end up with creases that look different. It is also the reason this eyelid is planned around its own anatomy and not by applying the scheme of a European blepharoplasty.

The aims of Asian blepharoplasty

The main purpose of this surgery is to create a visible, symmetrical crease in the upper eyelid, respecting the proportions of the face and the patient’s ethnic identity. The most frequent aims are:

• Creating a supratarsal crease where there is none.
• Increasing the depth and definition of the upper eyelid.
• Improving how the lashes sit.
• Making it easier to apply make-up.
• Achieving a more open look without losing a natural appearance.

The operation does not set out to westernise the face but to bring the eyelid into harmony with the rest of the features, in accordance with each patient’s own wishes and aesthetic values.

Surgical techniques in Asian blepharoplasty

There are several surgical techniques for this operation, and the choice depends on factors such as the type of skin, whether there is a weak crease already, the amount of fat and the patient’s age. The main ones are:

The full incision technique

This technique creates a defined and permanent crease through a linear incision in the upper eyelid. Through that incision, fat, fibrous tissue or excess muscle can be removed, and the new crease is fixed to the aponeurosis of the levator muscle.

Characteristics:

• A lasting and precise result.
• It allows asymmetry or excess fat to be corrected.
• It is recommended in patients with thick skin or a bulky eyelid.
• It requires a longer recovery.

The partial incision (mini-incision) technique

One or several small incisions are used to form the crease, fixing the skin to the aponeurosis with internal sutures. No large amount of skin or fat is removed.

Characteristics:

• A quicker recovery.
• Minimal scars.
• Indicated in younger patients with no excess skin.
• It may be less durable in eyelids with thick skin.

At the Instituto de Cirugía Plástica del Mediterráneo, the surgeon selects the most suitable technique according to the patient’s anatomy and aesthetic wishes, always seeking a balance between a natural look, durability and safety.

Assessment before surgery

The consultation beforehand is essential in drawing up an individual surgical plan. During that assessment we analyse:

• The presence or absence of the supratarsal crease.
• The height of the crease the patient wants.
• The symmetry between the two eyes.
• The amount and distribution of fat in the eyelid.
• The thickness of the skin and the muscle tone.
• Any history of previous surgery.

The patient’s expectations are also explored and examples of possible results reviewed, so that the decision is informed and realistic. The aim is not to copy an external model but to define a crease that respects the expression and the proportions of the face.

The surgical procedure

The operation is carried out in theatre, usually under local anaesthetic with sedation. Its length depends on the technique chosen, but ranges between 45 minutes and 90 minutes.

The procedure includes:

• Marking the crease at the height wanted.
• Applying local anaesthetic.
• An incision according to the technique chosen.
• Controlled removal of fat or tissue if needed.
• Fixing the crease with internal sutures.
• Closure with a fine suture in cases with an incision.

The patient can go home the same day, with the necessary instructions for aftercare.

Aftercare

Recovery is well tolerated, although it differs according to the technique. The usual advice includes:

• Applying cold locally during the first 48 hours.
• Sleeping with the head raised.
• Not touching or rubbing the eyes.
• Avoiding direct sun exposure.
• Following the topical and oral treatment prescribed.
• Not applying make-up to the area until the sutures are out and the skin has healed completely.

With the full incision technique, swelling can last between 7 and 14 days. With mini-incision techniques recovery is quicker and less visible. Stitches come out between the fifth and seventh day where they are external.

The results to expect

The results of Asian blepharoplasty are visible from the first few weeks, although the definitive shape of the crease settles after one or two months. The benefits include:

• A clear, natural crease in the upper eyelid.
• The symmetry between the two eyes.
• An improved contour around the eye and a more open look.
• Greater facial expressiveness with no loss of identity.

Depending on the technique used, the results may be permanent or adjustable. Techniques with an incision usually last a very long time, while buried-suture techniques may need touching up as time goes on.

Risks and possible complications

Although this is safe surgery, it is essential to have it carried out in a specialist setting and by a surgeon experienced in East Asian facial anatomy. Some uncommon complications may include:

• Asymmetry in the height of the crease.
• A visible scar or pigmentation in sensitive skin.
• Loss of definition of the crease over time.
• Local infection or bleeding.
• A temporary sensation of tightness or discomfort.

Postoperative follow-up is essential in monitoring how the result develops and making adjustments if necessary.

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Asian blepharoplasty is a specialised technique that requires surgical precision, anatomical knowledge and a deep understanding of the patient’s aesthetic goals. Its purpose is not to westernise the features but to enhance the eyes by creating a natural crease, coherent with the structure of the face.

At the Instituto de Cirugía Plástica del Mediterráneo, every operation is designed with respect for the patient’s identity, with results that are natural, safe and lasting. If you are considering this surgery, we recommend a professional consultation, where we can help you define the result you want with complete clarity and medical honesty. Surgical excellence and an individual approach are the foundation of every case we treat.