Asian Blepharoplasty and the Eyelid Crease 3

Appendix 2  Modern Literature on Asian Eyelid Surgery (in English)
353
Modern Literature on Asian Eyelid Surgery (in English)
Author
KY Song
YH Bang
WPD Chen
Year
1990
1991
1994
Journal
Chin J Plast Surg 6:96–97
Plast Reconstr Surg 88:12–17
Asian Blepharoplasty (A Surgical
Atlas) Butterworth–Heinemann
(First Edition)
Country
China
Korea
USA
Conjunctival suturing
Skin incision
Three stab incisions
Yes
Remove skin
No
Orbicularis
Trims orbicularis muscle,
connective tissue, and
pretarsal fat
Orbital septum
Preaponeurotic fat
Remove fat if prolapsed
inferiorly
Crease form
Transcutaneous intratarsal
and intradermal
suturing
Skin to orbicularis: basting
sutures
Suture
Three buried stitches
Three 6-0 silk
Days left in
5–6
Effectiveness
Comments
First textbook on this topic:
Detailed terminology, cultural
perception, comparative
anatomy, crease variation, shape,
height, continuity and
permanence; main schools of
technique, complications,
revisions and literature
publications
Continued

354
Asian Blepharoplasty and the Eyelid Crease
Modern Literature on Asian Eyelid Surgery (in English)
Author
Li Dong et al.
WPD Chen
JI Park
JS Lee, WJ Park, MS
Shin, IC Song
Year
1994
1996
1996
1997
Journal
Chin J Plast Surg Burns
10:436, Plast Reconstr
Surg 1996;98(5):919
Plast Reconstr Surg
97(1):212–218
Triangular,
trapezoidal and
rectangular
debulking of eyelid
tissues in Asian
blepharoplasty
Plast Reconstr Surg
98(4):602–609
Z-epicanthoplasty
Plast Reconstr Surg
100(1):170–178
‘Septodermal’
fixation technique
Country
China (Beijing Med Univ)
USA
USA
Korea (Samsung Med
Center)
Conjunctival suturing
Skin incision
Yes
Yes
Variable placement of
skin/septum–levator
attachment
Remove skin
Yes
By flap transposition
Orbicularis
Trims orbicularis
Orbital septum
Opens septum
Preaponeurotic fat
Variable
Crease form
Skin–apon.–skin
Suture
6-0 interrupted
sutures and 7-0
continuous suture
Days left in
5–7 days
Effectiveness
Permanent
Comments
Emphasizes removal of
fascial tissues in
double blepharoplasty
(review by Boo-Chai in
Int Abstracts of Plast
Reconstr Surg)
Arch Facial Plast
Surg 2000;2(10):
43–47 Modified
Z-epicanthoplasty

Appendix 2  Modern Literature on Asian Eyelid Surgery (in English)
355
Modern Literature on Asian Eyelid Surgery (in English)
Author
Sergile, Obata
JW Kim, JO Lee
KC Yoon, S Park
YS Kao, CH Lin, RH Fang
Year
1997
1998
1998
1998
Journal
Plast Reconstr Surg
99(3):662–667
translation of
Mikamo’s 1896
paper
Aesthet Plast Surg
22(6):433–438 Asian
blepharoplasty with
short-pulsed contact
ND-Yag laser: limited
incision
Plast Reconstr Surg
102(2):502–508
Selective tissue
removal in
blepharoplasty for
young Asians
Plast Reconstr Surg
102(6): 1835–1841
Epicanthoplasty with
Y–V advancement
Country
USA
Korea
Korea (Univ of Ulsan)
Taiwan (Vet Gen Hosp)
Conjunctival suturing
Skin incision
Yes
Remove skin
Yes
Orbicularis
Yes
Orbital septum
Yes
Preaponeurotic fat
Yes
Crease form
Levator–tarsus–skin
Suture
7-0 nylon, or tissue glue
Days left in
Effectiveness
Comments
A general discussion
on incisional
technique
Modern Literature on Asian Eyelid Surgery (in English)
Author
JI Park
SL Jeong, BN Lemke,
RK Dortzbach et al.
YH Bang, HH Chu, SH
Park et al.
YW Kim, HJ Park, S Kim
Year
1999
1999
1999
2000
Journal
Arch Facial Plast Surg
1(2):90–95 Orbic.–
levator fixation
Arch Ophthalmol
117(7):907–912
Comparison of
Asian and Cauc.
upper lid anatomy
Plast Reconstr Surg
103(6):1788–1791
The fallacy of the
levator expansion
theory
Plast Reconstr Surg
106(6):1399–1404
Revisional correction
by interposing
preaponeurotic fat
Country
USA
Korea (Chonnam
Univ), USA
Korea (Inha Gen
Hosp)
Korea (Ewha Women
Univ)
Conjunctival suturing
Skin incision
Yes
Remove skin
Yes
Orbicularis
Orbital septum
Opens
Preaponeurotic fat
Crease form
Orbic.–levator
Suture
Days left in
Effectiveness
Comments
Continued

