AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Future and Controversies
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Future and Controversies
• References

Asians are stereotypically described as having straight black hair, yellow skin pigmentation, puffy slitlike eyes with a medial epicanthal fold, a broad flat nasal dorsum with thick lobular skin that is yellow or brown in coloring, and a flat face with high cheekbones. This description consistently appears in books, television, and movies; however, these characteristics only apply to a small subgroup of individuals.

Because of geographic diffusion and interracial breeding, the physical characteristics of people of Asian descent show tremendous variation. For example, the skin of Asians living in southern latitudes tends to be darker and thicker than the milky skin pigmentation found in other Asian populations. The standard of beauty also varies among societies. Many people, especially whites, believe that a perfectly bronzed tan body suggests healthiness, whereas some Asian women preserve their milky skin, choosing to shade themselves from the sun with hats or umbrellas. The facial plastic surgeon should be aware of the anatomic and cultural differences among individuals of Asian descent when cosmetic surgery is being considered.

The facial plastic surgeon can offer several cosmetic surgeries unique to Asian individuals. The 2 most common invasive aesthetic procedures performed on Asian individuals are the double-eyelid procedure and the augmentation rhinoplasty. The double-eyelid procedure is the most common aesthetic procedure performed on Asian individuals and involves the creation of a superior palpebral fold from a single eyelid (a characteristic of approximately 50% of Asian people). Augmentation rhinoplasty, as opposed to nasal reduction, is also frequently performed, usually with the use of an alloplastic implant. Rhytidectomy can offer a reduction in rhytides; however, rhytidectomy is not performed as frequently as the previous 2 procedures because of the increased dermal thickness observed in Asian people.

Less-invasive procedures are becoming more popular in facial plastic surgery as well. Botulinum toxin (BOTOX®), dermabrasion, and chemical peeling are being used in increasing numbers for cosmetic purposes in patients who do not wish to undergo surgery. With the advent of laser surgery in the 1980s, lasers and light-based treatments offer another option for addressing surface cosmetic imperfections. Although wrinkling is an issue in the aging face in general, classic clinical features of photoaging in Asians are primarily discrete pigmentary changes. These include actinic lentigines, flat pigmented seborrheic keratoses, and mottled hyperpigmentation. The laser and light-based therapies are becoming more popular options for addressing these skin changes. In Asian patients, special consideration is required because ethnic skin has the potential for more complications than the skin of the general white population. 

This article focuses on the double-eyelid procedure, the nasal augmentation procedure, and the use of laser-based and light-based therapies in Asian patients, since these cosmetic procedures require special considerations that are unique to Asian patients.

History of the Procedure

Blepharoplasty techniques have been described as early as the 19th century, with some possible references to even earlier dates. However, popularization of the double-eyelid procedure in the Asian population did not occur until after World War II. Since the 1960s, various techniques have been described to create a double eyelid in individuals lacking a supratarsal fold. The basic premise is to create a firm adherence between pretarsal skin and the tarsal plate. When creating a supratarsal fold, different techniques have been incorporated to address the epicanthal fold that may also be present.

The goal in rhinoplasty surgery is to enhance the aesthetics of the nose and create a harmonious appearance with regard to the patient's other facial features. Although most rhinoplasty techniques in the white patient focus on nasal reduction, the anatomy of the Asian nose often requires augmentation. Although the best material for augmentation remains controversial, apparently most Western surgeons prefer autogenous material, whereas alloplastic material is favored in Asia.

Lasers were first developed in the 1980s and, since that time, laser treatments have been increasingly indicated, including for scar revision and the removal of skin lesions. For cosmetic purposes, lasers are used for skin resurfacing and can be effective for exfoliating the surface of the skin as well as restoring the skin's elasticity by tightening the skin's collagen fibers. Laser pulses target the surface layer of the skin, vaporizing water and the skin's surface without affecting the deep layers. A new surface layer then grows back as a soft and younger-looking layer. Additionally, photorejuvenation, which is a light-based treatment for photoaged skin, is available.¹ These options afford minimal risk and less downtime for the patient, and are therefore becoming more popular globally, regardless of ethnicity. With the increasing demand, the properties unique to Asian skin must be carefully considered.

