Lower Eyelid Surgery and Asians: Why Has it Become So Complex and What is Unique for Asians?


In today’s article, Dr. Kenneth Kim will discuss why lower eyelid has become so complex in Asians and why this procedure is so unique for Asians.  People often think lower eyelid surgery as simply the removal of some lower eyelid fat and perhaps excising some skin if there are skin redundancy.  However, lower eyelid surgery has become much more complex in Asian patients for various reasons which we will discuss in this article.   

Simple fat removal process was a surgery that was performed traditionally when performing lower eyelid surgery.  A surgeon can remove fat by way of an external skin incision or without an external skin incision.  Either way, this method of simply removing fat leads to hollowing out of the eyes and ultimately, an unhealthy appearance for the patient.  A healthy and youthful lower eyelid is a lower eyelid that is not hollow or sunken in.  During the aging process a few things things occur to the lower eyelid region. One, the lower eyelid fat herniates outward and the muscle surrounding the fat descend as well.  Additionally, the tissue just below the lower eyelid fat (midface region) undergoes deflation (soft tissue / fat loss).  Therefore, fat transposition to the depressed midface is the preferred method to provide more volume and a smoother lower eyelid while avoiding hollowing of the eyes.

Some patients have dark circles that gives their lower eyelid a pinkish coloration. If the cause of the dark circles are due to the vascular imbalance of the lower eyelid, the vessels can be addressed and corrected during the fat transposition procedure. However, there are other causes that can be attributed to dark under eye circles, therefore one should talk with their plastic surgeon to determine the cause before undergoing this procedure.

Asians with excess lower eyelid skin also require removal and tightening of the lower eyelid skin.  Simply put, the removal of skin will lead to scarring and because Asian skin is more prone to scar formation, a surgeon in performing this procedure, should utilize a special suturing and tension free closure for minimal scar formation and paramount results.  The tension free closure technique causes the tension to be placed on the muscle below the skin in order to avoid tension being placed on the skin edges. (add one more explain why placing tension on the skin edges leads to less scarring)

An attribute in many younger Asians is lower eyelid fullness or what is referred to as “aegyosal”.  Aegyosal is a fullness of tissue just below the lower eyelashes.  This fullness becomes more apparent when one smiles and is more common in younger Asians.  As one ages, this fullness of the aegyosal tissues begins to go away.  Therefore, by recreating the fullness or aegyosal in addition to their eyelid surgery, a patient will look younger and brighter.  In the instances where the aegyosal is not recreated, a patient may say they  look younger from the eyelid surgery itself but that they do not look quite like their former, younger selves.

Some Asian patients may have weak lower eyelid tone or muscle support.  In these patients, the surgeon must use caution not to bring on ectropion or scleral show.  Ectropion is when the lower eyelid everts whereas scleral show is when the white portion of the eye (sclera) below the lower eyelid is visible.  Traditionally in these instances, the surgeon would perform canthopexy or canthoplasty to provide more support.  However in Asians, performing these lateral tightening procedures (e.g., canthopexy or canthoplasty) would drastically alter their appearance resulting in an unnatural look.  The goal of patients desiring lower eyelid surgery is to simply to look younger as they once had years before.  Thus, in order to give more support to the lower eyelid, the surgeon should support the entire lower eyelid muscle by re-suspending it back to where it was originally without pulling on the outer corner or creating a harsh look that a canthopexy or cantoplasty would do.  Another benefit of re-elevating the entire lower eyelid muscle is that it gives more support to the lower eyelid fat.  This extra support lessens the chances of recurrent fat herniation (fat bulging) in later years.

Lastly, often people mistaken believe the lower eyelid does not move.  However, when we smile or make facial expressions, if you pay attention, our lower eyelids actually do move.  So it is important that we maintain the natural function of the lower eyelid.  Without this movement in conjunction with facial expressions, patients who have had lower eyelid surgery will complain that something about their lower eyelid appears unnatural. Our eyes are most susceptible indications when detecting what is normal and natural vs. what is obviously not.  When the eyes look unnatural it is apparent that something is just not right.  Therefore, when performing lower eyelid surgery, a dynamic lower eyelid surgery technique needs to be performed in order that you maintain function and naturalness of the lower eyelid muscles.

As you just read, lower eyelid surgery is much more than simply removing fat and possibly removing some skin.  In Asians, preventing visible scar and not altering the eye tilt or shape is paramount in natural looking results.  In addition, what makes Asian eyelid uniquely different is that they have lower eyelid fullness (aegyosal) when they are younger whereas people from other ethnic backgrounds lack this attribute.  Therefore, we need to recreate these elements during surgery in addition to preserving their lower eyelid innervation by performing a dynamic lower eyelid technique.