Asian Cosmetic Surgery:

Lisa is a 25-year-old Korean female who, like 50% of the Asian population, was born without an upper eyelid crease. Not only does this make her eyes look small, but also, eye make-up is almost impossible to wear.

To help create a crease and give an open-eye look she has been gluing and taping her upper eyelids since she was a teenager. Tired of these hassles that are a very impermanent solution, she has decided to under go a simple upper eyelid procedure called an Asian blepharoplasty, which will create a permanent crease.

Lisa is not alone. It is estimated that 250,000 Asians a year undergo upper eyelid surgery to create a double fold, thus making this the most common procedure performed on Asians.

For many the thought of changing one’s body is culturally and spiritually not accepted. S

However, since the Korean War more and more Asians have broken traditional barriers and elected to have the procedure. Changing social restrictions, combined with the increased migration of people throughout the world means many cosmetic surgeons and aestheticians are seeing more and more Asian patients.

Cultural Differences
There are some significant cultural differences which need to be recognized to allow the skin care specialist and surgeon to help the patient experience a successful outcome.

The Asian patient generally has a well-defined sense of harmony and beauty. As a culture this is manifest in the beautiful paintings, gardens and other art forms. In daily life this aesthetic sense may manifest as a fixation on a particular feature. Often the Asian patient may focus on the black and white, expecting perfection while not realizing that the goals are gray, focusing on improvement.

Guilt plays a role in most cultures but especially in the Asian patient where altering one’s appearance may be considered a sign of disrespect for one’s parents. However the appreciation and desire for beauty have drastically overridden these feelings. Most Asian patients are not looking to have a Westernized look but are looking for enhancements that preserve their heritage.

Consultation, Communication & Computer Imaging
The first meeting of the patient in the surgeon’s office is called the consultation. During this meeting patients share concerns about their appearance and desires for improvement. Communication is very important to ensure that both parties have a common understanding.

Many Asian patients may be shy and others may speak little or no English. An interpreter is necessary for the patient with minimal English skills. I have several Japanese magazines in the consultation room and encourage the patients to look through them and identify features that they like and dislike.

The computer imager is a another valuable tool in depicting the effects various procedures may have. Both patient and surgeon view the same image and then hopefully share a common understanding.

Asian Skin Traits & Treatments
Asians are members of the Mongoloid race, the largest race on earth and very diverse because of its geographical distribution. This physical variety is similar to other races where there is considerable variation of physical traits.

One Asian characteristic is yellow skin pigmentation. Groups originating in southern Asia tend to have darker skin than their northern counterparts. The yellowness of the skin is a reflection of the activity of the melanocytes or pigment cells of the skin and the shape of the pigment granules.

Due to this increase in pigmentation, many Asians are prone to brown spots on the face. This spotty look is a common reason for the patient to present to the aesthetician or cosmetic surgeon. Usually the first step in treating these dark spots is to have the patient apply bleaching creams to the areas.

One of the most popular bleaching agents is called hydroquinone. To maximize the effectiveness of the hydroquinone or other bleaching agent it is frequently mixed with hydrocortisone and tretinoin (RetinA). The hydrocortisone also acts as a lightening agent. The tretinoin helps to disrupt the protective layer of the skin and allow deeper penetration of the other bleaching agents. The tretinoin also decreases the activity of the pigment cells. Patients should use bleaching agents twice a day for maximum effectiveness.

Since it takes four to six weeks for the skin to go through a growth cycle, the patient’s results should be reexamined in this time frame. If the patient‘s dark spots persist, performing microdermabrashion and/or medium-depth peels may be necessary to affect long-standing pigmentation problems.

Asian skin is much thicker than Caucasian skin. This generally means fewer wrinkles and a slower aging process. Asian skin is generally not dry except for the ear canal.

After surgery, the thicker and more fibrous dermis or supporting layer of skin causes incisions to stay red longer and require a slightly longer time to heal generally. If a patient has significant acne scars the skin can be safely lasered but generally requires pretreatment with bleaching agents as described previously to reduce post-operative hyper-pigmentation.

The Asian Eyelid
Approximately 50% of Asian patients have a single eyelid. This is an autosomal dominant trait, which means that if one parent has the single eyelid there is a good chance the children will have it. The cause of the single eyelid is due to a muscle not inserting into the skin of the upper eyelid and creating a crease.

Prior to the procedure, examining photos of Asian eyelids the patient likes will guide the surgeon as to the size and shape of the new eyelid. The upper eyelid blepharoplasty in the typical Asian patient involves making a new crease (lower than a Caucasian crease to not westernize the eyelid).

Most patients have no skin removed, only excess fatty tissue. An exception to this is the older Asian patient who has excess upper eyelid tissues. The excess eyelid tissues should be removed but in a conservative fashion. Patients recover quickly from this procedure in usually less than a week.
Many Asian patients have a fold of tissue in the inner corner of the eyelid. If this fold is very prominent it can be softened by creating a series of small flaps called “Z” plasties. The down side is the possibility of a visible incision. The presence of the fold will often determine the final shape of the eye.

Asian Facial Features
A flat broad bridge to the nose is another characteristic of this race. This creates an optical illusion which tends to make the eyes look farther apart. Computer imaging is an excellent tool for the patient and surgeon to arrive at a common understanding of the goals of surgery.

To build up a weak bridge a number of options are available, including ear cartilage, septal cartilage, cadaver rib, silicone prosthesis, and a host of other man-made materials. In addition to building up the bridge, the tip cartilages usually need support. It was for this reason the “L” shaped silicone prosthesis became very popular amongst Asian patients. The procedure was performed quickly and often gave very nice results. The down side was the implant could work its way out into the nose or through the skin.

Building up the bridge using the patient’s ear cartilage is one of the most popular methods. The patient generally does not have to worry about the body rejecting the material, unlike some man-made materials. The down side to the use of the patient’s ear cartilage is a tender ear for a week; however this is usually not a problem.

The other challenge facing the surgeon is the fact that the cartilage is not straight, therefore it has to be shaped and sutured into a relatively straight implant. The thick skin of the nose will hold onto the swelling for up to 18 months. Minor asymmetries can be fine-tuned when the swelling appears to have resolved. This swelling is generally only noticeable to the surgeon and patient.

Another Asian facial characteristic is a flat mid-face or cheek area. The cheek areas can be enhanced nicely with cheek implants. Most Asian patients are not looking for a chiseled look to their face but improved symmetry and balance. Therefore smaller cheek implants will generally achieve the patient’s goal. The chin is another area which can be strengthened with the use of implants. The use of silicone or other man-made implants to balance these areas is performed in a traditional fashion.

Facelift, Asian Style
Face lifting in the Asian patient is customized as in the Caucasian patient to address the drooping neck, neckbands, jowls, or cheeks. One of the biggest differences in the Asian population is that they usually present later in life for face lifting due to the thicker skin. Currently used minimal incision techniques work great in this population, another benefit of thicker skin.

More traditional incisions around the ear can be performed, however it may take slightly longer for them to mature. Due to the thicker skin many patients inquire about the possibilities of developing keloids or large scars. Keloids are extremely unusual on the face; but a careful history about scarring should be taken prior to developing a surgical plan.

In summary, due to greater diffusion of cultures, the cosmetic surgeon and cosmetic professional will be exposed to more and more Asian patients. It is very important to recognize the cultural differences regarding beauty and psychology to increase the chances of a successful outcome. It is also important to understand the physical differences and the patients’ desires for enhancement of their ethnic characteristics and not westernization of their features.

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