Problem

The Asian upper eyelid is characterized by lack of a superior palpebral fold, laxity of pretarsal skin, excessive fat, and the presence of an epicanthal fold. The typical Asian nose can be described as having a flat and broad dorsum, deficient tip projection, a wide lobule, thick lobular skin, abundant subcutaneous fatty tissue, alar flaring, and a retracted columella.

Etiology

Most patients who undergo cosmetic procedures in Asia are women, although cosmetic surgery is gaining popularity among men. Since the end of World War II, Asian women have become liberated from traditional habits, allowing them to explore and accept ways to make themselves look younger. As a result, the number of procedures for facial rejuvenation or alteration has increased.

Some people believe that the Asian person seeking cosmetic surgery wishes to look like a westerner. Although this may hold true for a small minority of patients, most Asian persons wish to preserve their heritage and undergo changes to make themselves more attractive. In fact, creation of westernized features may produce unsatisfactory results and complications that may disrupt the harmony and balance of the facial features of the patient. As in all facial plastic surgery procedures, the physician should clearly understand the wishes and desires of the patient and discuss realistic alterations that create an aesthetically pleasing face.

Clinical

A thorough history is important in evaluating any patient who desires cosmetic surgery. Carefully ascertain from the patient specific desires regarding the procedure, which helps to foster a relationship between the patient and physician. Unrealistic expectations only lead to disappointment for both the patient and the surgeon. Westernization of the Asian upper eyelid or nose may be desired by a few individuals; however, most patients only desire to enhance their features and preserve their ethnic identity.

Also include in the patient assessment any significant past medical or surgical history. Knowledge of systemic disease is imperative, as laser-based or light-based treatments may exacerbate inflammatory conditions such as psoriasis, rosacea, and contact dermatitis. Determine if any prior procedures were performed to the eyes or nose, especially cosmetic procedures, and make every effort to ascertain the details of such procedures. Make note of any history of hypertrophic scar formation or of hyperpigmentation after surgery or injury to skin. Record medications and smoking or alcohol history, which may affect postoperative wound healing.

The physical examination focuses on the characteristics of the eyes and/or nose; however, these areas also need to be examined in relation to the rest of the patient's facial features, such as the width and contour of the face. The facial plastic surgeon must also acknowledge the anthropometric differences of Asian faces and white faces. Applying Western ideals of facial beauty to an Asian face can result in a loss of ethnic identity along with a dissatisfied patient.

The presence of wrinkles and the laxity of skin or notable skin imperfections can also help dictate if any other ancillary procedures need to be performed.

INDICATIONS

Section 3 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Future and Controversies
• References

Consider for surgery any individual of Asian descent who wishes to undergo a surgical procedure to enhance aesthetic appearance. Excessively thick upper eyelids with redundant skin that overhangs the eyelashes can make a person less attractive. Also, a single eyelid makes the eye look small, with the overall effect of making the patient look tired. Creation of a double eyelid everts the eyelid, making it more attractive. The double-eyelid procedure also makes the eye appear larger and more relaxed.

Patients who wish to undergo rhinoplasty usually seek to increase the height of the nose, while also refining the lobule/tip area. They may also wish to decrease the width of the nostrils.

Surgical corrections are the hallmark for cosmetic correction; however, surface skin abnormalities can be addressed with nonsurgical interventions. For patients who desire a more youthful appearance or to remove skin imperfections such as actinic lentigines, pigmented seborrheic keratoses, and mottled hyperpigmentation, laser skin resurfacing and photorejuvenation are available.² They are both minimally invasive, requiring minimal downtime for the patient. These can also be performed as adjunctive therapies to the more invasive procedures.

RELEVANT ANATOMY

Section 4 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Future and Controversies
• References

The Asian upper eyelid is characterized by a lack of a superior palpebral fold, laxity of pretarsal skin, excessive fat, and the presence of an epicanthal fold. Of note, approximately 50% of the Asian population lacks a superior palpebral fold, and 90% of Asian people demonstrate an epicanthal fold. The epicanthal fold is a semilunar fold of skin that extends from the upper eyelid across the medial canthal area to the lower eyelid. Although the double-eyelid operation is the most common cosmetic procedure performed in the Asian patient, debate still surrounds the anatomic reasoning for the lack of the superior palpebral fold. Two leading explanations for the variation between the folds exist, but one must first understand the structures of the upper eyelid.

