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Asian Blepharoplasty: Ageing Patterns, Anatomophysiological Considerations and Ethnic Differences

Ageing results in the gradual loss of elastic fibers and relaxation of skin, giving it a loose appearance, and one of the most prominent areas to show signs of ageing is in the eyes. It has been argued that muscle ptosis of the eye area contribute to the ageing of the eyelids, especially so for upper eyelids as the periorbital fat (ie, the retro–orbicularis oculi fat) in the upper periorbita occasionally bulge excessively due to the result of ageing. Such anatomical changes may result in various functional and cosmetic deformities, such as, but not limited to, ptosis and limitation of visual fields and/or unattractive upper eyelids, requiring either one to undergo surgical or non-surgical intervention.

Today, blepharoplasty has been performed on Asians for over a century, and although there is debate as to it is a product of western influence or otherwise, the popularity of the surgery indicates that it is here to stay.

Ageing Patterns in Blepharoplasty

Age and gravity may cause the eyebrow and eyelid areas to sag or droop. Sagging skin and weakening of facial muscles, together with the build-up of fat pockets around the eyes, can cause unsightly eye bags and dark circles. Not only do these conditions adversely affect a patient's overall aesthetics, they may also impair vision and cause eye strain or fatigue. This may also lead to the eyes appearing smaller, puffier or looking tired.

Ageing Related Fat Pad Loss

Histopathologic Sections of Full-Thickness Eyelid Specimens

Image credit: Age-Related Changes of the Eyelid (2015)


Changes to the orbicular muscle and its connective tissue play a central role in the ageing patterns of the eyelid; with age-related changes of orbicular muscle comprising of a a decrease in muscular fibers and a disorganization of banding structures (appearance of nemaline bodies, Z-line streaming, cytoplasmic bodies, and Z-line doubling). In some studies, mitochondria, particularly in the subsarcolemmal area, showed either a decrease in number and loss of cristae, or enlargement and proliferation of cristae. In combination with both alterations, intramitochondrial crystal formation and altered succinyl-dehydrogenase activity were also a frequently observed.

Similarly, it has also been noted that, in the ageing patterns of the eyelids, the tubular aggregates originated from the sarcoplasmic reticulum as well as various sarcoplasmic inclusions were also observed. Intramuscular connective tissue density also increased with age, and it is thought to be associated with the increased glycation of collagen fibers. While these alterations are not necessary considered to specifically be the cause and effect of ageing, their particular combination may be responsible for the development of well-known, age-related changes and diseases of the eyelid.

Anatomophysiologic Consideration in Blepharoplasty

The antomophysiological ageing of the eye suggests that the ocular adnexal tissues share the progressive loss of tone and bulk, common to many ageing tissues; and as a result of these progressive involutional changes, the anatomy of the eyelid is altered inducing senile ptosis, ectropions, entropions, canthal laxity and epitheliomas.

Senile ptosis is one acquired ptosis usually due to dehiscence or disinsertion of the levator aponeurosis (below the orbital septum); blepharoplasty may be performed to the tarsal plate via either anterior or posterior approach to correct the ptosis. Senile ectropions and entropions share several aetiologic factors: horizontal laxity, lid retractors, laxity migration of the preseptal orbicularis for senile entropion; stretching of the canthal tendons, secondary skin retraction and conjunctival thickening for senile ectropion.

The advanced loss of laxity and tone, which is a characteristic feature of ageing ocular adnexal tissue, results in sagging eyelids and a reduction in elastic fibers, which are essential components of the function and structure of the lymphatic system. The pathogenesis of dermatochalasis may begin with subclinical inflammation and lead to elastolysis and secondary lymphostasis.

One of the most common pathogenesis for ptosis is aponeurotic ptosis, where the levator muscle starts thinning and begins to lose muscle tone. As a result, it is unable to keep the upper lid in the correct position above the eye and ptosis ensues. Disinsertion or dehiscence of the levator aponeurosis can also cause ptosis. Other risk factors for ptosis include intraocular surgery and chronic inflammatory diseases that disinsert the levator aponeurosis from the tarsal plate.

The lateral laxity of the canthal tendon is also another important reason for the appearance of involutional ectropion and entropion. Laxity of the medial canthal tendon as well as false insertion of the lower retractors are also conductive parameters. Age-related decrease and atrophy of the orbital fat as well as the relaxation of the ligamentous support can lead to an increasing eyelid-globe disparity that again compounds eyelid laxity.

Some studies have reported the presence of abnormal elastic fibers in involutional ectropion and entropion, as well as a decrease in elastic fibers in the pretarsal orbicularis oculi muscle, in the tarsal stroma, and in the eyelid skin in patients suffering from age-related involutional ectropion and entropion.

Lastly, collagen and elastic fibers are essential components of the extracellular matrix of the eyelid and are responsible for its function. Collagen fibers are liable for the tensile strength; elastic fibers responsible for the flexibility and resiliency.

Ethnic Differences

As with most procedures, ethnic differences must be always be taken into consideration, and for blepharoplasty is no different. Generally, Asians tend to have higher eyebrows than Caucasians - possibly due to an overactive forehead musculature mechanism. In addition, Asians also have more pretarsal fat and suborbicularis fat, which projects inferiorly and tends to make their eyes puffy.

On the other hand, Caucasians tend to have more prominent supraorbital rims, relatively lower-set eyebrows, less postseptal fat, and thinner upper eyelid skin. This ethnic distinction of relatively lower-set eyebrows makes Caucasian in general less suitable for subbrow blepharoplasty (SBB), and probably more suitable for forehead lift and suprabrow blepharoplasty.

Broadly speaking, upper eyelid blepharoplasty procedures in Asians may be divided into two categories: external incisional techniques and non-incisional or suture ligation techniques.

Most Asians, in general, have single eyelid, which is to say, there is no supratarsal crease on the eyelid. Furthermore, it has been observed in some studies, that Asians tend to possess a greater number of eyelid fat pads and a larger amount of subcutaneous and suborbicularis fat than Caucasians, with the latter's periorbital fat being lower. These qualities of the periorbital fat compartment in the upper eyelids may contribute to the “puffiness” of the single eyelid, which further obscures the supratarsal crease, producing pseudoptosis.

Another anatomical difference between the upper eyelids of Asians and Caucasians is the presence of an epicanthal fold, which obscures the medial canthus (inner corner) and gives the eye a relatively narrow appearance. This fold is universally present among humans at birth but is only seen in few non-Asian adults, while the incidence in Asians may be as high as 90%.

Succeeding in the Art of Blepharoplasty

To possess the necessary skills and be equipped with the latest and most advanced techniques is a given in the art of blepharoplasty. However, to successfully deliver the best results in patients, a practitioner must not only take into consideration, the ageing pattern of the eye area, the anatomophysiology of the eye and ethnic differences of the patient; but also understand how these factors can and will affect the expectations as well as the outcome of the procedure.

It is only when all of the considerations have been taken into account, and combined with the right skills and correct techniques, can a surgeon successfully deliver the best results in patients.

Hope you have enjoyed the article! Stay tuned for our future posts about more techniques and information related to our advanced aesthetic and cosmetic training courses!



Learn How Ageing Patterns of the Eye Area, the Anatomophyisology of the Eye and Ethnic Differences can Affect and Determine Results at our upcoming Blepharoplasty Master Class and Mini-Fellowship!

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