Double eyelid surgery, also referred to as Asian eyelid surgery and Asian blepharoplasty, was first described by a Japanese surgeon by the name of Dr. Kotaro Mikamo in an 1896 publication entitled “Plastic operation of the eyelid” in J Chugaii Jishimpo, during the Meiji era. In his publication he describes the prevalent eyelid appearance in the Japanese population to be the “double” eyelid, which occurred by his account in approximately 80% of the population, and sought to emulate and recreate this aesthetic for the minority who did not possess it at birth. He sought to define and enhance a Japanese aesthetic to create natural looking eyes, eyes that look like the patient could have been born that way. One of his before and after photos includes a patient with a natural supratarsal crease (upper eyelid crease) on her left eye, which he successfully recreated with surgery on the right eye.

More than half a century later, an American by the name of Dr. Ralph Millard began his rudimentary attempts at double eyelid surgery while stationed in Korea during the Korean War (1950-53), operating primarily on Korean war brides married to American servicemen, with middling results. While he often did create an upper eyelid crease, judged by the lens of today’s cosmetic surgery standards, the aesthetic would have likely made him the center of a bit of derision. Nevertheless, this marked the seminal moment for Korean surgeons to begin developing their techniques and refining their aesthetics. In 1961, the first university department of plastic surgery in Korea was developed at Yonsei University, and in 1974, the Supreme Court in Korea approved plastic surgery for cosmetic purposes as medical practice.

Fast forward to today, and Korea has enjoyed a reputation for decades of being a world leader in plastic surgery and especially cosmetic plastic surgery. K beauty has come to symbolize the blending of leading technology with the most advanced cosmetic treatments. Part of this rapid rise in plastic surgery mirrors the rapid rise of Korea’s economy, technology and infrastructure coming from the ruins of the Korean war. The combination of work ethic, creativity and innovation have helped to push forward development and progress, with increasingly refined results.

In this globalized climate contemporary plastic surgeons occupy, the sharing of knowledge, techniques and ideas through publications, meetings, and instantaneously through broadband connections, allows us all to push each other to even greater heights.

Although a generalization, most Asians patients seeking rhinoplasty desire some degree of augmentation or projection, while most white, Middle Eastern, or Jewish patients will seek out a more reductive rhinoplasty procedure. During traditional reductive rhinoplasty, the existing width, volume and size of the nose can effectively be reduced by removing and excising the pre-existing cartilage and bone. Commonly a white, Middle Eastern or Jewish patient will seek out reduction of a dorsal hump, or bump on the bridge of the nose, which can be accomplished by removing excess bone and cartilage, followed by fracturing and narrowing the nasal bones. These surgical maneuvers require no additional tissue or support to supplement the nasal anatomy.

In contrast, many Asian patients have a smooth and straight dorsum (nasal bridge) naturally, and the shape of the intrinsic anatomy may be preserved. The nasal pyramid often has a wide appearance from frontal view not due to wide nasal bones, but due to the small overall size and projection of the nasal bones. In other words, the base of the nasal pyramid frequently has an optimal width naturally, and thus does not require frequent fracturing. Rather, Asian patients more commonly benefit from augmenting the projection of the nasal pyramid and dorsum, creating a taller profile but also generating a slimmer appearance from the frontal view by establishing the contours of a well-defined dorsal aesthetic line. In order to augment the nasal bridge or dorsum, more volume is needed.

This volume for dorsal augmentation can potentially come from a variety of sources, including synthetic (alloplastic), natural (autologous) or even from a deceased person (cadaveric). Of all the potential options, tissue from your own body (autologous) has the lowest risk of side effects and complications, and produces the most permanent, natural results when used correctly. In white rhinoplasty, Middle Eastern Rhinoplasty or Jewish rhinoplasty, there typically exists an abundance of cartilage within the nasal septum. This cartilage divides the left and right sides of the nasal cavity, and a portion of this cartilage can be removed to support or reinforce other parts of the nose during rhinoplasty. Surgeons will commonly remove a portion of the septum if it deviated in order to straighten it. For a white, Middle Eastern or Jewish patient’s nose this septal cartilage may be sufficient to reshape the nose. However for most Asian patients the available septal cartilage will be insufficient in both quantity and strength to add appropriate volume or reinforcement to the nose to create the desired aesthetic outcome.