356
Asian Blepharoplasty and the Eyelid Crease
Modern Literature on Asian Eyelid Surgery (in English)
Author
RS Sim, JD Smith, AS
Chan
Y Lee, E Lee, WJ Park
DH Kang, SH Koo, JH
Choi et al.
Yang
Year
2000
2000
2001
2001
Journal
Arch Facial Plast Surg
2(2):113–120
Comparison of
aesthetic facial
proportions of
Chinese and
Caucasian women
Plast Reconstr Surg
105(5):1872–1880
Anchor
epicanthoplasty
combined with
outer-type lid crease
procedure
Plast Reconstr Surg
107(7): 1884–1889
Use of CO2 laser
Ann Plast Surg
46(4):364–368
Double eyelid: a
limited incision
technique
Country
Singapore (National
Univ)
Korea (Seoul National
Univ)
Korea (Univ MC)
Korea (Catholic Univ)
Conjunctival suturing
Skin incision
Yes
4 mm skin incision
Remove skin
Yes
Orbicularis
Orbital septum
Opened
Preaponeurotic fat
Optional
Optional removal
Crease form
6-0 vicryl: inf.
skin–tarsus–levator
Levator–tarsus to
skin–muscle
Suture
Days left in
Effectiveness
Comments
General aesthetics

Appendix 2  Modern Literature on Asian Eyelid Surgery (in English)
357
Modern Literature on Asian Eyelid Surgery (in English)
Author
J Cheng, FZ Xu
Miyake, Hiraga
MT Yen, DR Jordan, RL
Anderson
BC Cho, KY Lee
Year
2001
2001
2002
2002
Journal
Plast Reconstr Surg
107(7):1665–1668
Microstructure of
Asian eyelid crease
Jpn J Plast Reconstr
Surg 44:815
Selection of skin
resection or
double eyelid
operation
Ophthalm Plast Reconstr
Surg 18(1):40–44
Epicanthoplasty:
subcut. approach
through ext. skin
incision
Plast Reconstr Surg
110(1):293–300 Med.
epicanthoplasty
combined with
pilcation of med.
canth. tendon
Country
China (Hangzhou
Zhejiang Univ.
Med School)
Japan
USA
Korea (Kyungpook
National Univ Hosp)
Conjunctival suturing
Skin incision
Remove skin
Orbicularis
Excise offending
orbicularis underlying
the epicanthal fold
Orbital septum
Preaponeurotic fat
Crease form
Suture
Days left in
Effectiveness
Comments
Scanning EM
showed
aponeurotic fibers
penetrate
orbicularis to fuse
with skin
Basing skin resection
on whether brow
position is ptotic
Continued

358
Asian Blepharoplasty and the Eyelid Crease
Modern Literature on Asian Eyelid Surgery (in English)
Author
WM Yoo, SH Park, DR
Kwang
Hwang, Kim et al.
Lam, Kim
SH Chen, Mardini S,
Chen HC et al.
Year
2002
2003
2003
2004
Journal
Plast Reconstr Surg
109(6):2067–2071 Root
Z-epicanthoplasty in
Asian eyelid
Ann Plast Surg
50(2):156–159
Aesthet Surg J
23(3):170–176
Partial-incision
technique
Plast Reconstr Surg
114(5): 1270–1277
Corrective Asian
blepharoplasty
after failed
revisions
Country
Korea
Korea (Inha and Yonsei
Univ)
USA/Korea
Taiwan (Chang
Gung Univ)
Conjunctival suturing
Skin incision
15–18 mm wide skin
incision
Remove skin
No
Orbicularis
Through orbic.
Orbital septum
Open
Preaponeurotic fat
Partial excision
Crease form
Levator–inf. skin edge
Suture
Days left in
Effectiveness
Comments
(See JI Park’s 1996 Plast
Reconstr Surg article
on Z-epicanthoplasty)
Lateral
septoaponeurotic
artery as source of
bleeding during
upper blepharoplasty
Clin photo shows skin
incision spans 34 of
width of ciliary
margin. Crease may
appear deeper
centrally. (See
Yang’s 2001 paper)
A general
discussion of
factors that lead
to failures and
their corrections