A cross-section of the upper eyelid reveals 7 layers. From superficial to deep, these layers are the skin, loose subcutaneous tissue, the orbicularis muscle, a submuscular/areolar layer, a fascial layer, the tarsus, and the conjunctiva. The fascial layer consists of the orbital septum, which forms the anterior wall of the supraorbital fat compartment and extends from all of the edges of the orbital rim. The expansion of the levator palpebrae muscle lies deep to the supraorbital fat and forms the posterior wall of the compartment. Although it has not been demonstrated histologically or grossly, the consensus is that the formation of a double eyelid results from penetration of the expansion of the levator palpebrae muscle through the septum and orbicularis muscle to the overlying dermis.

Others believe that fibrous septa that extends from the tarsal plate, which causes a firm adherence between the pretarsal skin and tarsus, is absent in Asians. In whites, this adherence allows the pretarsal tissue to move as a unit with the mobile preseptal eyelid segment, which results in the supratarsal fold on lid retraction. Proponents of this theory believe emphasis should be placed on the removal of soft tissue between the dermis and tarsus, as opposed to levator fixation, to allow for a successful double-eyelid surgery. In either respect, creating a firm fixation and/or excising pretarsal tissue is important in creating the supratarsal fold in double-eyelid surgery.

Another important finding in the Asian upper eyelid is the presence or absence of an epicanthal fold. The exact anatomy of the epicanthal fold is unclear, but several possibilities are proposed. The epicanthal fold is widely believed to be a result of an underdevelopment of the nasal root and excess horizontal medial canthal skin. However, anatomic studies suggest that the epicanthal fold results from insertion of superficial fibers from the medial canthal ligament and orbicularis oculi muscle through the fold. These studies also suggest that differences in thickness between the nasal and eyelid skin may contribute to the epicanthal fold.

Certain characteristics of the Asian nose often create the basis for surgical alteration. The typical nose is described as one with a flat and broad dorsum, deficient tip projection, a wide lobule, thick lobular skin, abundant subcutaneous fatty tissue, alar flaring, and a retracted columella. The thick lobular skin causes the bulbous appearance of the nose, which can be exacerbated further by separation at the dome of the alar cartilages. The lower lateral cartilages also may not be strong enough, resulting in decreased projection of the nose. The medial crura of the lower lateral cartilage are much longer in Asians than in whites. Variations exist, and any one patient can present with one or more of these features. The aesthetic desires of the patient and the limits of what is technically feasible dictate the operative course of action.

Skin is typically grouped into the Fitzpatrick classification, which describes the propensity for sun reactivity. In general, all skin types are susceptible to photoaging. However, those who fall into higher Fitzpatrick phototypes are less susceptible, likely due to the protective role of melanin. Asians generally fall into categories IV-VI. Although no differences are evident in the number of melanocytes per unit area of skin when comparing lighter and darker skin, darker skin has a higher amount of melanin. Melanin, along with water and hemoglobin, is the target chromophore in skin for lasers and light devices. This is an important consideration because laser energy intended for deeper targets can be absorbed by melanin in the basal layer of the epidermis and can cause unintended epidermal damage, risking blistering, permanent dyspigmentation, textural changes, focal atrophy, and scarring. Therefore, the use of lasers in patients with darker skin, who have a higher melanin content, can result in more complications.

CONTRAINDICATIONS

Section 5 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Future and Controversies
• References

Any person who has a medical condition that would not allow them to undergo elective surgery contraindicates blepharoplasty or rhinoplasty. Patients with dry eye syndrome also should not undergo blepharoplasty.

Patients with an impaired immune system, scleroderma, extensive radiation therapy, burns in the treatment area, or poor healing in the treatment area should not undergo laser skin procedures. Additionally, use of isotretinoin in the past 12 months is a contraindication for laser-based or light-based therapy.