Since we know that tissue from your own body produces the best outcomes in rhinoplasty and nose job surgery, the next question that arises is that of possible sources for this tissue. The nose consists of primarily cartilage, bone and fibrofatty soft tissue underneath the skin envelope, so the best source will emulate the existing anatomy of tissue. Bone could be used, but it would also produce sharp contours, an extremely rigid nose, and come with significant donor site morbidity relative to available sources for cartilage. Cartilage can be harvested from very discrete incisions, most commonly from behind the ear or through a tiny (~1 centimeter) incision hidden in the crease below the right chest. Both these sources provide optimal tissue for grafting inside the nose while leaving no changes to the function or form of the harvest sites.

Undereye bags can result from a number of issues, but one of the most common reasons is the presence of excess orbital fat within the lower eyelid that protrudes or herniates into the cheek. All of us have multiple orbital fat compartments that serve to cushion and lubricate the movement of the eye, but as a result of age or genetics for some of us this lower eyelid fat, which normally resides below the eye and behind the cheek, begins to bulge forward, or pseudoherniate, thus creating a visible eye bag and a tear trough below it.

Protrusion of the eyelid fat will typically accentuate the hollowing that naturally occurs below the eyes and along the cheeks with age, as it creates a convexity above this depressed area below the orbit and eyes. When the amount of fat is minimal but there exists a significant volume deficit or hollowing in the infraorbital area and tear troughs, then adding volume by way of filler injections or fat grafting are viable options that can produce significant improvement. Volume may also be replenished with newer options such as Juvelook or platelet-rich plasma (PRP) and platelet-rich fibrin (PRF).

For patients with a significant amount of lower eyelid fat, the lid-cheek contour can only be fully improved by addressing the lower eyelid fat, either by repositioning or by removal during a lower blepharoplasty surgery. The traditional surgery involved making an incision through the lower eyelid skin (subciliary approach) and orbicularis muscle to expose the orbital fat, with a subsequent removal of various portions of fat, muscle and skin. Some of the marked disadvantages of this approach included a hollow appearance to the lower eyelids with advancing age, lid malposition as involutional volume changes occurred or as cicatricial scarring forces caused the lower eyelid to evert with a resultant ectropian. Even in the best outcomes, a visible scar remained along the lower lash border.

For these factors many contemporary surgeons choose to approach the lower eyelid via a transconjunctival approach (an incision made in the back of the eyelid along the pink conjunctiva, where it is completely hidden) so as to obviate the appearance of a scar. Since the anterior lamella of the eyelid is not violated, this approach has also significantly minimized the risk of eyelid malposition and eyelid retraction post surgery. Another generational paradigm change has been that of volume preservation versus simple excision and removal of fat. Studying the anatomic changes that occur with aging has taught us that we lose fat volume in our face as we age. For this reason most contemporary surgeons have transitioned to repositioning this precious fat volume into an area that needs it, namely the tear trough. By reducing volume in an area with excess, the eyebag, and instead applying it to an area of hollowing, the tear trough, the lid-cheek contour becomes smooth and a youthful appearance is restored.

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The anatomy of the upper eyelid in Asian patients tends to have some differences relative to patients of other ethnicities with regards to a few aspects. One concerns the appearance, depth and height of the upper eyelid crease, or the supratarsal crease. In patients with a distinct crease, there exists a strong connection between the skin and underlying levator aponeurosis as the distal ends of the muscle interdigitate with the dermis of the skin. In these patients, as the levator lifts open the eyelid the skin folds predictably and reliably along this connection to create the appearance of the upper eyelid fold. In traditional upper blepharoplasty these patients as they age will develop an increase in excess skin above the upper eyelid crease, thereby covering the amount of visible pre-tarsal skin. This results in a tired and aged appearance, and also decreases the amount of eyelid to place eye liner and eye shadow.