359
RECENT LITERATURE
(1998–2014) ON ASIAN EYELID
SURGERY (IN ENGLISH)
A P P E N D I X 3
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
Hwang, Kim et al.
Kim, Lee
Mutou, Homma
Morikawa, Yamamoto
Year
1998
1998
2000
2001
Journal
Br J Plast Surg 51(8):
594–598
An anatomical study of
the junction of orbital
septum and levator
aponeurosis in
Orientals
Aesthet Plast Surg
22(6):433–438
Asian blepharoplasty using
short-pulsed contact
Nd–Yag laser: limited-
incision resectable laser
double fold with internal
medial and lateral
functional epicanthoplasty
Aesthet Plast Surg
24(4):289–291
Intradermal stitch
blepharoplasty for
Orientals: does it
disappear?
Aesthet Plast Surg
25(1):20–24
Scanning EM study
on double and
single eyelids in
Orientals
Country
Korea
Japan
Japan
Conjunctival
suturing
Intradermal stitch;
over 7 yr,
1,570 pts
Skin incision
Remove skin
No
Orbicularis
Orbital septum
Preaponeurotic fat
Crease form
Sutures
Days left in
Effectiveness
3.4% ‘revisited’ their
clinic re. loss of
crease
Comments
Septum has outer
(superficial) layer
and inner (deep)
layer that lies
adjacent to the
levator sheath
Reflective of interests at the
time for use of various
laser modalities
30% loss within first
year, 88%
occurred within
5 yr. Failure rate
based on only
those who
returned for Rx
Confirms branches of
lev. apon. running
through orbicularis
to skin in Japanese
born with crease
Continued

360
Asian Blepharoplasty and the Eyelid Crease
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
Liao, Tung et al.
A Chuangsuwanich
Kim, Youn
WPD Chen
Year
2005
2006
2006
2007
Journal
Aesthet Plast Surg
29(6):540–545
Celebrity arcade
suture
blepharoplasty for
double-eyelid; CAS
Aesthet Surg J
26(3):280–286
Short incisional
double-eyelid
blepharoplasty for
Asian pts
Plast Reconstr Surg
117(3):782–789
Management of
adhesion using
a pretarsal
fibromuscular flap or
graft in secondary
blepharoplasty
Plast Reconstr Surg
119(1):379–386
The concept of a glide
zone as it relates to
upper lid crease, lid
fold, and application
in upper
blepharoplasty
Country
RO China, Taiwan
Thailand
Korea
USA
Conjunctival suturing
Trans-tarsal suturing
Skin incision
Stab incision(s)
Partial incision
Revisional
blepharoplasty
Yes
Remove skin
No
Yes
Orbicularis
Orbital septum
Preaponeurotic fat
Removed centrally
Treatment and
preservation of fat
Crease form
‘Bridge connection’
Skin-to-tarsal plate
fixation
Skin–apon.–skin
Sutures
?
6-0, 7-0
Days left in
7
Effectiveness
Partial incision
technique. 652 pts,
10 lost crease
within a year, 8 pts
with asymmetry
Comments
Use of pretarsal
fibromuscular flap or
free graft to prevent
re-adhesion
Concept paper on fat
as a glide zone