WORKUP

Section 6 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Future and Controversies
• References

Lab Studies

Obtain the following standard laboratory tests if required for medical clearance:

• CBC count
• Basic metabolic panel
• Coagulation studies

Imaging Studies

• Chest radiography should be performed if required for medical clearance, and its performance is dependent upon the age of the patient.
• Obtain standard facial photographs. According to the Clinical Photography Committee of the Plastic Surgery Education Foundation, the same camera, lens, setting, lighting, and patient positioning should be used for each photograph to ensure reproducibility. First, full-face views are taken of the patient in the frontal position, both oblique positions, and both lateral positions. The specifications include a 90-mm lens, a distance of 38 inches, reproduction ratio of 1:9, and vertical orientation of the camera. Next, close-up views are taken at a distance of 21 inches with a reproduction ratio of 1:4. Orienting the camera horizontally, the patient is photographed from the front with eyes open, from the front with eyes closed, and with a frontal gaze upward. The patient is photographed in both oblique positions, both lateral positions, and from a basal view with the tip of the nose aligned with the upper-eyelid crease.
• Computer imaging can also be used to help the patient understand the goals and limitations of the treatment plan.

Other Tests

• ECG should be performed if required for medical clearance.
• A Schirmer test is important to document tear production.
• A snap test of the lower eyelid also is helpful, and the lid should spring quickly to contact the globe. If the lid remains away from the globe, a lid-shortening procedure is indicated.

TREATMENT

Section 7 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Future and Controversies
• References

Medical therapy

While there are no nonsurgical therapies for nasal augmentation, nonsurgical creation of a superior palpebral fold has been performed with the use of glues or tapes. Drawing a double-eyelid line also provides a temporary alternative; however, these procedures can be quite time consuming.

Many options are available for nonsurgical or noninvasive cosmetic treatments. Different types of lasers are available, varying according to their wavelength and pulse duration. Carbon dioxide and erbium: YAG lasers are the 2 most commonly used. The NLite (nonablative laser resurfacing), also known as photorejuvenation, uses light energy to stimulate new growth of collagen without removing skin tissue. Although it is less powerful at removing wrinkles than the other resurfacing methods, it may be used for delicate areas such as the eyes and neck, since it causes very little irritation. Myriad laser protocols are used today, which vary by type of laser, the amount of energy used, the pulse mode, and the number of passes made. The laser resurfacing and photorejuvenation procedures are office-based procedures that can be performed with local anesthesia with or without sedation.

Surgical therapy

Asian blepharoplasty

For the Asian patient seeking a more permanent solution to create a double eyelid, surgery is the only option. Although many methods have been described, creation of a firm adhesion between the mobile pretarsal tissue and the tarsus relies on creation of a firm fixation at the desired level and the removal of pretarsal tissue at a specific level.

Several techniques have been used to modify the epicanthal fold; the degree of effacement of the epicanthal fold depends on the placement of the medial aspect of the incision with regard to the epicanthal fold.

Asian rhinoplasty

Preoperative details

Asian blepharoplasty

The patient's desires must be thoroughly understood prior to the surgery. The size of the supratarsal fold, the shape of the eyelids, and the status of the epicanthal folds should all be addressed in the preoperative assessment.

The most important aspect of any eyelid surgery is symmetry. Regardless of the method used, place emphasis on meticulous measurement of the inferior, medial, lateral, and superior limits of the incision. Address the need for alteration of the epicanthal fold. Failure to address this area in double-eyelid surgery can result in an aesthetically unpleasant result.

The patient should be sitting with eyes closed when marking the incisions. The inferior incision is usually made 6-10 mm from the ciliary margin while slight upward retraction of the mobile pretarsal skin is performed. An incision 6-7 mm from the ciliary margin is used for patients wishing for a smaller double eyelid, and patients who truly wish to have a westernized appearance need an incision 10 mm from the ciliary margin. The mark is extended both medially and laterally to the extent of the palpebral fissure, parallel to the tarsal margin. Placement of a curved paperclip along the proposed inferior incision can be used to retract the tissue and simulate the postoperative result.

The level of the superior incision is usually determined by the laxity of the eyelid skin. In younger patients, the skin does not need to be excised in every case. Pinching the skin with forceps provides an estimate of the maximum amount of tissue that can be removed. The amount of skin excised determines the eyelid size and, therefore, should be tailored to the type of eyelid desired. An elliptical area is then marked, which provides the margins for excision.