During traditional blepharoplasty an incision can be made along the crease, excess skin and fat removed, and the skin re-approximated without much consideration for stabilizing or reinforcing the upper eyelid crease. Since the levator aponeurosis has such a strong and adherent connection to the skin, the supratarsal crease will continue undisturbed. For Asian patients, there exists a variable connection between the levator and skin, resulting in a fold that may be well-established and stable, or an upper eyelid fold that may only intermittently be present, or may present at different heights and shapes depending on a patient’s condition. This unpredictability will lead some patients to utilized eyelid tape or eyelid glue to more reliably establish a consistent height and shape to the upper eyelid or “double eyelid”.

Asian patients undergo a similar aging process in terms of developing excess skin and sagging of that excess skin along the upper eyelids, sometimes with the development of pseudoherniation of orbital fat causing fullness in the upper eyelids. In a similar manner then, the eyelid surgery specialist must take into account addressing any excesses in skin and fat to account to optimize symmetry between the two eyes, just as in traditional blepharoplasty. Where the surgery diverges relates to the establishment of the supratarsal crease, upper eyelid crease or “double eyelid” with anchoring sutures placed between the tarsal plate or levator aponeurosis and the dermis of the skin. The size, shape and height of the crease can have dramatic effects on a patient’s appearance, therefore detailed and comprehensive discussion of the desired aesthetic during consultation and prior to surgery is critical to a successful outcome that is pleasing to the patient and surgeon alike.

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Autologous cartilage techniques have exploded in popularity and have become widely adopted by rhinoplasty surgeons throughout the world in the 2000s as the techniques have proven to be the safest and most predictable in achieving permanent results. While initially reserved primarily for reconstructive cases and for complex revision rhinoplasty cases prior to the turn of the current century given the inherently increased difficulty in harvesting and crafting noses from a disparate part of the body, the tide has turned away from the quick and easy use of silicone, Goretex, Medpor and other off the shelf synthetic implants that provide limited downtime but also limited results and a lack of permanence.

Especially for Asian patients, the need for additional structure and support fo the intrinsic architecture of the nose has presented a challenge for rhinoplasty surgeons from the start. The solution for this challenge has been attempted my myriad Asian plastic surgeons and non-Asian plastic surgeons alike, with varying degrees of success but ultimately all failing to achieve ideal results. Materials as varied as jade, wax, and ivory were stuffed inside unfortunate noses in an attempt to augment or build them up. During the Korean war, early plastic surgeons like Ralph Millard tried to apply crude reconstructive techniques to reshape Korean noses in the most rudimentary of ways, with Asian nose job results that could only be objectively described as abject failures by today’s standards. A breakthrough for Asian rhinoplasty came in the 1970s, when silicone implants became widespread and widely adopted as a safe and reliable method, at least for the short term, in achieving dorsal augmentation.

Fast forward a few decades into the 1990s, and plastic surgeons began seeing the untoward effects of placing a foreign body and synthetic object in an area with a fragile blood supply and delicate soft tissue coverage like the nose. Graft visibility, mobility, infection, and even implant extrusion was happening by the droves. Out of the desire to achieve safer, longer-lasting results came the move towards using tissue from a patient’s own body, that would become fully integrated with zero chance of rejection and thus minimizing the risk of complications as much as possible.

When it comes to nonsurgical rhinoplasty, the only filler materials that should be used are hyaluronic acid fillers. Hyaluronic acid fillers are the only type of fillers that are reversible, so in the event of any complication they can be dissolved and reversed before creating permanent injury. The landscape of nonsurgical rhinoplasty and liquid nose job has been made murky by some misguided nurses and doctors, and even rarely by some surgeons, who have promoted injecting permanent and semi-permanent materials in the nose. Materials like acrylic and silicone do not belong in a delicate structure like the nose, yet some have insisted on injecting patients with Artefill, Bellafill and Silikon-1000.

What’s the issue with permanent and semi-permanent injections for nonsurgical nose job? The first relates to the lack of biocompatibility of materials like Bellafill and Silikon 1000 with the soft tissue and skin of the nose. They exist inside the nose as foreign material that will never incorporate into the tissue of the nose, but are hardly inert. At best they will remain as discrete microdroplets within the subcutaneous fat, while more commonly they will cause inflammation with subsequent scarring and fibrosis over time. At worst they will form granulomas and nodular scarring, creating contour irregularities throughout the subcutaneous layer but sometimes extending to the skin surface. To make matters worse, even though Bellafill and SIlikon 1000 can easily be injected in a matter of minutes, it takes extremely meticulous and tedious surgical dissection to excise from the nose.