Appendix 3  Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
361
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
WPD Chen
Fengzhi, Wei et al.
A Kruavit
Choi, Eo
Year
2007
2009
2009
2010
Journal
Plast Reconstr Surg
120(2):545–552
Beveled approach for
revisional surgery in
Asian blepharoplasty
Ann Plast Surg
63(3):242–248
Double-eyelid
operation recreating
the anatomic
microstructure
Aesthet Surg J
29(4):272–283
Asian blepharoplasty:
18 yr in 6,215 pts
Ann Plast Surg
64(4):376–380
Tissue thread
grafting:
nonincisional
Double-eyelid
operation
Country
USA
PR China
Thailand
Korea
Conjunctival suturing
Skin incision
Yes. Revisional
blepharoplasty
On middle-third of
eyelid only
Likely through small
incisions
Remove skin
Minimal
Dissect medially,
laterally, superiorly
Orbicularis
Orbital septum
Preaponeurotic fat
Crease form
Skin–apon.–skin
Three inverted
stitches, skin to lev.
apon. or inf. edge
dermo-orbic.
junction (subcut.)
buried
Thread was passed in
‘same pattern as
other non-incisional
technique’
Sutures
6-0, 7-0
Threads made from
autogenous
temporal fascia,
CPF, or cadaveric
dermis
Days left in
7
9.3
Effectiveness
Partial incision
technique
Comments
Technique and series of
patients that
underwent revision
blepharoplasty for
correction of high
crease. Net lowering
is 2.75 mm in crease
height
EM and light
microscopic study
confirms presence
of levator fibers to
pretarsal skin
In 70%, author could
use medial anchor
stitch to create an
outer fold without
epicanthoplasty
Unclear about the
techniques used for
passing thread,
since such variants
exist
Continued

362
Asian Blepharoplasty and the Eyelid Crease
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
Cho, Byun
Ma, Cheng
Liu et al.
Choi, Eo
Year
2010
2010
2010
2010
Journal
Plast Reconstr Surg
125(1):324–331
New technique
combined with
suture and incision
method
Aesthet Surg J
30(3):329–334
Mini-incision double
eyelidplasty
Plast Reconstr Surg
126(6):2133–2139
Transcut., subcut. and
intratarsal suturing
in double-eyelid
surgery
Plast Reconstr Surg
126(3):1048–1057
A new crease fixation
technique for double
eyelidplasty using
mini-flaps derived
from pretarsal
levator tissues
Country
Korea
Hong Kong
PR China
Korea
Conjunctival suturing
Skin incision
Partial incision +
buried continuous
suture
Mini-incision; two
3 mm incisions
Five stab skin
incisions; transcut.
approach, takes
bites of tarsal plate
Remove skin
No
No
Orbicularis
Debulk pretarsal soft
tissues
Orbital septum
Preaponeurotic fat
Crease form
Levator is fixed to
tarsus, just below
end of apon. to
tarsus
Transcut.–intratarsal
suturing
Sutures
One continuous suture
is buried
Four buried 7-0 nylon
sutures
Days left in
Permanent
Effectiveness
Partial incision +
buried continuous
suture with single
knot
11% revision rate,
6% crease
disappearance
89.6% satisfied over 3
months to 3 years
period. 10.4%
dissatisfied
Comments
Combined approaches.
Benefit vs risks?
Hard to tell as period
of observation
spans 3 months to
3 years, both short
duration when it
comes to judging
permanence
Uses miniflaps of lev.
apon. and attach to
skin–muscle layers

Appendix 3  Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
363
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
Bi, Zhou et al.
Li, Lin et al.
Lew, Kang, Cho
Zhang, Yang
Year
2011
2011
2011
2012
Journal
J Plast Reconstr
Aesthet Surg
64(9):1138–1144
Small-incision
orbicularis–levator
fixation technique:
double-eyelid
blepharoplasty for
treating trichiasis
J Plast Reconstr
Aesthet Surg
64(8):993–999
Double-eyelid
blepharoplasty
incorporating
ptosis surgery
for ‘latent’
aponeurotic ptosis
Plast Reconstr Surg
127(3):1323–1331
Surgical correction of
multiple upper eyelid
folds in East Asians
Aesthet Plast Surg
36(5):1039–1046
Removal of large
amount of pretarsal
tissue via 3
mini-incisions
Country
PR China
PR China
Korea
PR China
Conjunctival suturing
Skin incision
Small incisions
medial, central
and lateral
External incision
approach
Revisional
blepharoplasty
Partial incision; 3
incisions, each
3–4 mm
Remove skin
Orbicularis
Debulk soft tissues
Excised inferiorly, and
to each side of
wounds
Orbital septum
Preaponeurotic fat
Crease form
Orbicularis–levator
fixation
Sutures
Days left in
Effectiveness
Improved eyelash
up-curling in
medial, mid- and
lateral sections
Comments
Clinical importance
for detection and
correction of mild
ptosis
Augmented preorbital
area using eyelid
tissues (orbicularis and
orbital fat) to prevent
re-adhesion of the
orbicularis and levator
Similar paper in
Aesthet Plast Surg
2013;37(1):22–28
An uncut strip of
orbicularis removed
through 3
mini-incisions
Continued