The pattern of the lateral incision dictates the shape of the eyelid. To create a more oval eyelid, a parallel incision is drawn so that the lateral limbus and the lateral canthus are in the same plane. To create a more round eyelid, the lateral incision is drawn so that the lateral canthus is approximately 2 mm below the lateral limbus.

The medial incision addresses the epicanthal fold. For patients who wish to preserve the epicanthal fold, the medial incision should be placed lateral to the epicanthal fold. For patients who wish to efface the epicanthal fold, the incision should be placed medial to the epicanthal fold. Some patients may desire an intermediate between the 2 folds in which the lateral aspect of the epicanthus is efface while the base of the fold is left intact; this can be addressed by placing the medial incision so that it terminates at or near the epicanthal root.

Those patients with prominent epicanthal folds who want more effacement of these folds may require a modified advancement flap. Several flaps have been described to modify the epicanthal fold.

Asian rhinoplasty

Discussing the specific desires of the patient is important in developing the perioperative plan. The characteristic anatomy of the nose usually requires an augmentation procedure as opposed to reduction rhinoplasty. The type of implant used for augmentation purposes, whether it is an alloplastic and/or autogenous graft, should be discussed in detail, taking into consideration the patient's anatomy and the patient and surgeon's preference.

Autogenous cartilage from the septum or ear cartilage is often inadequate to provide the dorsal augmentation needed in Asian rhinoplasty. Some potential graft sites to obtain adequate augmentation material include the rib, iliac crest, and calvaria. The autogenous material is more difficult to alter and does not always provide a smooth continuous contour.

Of the alloplastic materials available, silicone is the most widely used in Asia. Alloplastic materials provide enough substance to achieve the augmentation needed when performing rhinoplasty on Asian individuals. To avoid some of the complications associated with silicone implants, some surgeons have combined the use of silicone and cartilage implants. Preoperative discussion with the patient should also include the wishes of the patient regarding correction of any alar flaring, keeping in mind that direct alar wedge resection results in an externally visible residual scar.

If an alloplastic material is used for augmentation of the nose, initiating cephalosporin 1 day prior to surgery is suggested.

Intraoperative details

Asian blepharoplasty (incision technique)

Once the incision lines are marked and the patient is prepped and draped, the skin is infiltrated with local anesthetic. An incision is made through the skin and subcutaneous tissue down to the orbicularis oculi muscle. Some surgeons excise a small 2- to 3-mm strip of orbicularis muscle from beneath the skin of the inferior incision. This maneuver provides a wider base for adhesion formation of the palpebral fold.

The orbital septum is excised, exposing the periorbital fat. The amount of periorbital fat removed depends on the depth of the sulcus desired. Conservative removal of the medial fat is urged to prevent the occurrence of a deep hollowness and hypertrophic scarring due to the increased tension placed on the skin with excessive removal.

Retract the remaining fatty tissue to adequately expose the levator aponeurosis, which appears as a white glistening membrane. To provide fixation, nylon sutures (6-0 or 7-0) are placed in the midpupillary, lateral canthal, and medial canthal areas from the levator aponeurosis and/or the tarsus to the dermis. Removal of soft tissue over the levator aponeurosis is important to allow a firm adhesion to form between the skin and the tarsus, effectively converting the mobile pretarsal portion of the lid to a rigid segment. The skin can be closed in a subcuticular fashion with either an absorbable or a nonabsorbable suture once hemostasis with electrocautery is achieved.

Asian blepharoplasty (nonincision technique)

The desired incision line is marked as previously described. The 2 points of entry of the suture are marked next. These points are determined by making the desired fold in the incision line using a fine forceps. Local anesthesia is then infiltrated into the skin and conjunctiva.

Each arm of a double-armed 6-0 Prolene suture is inserted into the marked skin points through the conjunctiva. Each end is then passed back through the full thickness of the lid, entering through the same needle hole on the conjunctival side and exiting through the marked skin site. With both arms now on the skin side, one needle is passed subcutaneously to exit out of the other marked site. The suture is then tied.

Asian rhinoplasty

The rhinoplasty procedure can be performed under local anesthesia using lidocaine with epinephrine. Sodium bicarbonate can be added to the mixture to decrease the amount of burning felt on infiltration of the nose.