The second issue relates to the permanence of acrylic and silicone injections in the nose. As a material occupying volume, initially the contours created by Bellafill and Silikon 1000 may actually be quite nice. This improvement is of course short-lived, as the soft tissue of the nose does not remain static but rather is a dynamic, viable part of your body that is constantly replenishing cells and changing in shape and form. The Bellafill and Silikon 1000 then have no chance at maintaining the same position within the nose, and subsequently will never be able to preserve the same shape as when initially injected.

Perhaps the most problematic issue with permanent and semi-permanent nonsurgical rhinoplasty relates to the most catastrophic potential complication with liquid nose job: vascular compromise. Vascular compromise results from either an injection into the vessel, or from compression of the vessel by an injection immediately next to the vessel. This leads to blanching of the skin initially, later with darkening and eventually necrosis and sloughing of the skin. Sound scary? It should, because it is. Should this happen with hyaluronic acid filler, the solution is straightforward. Dissolve the offending filler and restore blood-flow to the nose. What happens in the case of a semi-permanent or permanent filler? SOL.

As a patient the internet, social media and Youtube can be tremendous resources for obtaining information and education regarding virtually any topic. It can also be a double-edged sword as the amount of misinformation matches the reputable sources. When it comes to nonsurgical rhinoplasty, I hope you heed this surgical rhinoplasty specialist’s advice to seek out only rhinoplasty surgeons experienced in nonsurgical rhinoplasty to perform your liquid nose job with hyaluronic acid fillers only.

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Asian rhinoplasty refers to a specialized subset of rhinoplasty surgery used to reshape the nose to enhance the natural beauty in Asian patients. Experts in this focused surgery will have the ability to not only create projection, augmentation and definition to the nose, but to optimize the overall balance of the nose to complement the entire face.

One area that gets frequently overlooked during Asian nose job surgery remains the ala, alar rims and nostrils. Important considerations to determine the best way to comprehensively address the nostrils and alar include evaluation of the patient-specific anatomy as it relates to facial shape and proportions, but perhaps more importantly the patient-specific aesthetic goals. Every patient wants the nostrils and ala to look natural, and not a single patient wants them to look “pinched”, with Michael Jackson’s nose often pointed to as the kind of result that makes patients afraid of alar base reduction, or even rhinoplasty itself more broadly. A well-designed and executed alarplasty will leave no traces of surgery, while a poorly performed one will make it obvious something was done.

The attachment of the ala to the cheeks is referred to as the alar base, and determines the width of the nostrils. As a general guideline, the distance between the eyes (intercanthal distance) should closely approximate the width of the nostrils, assuming a normal distance between the eyes. When evaluating the cause of the width, attention should be directed at the size of the alar base as well as the width of the nasal sill. The level of flaring of the alar rim and nostril will determine the appropriate design of the alarplasty incision, incorporating the alar base alone (Weir incision), the nasal sill alone, or a combination of both. Some rhinoplasty surgeons mistakenly design the incision above the alar-facial groove instead of within the groove in a misguided attempt to preserve this natural crease, fearing that incisions designed within the crease will blunt it. In fact, with proper closure of the incision the resultant scar will hide within the preserved crease, becoming almost invisible once fully healed. Incisions designed above the alar-facial groove, on the other hand, will leave a scar that will always remain visible.

In addition to the width of the nostrils, the shape and degree of flare of the alar rims determine the overall appearance of the lower third of the nose when viewed from the front. When excess flare is present, the surgeon must carefully assess the contribution of the skin and lower lateral cartilages as well. In patients with thin skin and neutral to concave lower lateral cartilages, alarplasty alone will be extremely effective at reducing the width and flare of the nostrils in a manner that results in a natural and refined appearance. However, in patients with thick skin and convex lower lateral cartilage alarplasty alone without rhinoplasty may result in the tip of the nose and infratip appearing bulbous and even wider than before surgery.