Upper Lid Crease Terminology and Congurations

William P.D. Chen

Chapter

The configuration of the upper lid crease in Asians varies greatly. The terminology used to describe these configurations also varies, depending on the ethnic group and language concerned. Figure 3-1 illustrates the Chinese characters for the words double-eyelid fold. Figure 3-2 shows the Japanese Kanji writing for single (one) lid eye and double (two) lid eye. The characters common to Chinese and Japanese for the operation to construct a lid crease are illustrated in Figure 3-3.

Fig. 3-3 Characters common to Chinese and Japanese for the procedure to construct an eyelid crease, or double-eyelid procedure.

Fig. 3-1 Chinese written characters for double eyelid (skin).

Fig. 3-2 Japanese Kanji characters for single eyelid, (left) and double (two) eyelid (right).

As described in previous publications by the author,19 the crease may be asymmetric in its presentation, or be absent in one eye and present in the other. It may be continuous or segmented (fragmented). Figure 3-4 shows the various congurations of the Asian eyelid. Figure 3-5 shows an eyelid without a crease. There is mild degree of upper lid hooding, causing secondary downward rotation of the lashes. Figure 3-6 illustrates an eyelid with a distinctive crease. This is the parallel configuration. Figure 3-7 is an eyelid in which a portion of the crease has been obliterated. An eyelid with an incomplete or partial crease is shown in Figure 3-8. The crease originates in the medial canthus and medial upper lid fold (supracanthal web) and extends halfway across the upper lid. Multiple creases are illustrated in Figure 3-9, where two well-dened creases run parallel to each other. Figure 3-10 shows a minimal nasally tapered crease. The lateral third of the crease may be the same distance from the eyelash margin as the central third, or it may rise slightly to form
23

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Fig. 3-4 Chen1 has previously described the various forms of Asian eyelids: (a) Single eyelid without crease. (b) Same size eyelid ssure with crease. (c) Segmented or non-continuous crease. (d) Partial or incomplete crease. (e) Multiple creases. (f) Asian eyelid with a nasally tapered crease; in a small percentage of cases it shows some lateral are. (g) Asian eyelid with a parallel crease. (h) Typical Caucasian semilunar crease.

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Fig. 3-5 Asian lid without crease. This patient has moderate upper lid hooding causing downward rotation of the lashes. Note the apparent upper lid hooding (fold) that overshadows the smaller palpebral ssure laterally. Strategic placement of a crease would make the palpebral ssure seem larger.

Fig. 3-6 Asian eyelid with a parallel crease.

Fig. 3-7 Partial obliteration of crease.

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Fig. 3-8(A, B) Incomplete or partial crease.

B
Fig. 3-9 Asian with two well-dened creases that run parallel to each other but in a nasally tapered conguration.

Chapter 3 Upper Lid Crease Terminology and Congurations 27

Fig. 3-10 Minimal nasally tapered crease with a mild lateral are.

a laterally ared crease, in which the lateral third of the crease is further from the lash margin than the central third. A Caucasian upper lid crease is shown in Figure 3-11, where the central third of the crease is farthest from the lash margin. In Asians with a continuous eyelid crease, the crease may be of the nasally tapering type (NTC) (a less desirable term is inside fold) in which the crease converges toward the medial canthus, coming closer to the lashes as it reaches the medial canthal angle (Fig. 3-12A), or it may be a parallel crease (PC) (a less desirable term is outside fold), in which the crease runs fairly parallel to the lash margin from the medial canthus to the lateral canthus (Fig. 3-12B). In eyelids with a nasally tapered crease the crease may gently flare away from the lid margin as it approaches the lateral canthal region, forming a laterally flared crease (LTC) (Fig. 3-13). Another configuration is that the nasally tapering crease may run level to the eyelash margin from the central third of the eyelid laterally (Fig. 3-14). Asians rarely have a lid crease that is semilunar in shape, as is common in Caucasians (see Figs. 3-4 and 2-5). In a semilunar crease each end of the crease is closer to the respective lid margin than the central portion of the crease. Having a semilunar crease is by far the most frequent complaint heard from Asian patients who have had blepharoplasty performed in the United States2 (Fig. 3-15). This crease is often too high, unnatural, and harsh (termed the huh syndrome).