364
Asian Blepharoplasty and the Eyelid Crease
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
Tung, Tsai et al.
Moon, Yoon, Lee
JS Zubiri
T Mizuno
Year
2012
2013
2013
2013
Journal
Aesthet Plast Surg
36(4): 842–845
Simultaneous fat
removal with
suture upper
blepharoplasty
Arch Plast Surg 40(4):
409–413
Modified
blepharoplasty using
single-knot
continuous buried
non-incisional
technique
Aesthet Surg J
33(5):722–732
Subdermal placement of
sutures in double
eyelid surgery
J Plast Reconstr
Aesthet Surg
66(4):e95–e100
Two modified
techniques to
decrease
complications of
buried suture
double-lid
blepharoplasty
Country
RO China, Taiwan
Korea
Philippines
Japan
Conjunctival suturing
CA suturing
Yes, back and forth
through dermis and
conjunctiva
Buried suture
technique.
First technique:
transconjunctiva
only
Skin incision
Combine with a
4 mm lateral skin
incision to reduce
fat pad
Needle through four
stab skin incisions
Full incisional method
Second technique:
small skin incision
Remove skin
No
Yes
No
Orbicularis
Buried suture in orbic.
oculi through lateral
stab incision
Yes
Second technique:
resected some
pretarsal orbicularis
Orbital septum
Yes
Preaponeurotic fat
Remove portion of
fat
Removal as needed
Crease form
Take {skin–tarsus
+aponeurosis–skin}
fixation sutures x 5
buried 6-0 nylon
Sutures
Buried sutures
7-0 nylon back and
forth
Continuous 6-0 nylon
Buried suture over
anterior surface of
STB
Days left in
Permanent
Remove on 5th day
Buried suture is
permanent
Effectiveness
Follow-up period
unknown
Follow-up period
unknown
Follow-up period
unknown.
Fail rate of 26% with
buried suture alone;
9.6% if combined
with resection of
pretarsal orbic.
Comments
Hardly
‘non-incisional’?
Any Faden-like effect?
Skin fixation to tarsus as
well as to levator
aponeurosis;
combined effect

Appendix 3  Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
365
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
Jinghe, Huifang et al.
Year
2014
Journal
Ann Plast Surg
72(2):141–144
Three mini-incisions
double-eyelid
blepharoplasty
Country
PR China
Conjunctival
suturing
Skin incision
Partial incision; 3 incisions,
each 3–4 mm
Remove skin
Orbicularis
Excise inferior skin edge’s
orbicularis
Orbital septum
Preaponeurotic fat
Reduce fat
Crease form
Sutures
Days left in
Effectiveness
Comments
Author described incisions
as ‘minute’

366
A P P E N D I X 4
RECENT LITERATURE ON
EPICANTHOPLASTY (IN ENGLISH)
Recent Literature on Epicanthoplasty (in English)
Author
S Ma
Y Lee, E Lee et al.
SD Lin
Year
1996
2000
2000
Journal
Zhonghua Yan Ke Za Zhi
32(3):194–196
Epicanthoplasty during
double-fold eyelid
operation
PMID: 9590860
Plast Reconstr Surg
105(5):1872–1880
Anchor epicanthoplasty combined
with out-fold type double
eyelidplasty for Asians: do we
have to make an additional scar
to correct the Asian epicanthal
fold?
PMID: 10809119
Br J Plast Surg 53(2):95–99
Correction of the epicanthal fold
using the VM-plasty
PMID: 10878829
Country
PR China
Korea
RO China, Taiwan
Skin incision
Various epicanthoplasty
performed in 183 cases
Anchor epicanthoplasty, used for
out-fold crease (parallel crease
shape), anchoring medial end of
incision to deep tissue
VM-plasty with three V-flaps
Remove:
  Skin
38 cases (shuttle form),
120 (cuneiform), Z-plasty
in 25 cases
Trimming skin
  Orbicularis
And soft tissue under medial fold
  Orbital septum
  Preaponeurotic fat
Crease form
Parallel crease
Outer (parallel)
Effectiveness
183 cases, performed
together with double-
eyelid procedures
67 cases; 28 cases followed.
Disadvantages include technical
difficulty and chance for active
bleeding as stated by authors.
Blends into medial end of parallel
crease
Used alone in 8 cases, with
double-eyelid procedure in 51
young patients, and with
upper blepharoplasty and
crease procedure in 26 cases
Comments
Three techniques
depending on severity
This technique is based on the
concept of trimming of muscle
and soft tissue under the Asian
epicanthal fold and downward
medial advancement and
anchoring of the medial canthal
skin to the deep tissue. Avoids
incision over medial canthal skin
(medial to the medial canthal
angle)
Redness of incisions was
common but all faded away
within 2–3 mth