Because of the attenuated lower lateral cartilages in Asian patients, techniques of tip rhinoplasty usually performed on whites have disappointing results. The cartilages are usually not strong enough to provide tip projection and support, and thick lobular skin and subcutaneous tissue obscure the results. The most popular alloplastic implant used in the Asian patient is the L-shaped silicone implant. The long arm provides augmentation to the nasal dorsum, and the short arm of the implant serves as a columellar strut. A unilateral marginal incision creates the pocket for the implant. A marginal incision in the other nostril can be made if difficulty is encountered in creating the pocket.

With a blunt-tip scissors, dissection is performed between subcutaneous tissues above and the alar and lateral cartilages below. Do not dissect between the medial crura because the columellar portion of the implant will lie over the crura and create a new projected tip. The superior extent of the dissection is midway between the intercanthal and interbrow lines.

Once symmetry of the subcutaneous pocket is ensured, some surgeons shred the periosteum to allow for regrowth around the implant and to provide stabilization; however, stabilization of the implant can also be achieved through a subperiosteal dissection over the nasal bones that results in a pocket for the cranial portion of the implant. If a dorsal hump is present, use a rasp to shave it down.

Although some surgeons make a preoperative nasal cast and use it as a guide in fashioning the implant prior to surgery, the prefabricated silicon implant is usually tailored at the time of surgery. The cranial portion of the implant is carved to blend with the nasion and preserve the nasofrontal angle. The lateral walls of the implant are beveled to ensure that the implant cannot be readily palpated through the skin. The short arm of the implant should not be used to thrust the tip forward. Pressure necrosis will most likely ensue and result in extrusion of the implant and perforation of the lobular skin, which is a dreaded complication. A conservative length of the columellar strut is chosen. The function of the strut is to stabilize the implant between the medial crura, help position the new nasal tip, and provide bulk to the existing columella (so it becomes more visible).

Once the implant is contoured successfully, it is placed into the previously created pocket. At this point, alar trimming and/or lateral osteotomies can be performed, if necessary. Application of tape and a nasal splint is performed to stabilize the implant as the nose heals.

Postoperative details

Asian blepharoplasty

The amount of postoperative edema and resultant blepharoptosis is dependent largely on the amount of skin and fat excised and the level of fixation of pretarsal skin. Inform the patient that the swelling could last up to 6 months following surgery. Postoperative antibiotics are used at the discretion of the surgeon. Ice to the area may decrease the edema.

Asian rhinoplasty

The patient is recommended to refrain from any vigorous activity that may cause bleeding or disrupt the placement of the nasal implant. Postoperative antibiotics are administered to prevent infection.

Follow-up

Asian blepharoplasty

If a nonabsorbable suture is used to close the skin, the suture can be removed as early as postoperative day 4.

Asian rhinoplasty

The nasal splint may be left in place 5-7 days. Document postoperative results with photographs taken at varying times. If asymmetry is noticed and is not attributed to postoperative edema, the patient can be instructed to carefully manipulate the implant to the desired position.

Laser resurfacing/photorejuvenation

Postprocedural erythema and edema can be severe in the first 10 days after laser-based or light-based therapy. Redness, itching, and sensitivity may last up to 4 months. Patients must be advised to avoid sunlight during healing and, beyond recovery, to avoid excess sun exposure. Oral antibiotics are routinely prescribed and in severe cases, oral anti-inflammatory medications may be used. Dressings are used to keep the skin moist during the first 2 weeks after the procedure. After the dressings are removed, patients must be instructed to apply moisturizers for another 2-3 weeks.

COMPLICATIONS

Section 8 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Future and Controversies
• References

Asian blepharoplasty

• Asymmetry can result from differences in marking the skin incisions, differences in skin tension on supratarsal fixation, and differing skin excision widths. Asymmetry can be avoided by taking extra care in marking out lines of incision.
• Blepharoptosis usually results from a high supratarsal incision with a high supratarsal fixation. Levator function can be hindered with scarring that can occur at the level of fixation, resulting in ptosis.
• Supratarsal depression can result from overzealous orbital fat removal. This complication appears more pronounced in patients with thin lid skin and deep-set eyes.
• Retraction: Ectropion or lid margin eversion can occur if fixation of the orbicularis muscle and dermis are higher than normal skin tension.
• Failure to maintain lid fold: The importance of anchoring the dermis and orbicularis muscle to the levator aponeurosis or tarsal plate cannot be overemphasized. Otherwise, the lid fold may fade or disappear completely. Absorbable sutures may increase the risk of failure once they have been absorbed, allowing the distraction forces of the orbicularis muscle and dermis to continue.
• Hemorrhage can be a devastating complication if blindness occurs. Meticulous hemostasis with electrocautery can easily avoid this problem.