A high crease is one located 1012 mm from the ciliary margin. A high crease may result if a surgeon adheres to an empiric formula for the height of the lid crease, or uses techniques of supratarsal fixation in which a distance of 10 mm or more is applied without regard to ethnicity. Either method results in a crease that looks excessively high on an Asian patient. To summarize, such a regimented approach is countereffective in Asian blepharoplasty for the following reasons: Asians are usually smaller in build; correspondingly, the upper tarsus measures only 6.58.5 mm in height on average. The distance between the eyebrow and the upper lid margin is smaller on Asians than on Caucasians. A crease located 1012 mm from the lash margin would look much closer to the mid level of the upper lid than is natural (Fig. 3-16). Not only should ethnicity be a factor in blepharoplasty, but also each individuals features. When the crease is high, it is farther from the lid margin than the height of the tarsus, the surgically applied crease traverses thick dermis as it approaches the brow and is likely to be associated with hypertrophic scarring. The large distance between the lash margin and the crease also allows little camouage by the upper eyelashes, and the crease is exposed to scrutiny. A crease is harsh when it

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Fig. 3-11 Caucasian upper lid crease with a semilunar shape. Note that the widest separation of the crease from the ciliary border occurs centrally.

Fig. 3-12 (A) Asian eyelid with a nasally tapered crease. Note the merging of the crease medially into the medial upper lid fold and the relatively parallel course from the central third of the lid outward. (B) Asian eyelid with a parallel crease.

Chapter 3 Upper Lid Crease Terminology and Congurations 29

Fig. 3-13 Nasally tapered crease with a lateral are. The widest separation of the crease from the ciliary border occurs laterally.

Fig. 3-14 Nasally tapered crease that runs level to the eyelash from the central third of the eyelid outward (see Fig. 3-12A).

Fig. 3-15 Asian patient after blepharoplasty. Note asymmetry of the two creases and the high placement of the semilunar crease.

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Fig. 3-16 When a semilunar crease is placed more than 1012 mm in an Asian upper lid, the crease is in the mid level of the eyelid, halfway to the brow.

Fig. 3-17 Asian patient who underwent blepharoplasty with excessive removal of preaponeurotic fat. Note the hollow supratarsal sulcus and the formation of multiple creases.

is overtly prominent, deep, and indurated with dermal reaction. An unnatural crease describes a shape that is not aesthetically pleasing on the face of the person. The most frequent complaint is a semilunar crease. The overall impression of a crease positioned high and semilunar in shape is unnatural for Asians. Removal of an excessive amount of preaponeurotic fat also can cause an unnatural crease. When all the fat pads are removed from the preaponeurotic space, the result is a hollowed eye or famined look that appears incongruous on the relatively at face of an Asian2 (Fig. 3-

17). For Caucasians, the same complete excision of preaponeurotic fat pads used to be a necessary step in the performance of a total cosmetic blepharoplasty. It is important to recognize that there is a high degree of variation in the anatomy of the upper eyelids of Asians. A common misconception is that all Asians are born without an upper lid crease. In fact, half the Asian population does have a natural crease. For each person, the shape and height of the crease and the relation of the crease to facial conguration should be part of the overall assessment before a cosmetic surgical procedure is performed.

Chapter 3 Upper Lid Crease Terminology and Congurations 31

References
1. Chen WPD. Asian blepharoplasty. Ophthalmol Plast Reconstruct Surg 1987;3:135140. 2. Chen WPD. Review of Aguilar G. Complications of oriental blepharoplasty. In: Mauriello J, ed. Management and avoidance of complications of eyelid surgery. Vol. 3. Philadelphia: Field & Wood, 1994. 3. Chen WPD. Concept of triangular, rectangular and trapezoidal debulking of eyelid tissues: application in Asian blepharoplasty. Plast Reconstruct Surg 1996;97:212218. 4. Chen WPD. Eyelid and eyelid skin diseases. In: Lee D, Higginbotham E, eds. Clinical guide to comprehensive ophthalmology. Stuttgart: Thieme, 1999: 137182.

5. Chen WPD. Upper eyelid blepharoplasty in the Asian patient. In: Putterman AM, ed. Cosmetic oculoplastic surgery, 3rd edn. Philadelphia: WB Saunders, 1999: 101111. 6. Chen WPD. Expert commentary on blepharoplasty and blepharoptosis surgery in Asians. In: Mauriello J, ed. Unfavorable results of eyelid and lacrimal surgery. Oxford: ButterworthHeinemann, 2000: 6871. 7. Chen WPD. Aesthetic eyelid surgery in Asians: an EastWest view. Hong Kong J Ophthalmol 2000;3:2731. 8. Chen WPD. Oculoplastic surgery the essentials. Stuttgart: Thieme, 2001. 9. Chen WPD, Khan J, McCord C. Color atlas of cosmetic oculoplastic surgery. Oxford: ButterworthHeinemann, 2004.