Appendix 4  Recent Literature on Epicanthoplasty (in English)
367
Recent Literature on Epicanthoplasty (in English)
Author
Y Yang, HM Zhang et al.
H Zhang, H Zhuang et al.
SK Yi, HW Paik et al.
Year
2006
2006
2007
Journal
Zhonghua Zheng Xing Wai Ke
Za Zhi 22(2):130–132
[A new method for medial
canthoplasty combined
double eyelid formation]
(article in Chinese)
PMID: 16736618
Plast Reconstr Surg
118(4):900–907
A new Z-epicanthoplasty and a
concomitant double
eyelidplasty in Chinese eyelids
PMID: 16980849
Aesthet Plast Surg
31(4):350–353
Simple epicanthoplasty with
minimal scar
PMID: 17486401
Country
PR China
PR China
Korea
Skin incision
Performed with double-eyelid
procedure
Z-epicanthoplasty
Remove:
  Skin
  Orbicularis
  Orbital septum
  Preaponeurotic fat
Crease form
Effectiveness
86 cases; 67 cases followed
up. Designed for parallel
shape crease
230 cases together with
double-eyelid procedure,
included congenital and
traumatic medial epicanthi.
Followed 67 cases. Stated that
it is suitable for all types
except epicanthus inversus
52 cases, 2 showed a depressed
scar on the lower lid
Comments
Suitable for mild to moderate
epicanthal folds, all except
epicanthus inversus
Mild scar in early postop period,
then fade into gray–white line
Continued

368
Asian Blepharoplasty and the Eyelid Crease
Recent Literature on Epicanthoplasty (in English)
Author
JI Park, MS Park
FC Li, LH Ma
W Chen, S Li et al.
Year
2007
2008
2009
Journal
Facial Plast Surg Clin
North Am 15(3):343–
352, vi
Park Z-epicanthoplasty
PMID: 17658430
J Plast Reconstr Aesthet Surg
61(8):901–905 Epub 2007 Jul 2
Double-eyelid blepharoplasty
incorporating epicanthoplasty
using Y–V advancement
procedure
PMID: 17606424
J Plast Reconstr Aesthet Surg
62(12):1621–1626
Medial epicanthoplasty using the
palpebral margin incision method
PMID: 19028154
Country
USA
PR China
PR China
Skin incision
Z-epicanthoplasty,
correcting type II and III
epicanthal fold
Y–V advancement incorporated
into crease incision
Palpebral margin incision.
Performed together with double-
eyelid procedure.
Remove:
  Skin
  Orbicularis
  Orbital septum
  Preaponeurotic fat
Crease form
Outer-parallel
Effectiveness
Best suited for outer-
parallel crease shape,
patients who desire
‘higher’ double fold
92 cases, performed with
double-eyelid procedure. Only 3
cases with scar
82 cases (through upper and lower
palpebral margin incisions; trims
off orbic. oculi under epicanthal
fold, as well as superficial head of
medial canthal ligament)
Comments
Authors stated: ‘The size of the
epicanthal fold in Asians is
usually relatively small, and
thus aesthetically successful
effacement rarely requires more
complex procedures as
performed in the West.’