Nasal augmentation

• Infection risk is one of the leading reasons some surgeons do not advocate the use of alloplastic material. Infection may be due to a break in sterile technique or in processing of the implant. An implant that is too large may compromise the circulation on the surrounding tissues, decreasing the availability of inflammatory cells and antibiotics to the area. Improper antibiotic coverage and rough handling of tissue are also implicated in infection. If removal of the nasal implant is necessary, the underlying cartilage often is frail and difficult to manage.
• Perforation/extrusion of the nasal implant can occur; however, it is less commonly observed in Asian patients because of increased skin thickness. Proper contouring of the implant and proper creation of the pocket is essential to prevent any skin tension from occurring, which can make the implant more likely to perforate the skin. When using the L-shaped implant, the short arm component should not be used primarily to thrust the tip forward because this can increase the rate of extrusion of the implant.
• Implant malposition, displacement, and unnatural appearance are caused by technical error because of improper implant size, contouring, and/or pocket preparation. Having the patient carefully manipulate the implant into the desired position can treat early asymmetry. Otherwise, the implant may have to be removed and replaced.

Laser-based and light-based therapies

• Prolonged erythema can occur.
• Postinflammatory hyperpigmentation can occur.
• Scarring can occur.
• Patients with herpes simplex may experience acute exacerbations.
• As these are relatively new procedures, the long-term effects on skin are still not yet known.

FUTURE AND CONTROVERSIES

Section 9 of 10  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Future and Controversies
• References

Although autogenous grafting has been described and used for augmentation purposes in Asian rhinoplasty, many surgeons favor the use of alloplastic material because of its ease in contouring, wide availability, and decreased infection and extrusion rate. Decreased infection and extrusion rate are attributed to the increased thickness of Asian skin.

The future of facial plastic surgery performed on Asian patients largely depends on the types and variety of alloplastic material available on the market. Newer material, such as polytetrafluoroethylene and Medpor, may supplant the use of silicone as the implant of choice in augmenting and contouring the Asian nose.

Iin addition to surgical interventions, a growing trend toward noninvasive therapies such as laser resurfacing and photorejuvenation can be seen, as they afford the patient less down time, more convenience, and a more youthful appearance as a result. These are therapies that can be given alone or as a complement to the more invasive surgical procedures.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Future and Controversies
• References

1. Kono T, Chan HH, Groff WF, Manstein D, Sakurai H, Takeuchi M. Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians. Lasers Surg Med. Apr 2007;39(4):311-4. [Medline].
2. Munavalli GS, Weiss RA, Halder RM. Photoaging and nonablative photorejuvenation in ethnic skin. Dermatol Surg. Sep 2005;31(9 Pt 2):1250-60; discussion 1261. [Medline].
3. Ahn J, Honrado C, Horn C. Combined silicone and cartilage implants: augmentation rhinoplasty in Asian patients. Arch Facial Plast Surg. Mar-Apr 2004;6(2):120-3. [Medline].
4. Baek SM, Kim SS, Tokunaga S, Bindiger A. Oriental blepharoplasty: single-stitch, nonincision technique. Plast Reconstr Surg. Feb 1989;83(2):236-42. [Medline].
5. Choe KS, Sclafani AP, Litner JA, Yu GP, Romo T 3rd. The Korean American woman's face: anthropometric measurements and quantitative analysis of facial aesthetics. Arch Facial Plast Surg. Jul-Aug 2004;6(4):244-52. [Medline].
6. Chua SH, Ang P, Khoo LS, Goh CL. Nonablative 1450-nm diode laser in the treatment of facial atrophic acne scars in type IV to V Asian skin: a prospective clinical study. Dermatol Surg. Oct 2004;30(10):1287-91. [Medline].
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Article Last Updated: Jan 8, 2008