Appendix 4  Recent Literature on Epicanthoplasty (in English)
369
Continued
Recent Literature on Epicanthoplasty (in English)
Author
JJ Lu, K Yang et al.
Y Liu, J Huang
L Liu, S Li et al.
Year
2011
2011
2012
Journal
J Plast Reconstr Aesthet Surg
64(4):462–466
Epicanthoplasty with double
eyelidplasty incorporating
modified Z-plasty for
Chinese patients
PMID: 20682462
Aesthet Plast Surg
35(6):1112–1116
A modified and accurately
designed Z-epicanthoplastic
technique
PMID: 21607535
(Interepicanthal distances longer
than a palpebral fissure and
lacrimal caruncles obviously
covered by epicanthic folds
were considered an indication)
J Plast Reconstr Aesthet Surg
65(1):43–47
Inverted ‘V–Y’ advancement
medial epicanthoplasty
PMID: 21816696
Country
PR China
PR China
PR China
Skin incision
Modified Z-plasty
Modified Z-plasty
Inverted V–Y
Remove:
  Skin
  Orbicularis
  Orbital septum
  Preaponeurotic fat
Crease form
Effectiveness
322 cases(with double-eyelid
procedures); technique
includes cutting off
malpositioned superficial
head of preseptal orbic.
oculi
62 cases (42 simultaneous
double-eyelid surgery); stated
60 patients were satisfied
Comments
Stated that it can be applied to
all types except epicanthus
inversus
263 cases. Stated it can avoid
overly Westernizing the inner
canthus architecture

370
Asian Blepharoplasty and the Eyelid Crease
Recent Literature on Epicanthoplasty (in English)
Author
YH Shin, PJ Hwang et al.
X Hu, X Lin et al.
S Wang, F Shi et al.
Year
2012
2012
2013
Journal
J Craniofac Surg 23(4):e278–820
V–Y and rotation flap for
reconstruction of the epicanthal
fold.
(to treat overcorrected
epicanthoplasty cases)
PMID: 22801149
Aesthet Plast Surg
36(4):788–794
Two-Z-epicanthoplasty in
a three-dimensional
model of Asian eyelids.
PMID: 22437335
J Plast Reconstr Aesthet Surg
66(5):682–687
Epicanthal fold correction: our
experience and comparison
among three kinds of
epicanthoplasties.
PMID: 23499505
Country
Korea
PR China
PR China
Skin incision
V–Y
20 out of 23 cases
underwent
simultaneous double-
eyelid procedures
Three methods, 252 cases
(220 together with double-
eyelid procedure): horizontal
incision (mild), Z-plasty
(moderate) and V–W-plasty
(severe cases)
Remove:
  Skin
  Orbicularis
Excise orbicularis and thick
subcut. tissues
  Orbital septum
  Preaponeurotic fat
Crease form
Effectiveness
246 cases, 62 cases followed up; 6
cases needed reoperation.
Intercanthal distance lengthened
from 31.7 to 33.8 mm mean
Stated that intercanthal
distance decreased
from 37± 2.1 mm
preop. to 31.4±1.9 mm
postop. Inconspicuous
scar
Majority cases were mild,
underwent horizontal
incision which left
inconspicuous scar. Severe
cases (underwent V–W-
plasty) may leave obvious
scar
Comments
Used to repair overcorrection of
epicanthoplasty (overly exposed
caruncle)

Appendix 4  Recent Literature on Epicanthoplasty (in English)
371
Recent Literature on Epicanthoplasty (in English)
Author
L Wang, X Chen et al.
Year
2013
Journal
Aesthet Plast Surg 37(4):704–708
A modified Z-epicanthoplasty combined with
blepharoplasty used to create an in-type
palpebral fissure in Asian eyelids.
PMID: 23824058
Country
PR China
Skin incision
To create an in-type crease shape (NTC).
Performed together with double-eyelid
surgery
Remove:
  Skin
  Orbicularis
  Orbital septum
  Preaponeurotic fat
Crease form
In-type (nasally tapered)
Effectiveness
Reported ‘no scarring’ in 873 cases
Comments

372
A P P E N D I X 5
AESTHETIC EFFECTS OF
ASIAN BLEPHAROPLASTY
Author
Yu, Liao
Tsai, Wu et al.
Kim
Kim, Lee et al.
Year
2000
2012
2013
2013
Journal
Hua Xi Kou Qiang Yi Xue
Za Zhi 18(3):165–167 (in
Chinese)
PMID:12539668
Classification of eyelids,
design of double-eyelid
operations
J Plast Reconstr
Aesthet Surg
65(6):e141–145
Ocular surface area
changes after
double eyelidplasty
Aesthet Plast Surg
37(5):863-868
Effects in the upper
face of Far East
Asians after Oriental
blepharoplasty
J Craniofac Surg
24(5):1582–1585
What causes increased
contrast sensitivity and
improved functional
visual acuity after upper
eyelid blepharoplasty?
Country
PR China
RO China, Taiwan
Korea
Korea
Skin incision
Design based on
morphological characters
of eyelids
Comments
Classified according to
eyes’ length and height,
eyelid skin thickness,
eyeball protrusion and
eye shape, including
eyelids with long and
narrow eyes, eyelids with
thin and soft skin, eyelids
with thick subcut. tissue,
eyelids with small and
round eyes, eyelids with
protruding eyeball and
eyelids with triangle eyes
Increase in ocular
surface area after
double eyelidplasty
Their series of 612 pts
shows an increase
in palpebral fissure
vertical dimension
and relaxation of
brow position after
double-eyelid
surgery. (These
findings are not
unique to Asians)
Improved contrast
sensitivity and
functional visual acuity
after upper
blepharoplasty were
caused by changes in
ocular high-order
aberration and the
degree of lash ptosis
after surgery. There
were no changes in
corneal topography or
astigmatism
Author
Hwang, Spiegel
Year
2014
Journal
Aesthet Surg J 34(3):374–382
The effect of ‘single’ vs ‘double’
eyelids on the perceived
attractiveness of Chinese women
Country
USA
Skin incision
Comments
19 Chinese women were judged by
Chinese as well as non-Chinese
observers: creases were digitally
added as low, medium and high in
height.
Both Chinese and non-Chinese
observers considered the medium-
height upper eyelid crease most
attractive (P < 0.00001). An absent
upper eyelid crease was deemed
the least attractive (P < 0.00001)

373
A P P E N D I X 6
RECENT LITERATURE ON ANATOMY
Recent Literature on Anatomy
Author
O Galatoire, V Touitou et al.
H Kakizaki, I Leibovitch et al.
BS Kotlus, DE Heringer, RM Dryden
Year
2007
2009
2010
Journal
Orbit 26(3):165–171
High-resolution MRI of the upper
eyelid: correlation with the
position of the skin crease in
the upper eyelid
PMID: 17891644
Ophthalmology 116(10):2031–2035
Orbital septum attachment on the
levator aponeurosis in Asians: in
vivo and cadaver study
PMID: 19592104
(To examine the anatomic
relationships between the
preaponeurotic fat pad, orbital
septum, and the distal end of the
anterior layer of the levator
aponeurosis [DEALLA] in relation
to the superior tarsal plate border)
Ophthal Plast Reconstr Surg
26(6):395–397
Evaluation of homeopathic Arnica
montana for ecchymosis after
upper blepharoplasty: placebo-
controlled, randomized, double-
blind study
PMID: 20683279
Country
Comments
MRI provides excellent images
and allows a good analysis of
the upper eyelid components. It
permits a detailed analysis of
the architecture for a better
understanding of its appearance
and of the crease position
In vivo, the DEALLA was always
located above the STB, and the
lower margin of the preapon. fat
was always positioned below the
DEALLA and around the STB.
Orbital septum attachment on the
levator aponeurosis in Asians
seems to be situated above the
STB border in vivo
The authors find no evidence that
homeopathic A. montana, as
used in this study, is beneficial
in the reduction or the resolution
of ecchymosis after upper-eyelid
blepharoplasty
Recent Literature on Anatomy
Author
Q Zhou, L Zhang et al.
Year
2012
Journal
J Plast Reconstr Aesthet Surg
65(9):1175–1180
Preoperative asymmetry of upper
eyelid thickness in young
Chinese women undergoing
double-eyelid blepharoplasty
PMID: 22647567
Country
PR China
Comments
Using high-def. MRI and high-
precision weighing of tissue:
Demonstrated that the
orbicularis muscle and orbital
fat pad are consistently thicker
on the right side than on the
left. Concluded that upper
eyelid thickness asymmetry is a
common phenomenon in young
Chinese women