Cosmetic Surgery Tourism: A Tummy Tuck in Thailand, a Breast Augmentation in Brazil
By Charis Atlas Heelan
[In the spirit of bringing you reports on vacations that can only be described as "alternative," we give you this piece. Please note, we are not medical professionals and can in no way vouch for the doctors reported herein.]
You normally wouldn't pair "surgery" and "vacation" together, but a growing trend marries the two.
Although cosmetic surgery travel is increasingly popular for a number of reasons, the overriding issue is cost. In the United States, cosmetic and dental surgery are cost-prohibitive; in a number of other countries, predominantly in South America and Asia, prices are considerably lower.
Discretion is also a factor: It's easier to say, "I'm taking a two-week trip to Brazil" than letting everyone know you want implants. Additionally most Americans simply don't have the extra time, so it makes sense to use those available vacation days.
On the higher end of the cosmetic tourism scale is Surgeon and Safari (tel. + 27/11463-3154; www.surgeon-and-safari.co.za ). They describe their service as "surgery, recuperation and rejuvenation away from public scrutiny;" and where better, than on an adventurous safari in South Africa? Their options include dental, ophthalmic, orthopedic, infertility treatment, hair transplants and cosmetic procedures. (Their general inquiry form with drop down menus is like ordering an operation and expecting them to ask if you'd like fries with that!) Choose your procedure, your surgeon, your accommodation, flights and safari options all on one page -- I'll take a business class flight, guest house accommodation, a wilderness safari, Dr. Rick Van Der Poel in Johannesburg and liposuction please! Prices aren't listed on this site (as they are on many others) but expect to pay a fraction of what these procedures would cost in the States or in Europe -- a facelift in South Africa is approximately $4,500 compared with around $10,000 in the US. Guests can choose to recuperate in a luxury hotel in Cape Town or Johannesburg or take a variety of different safaris as part of a one-off package price. You can even arrange for a pre-operative consultation in London to meet your surgeon and discuss any concerns.
Brazil is famous for its stunning women and by admission, many get a helping hand, so it is only natural that it is home to a number of cosmetic surgery clinics marketing themselves to foreigners.
Cosmetic Vacations (tel. 877-627-2556; www.cosmeticvacations.com ) only uses surgeons licensed by the Brazilian Society of Plastic Surgery and they work in conjunction with the Fluminense Clinic, which has visiting plastic surgeons from all over the world. More importantly, the Clinic's owner Dr. Ronaldo Pontes and his daughter, Dr. Giselle Pontes, are members of the International Society of Aesthetic and Plastic Surgery. You can sign up for their e-mail newsletter and even enter a competition to win a free trip to Rio de Janeiro. Cosmetic vacation works with a specialist Brazil travel agent Must Travel (tel. 954/788-4332) and will arrange your accommodation (four hotels to choose from), airport transfers and pre-operative consultation. Their website also features links to Rio's tourism attractions and tourism information sites.
Get the best of both worlds by indulging in a cosmetic enhancement vacation with the safety of an ASPA registered surgeon. The Half Moon Club (tel. 866/648-6951; www.halfmoon-resort.com) in Montego Bay, Jamaica hosts aesthetic surgery vacations and medi spa weekends with New York City plastic surgeon Z. Paul Lorenc (tel. 212/472 2900; www.lorenc.com/wn_half-moon-club.php?area=43) in its on-site state-of-the art hospital, MoBay Hope Medical Center. The rates may be the same as they would be in Manhattan, but you get the benefits of the idyllic resort destination and the vacation feel. The Club has hosted several of these successful weekends, and apart from Botox, you can also get an eyelift and liposuction, recovering in tropical luxury.
Costa Rica is known for its natural beauty, and now increasingly, its medical and dental services. The Health Escape (www.healthcostarica.com) is another company offering its cosmetic and dental procedures predominantly to foreigners. A team of doctors, largely trained in the US and Central America perform a number of procedures as significantly lower prices that you would pay at home. Post-operatively, you will stay at the Las Cumbres Inn, a surgical retreat located 15 minutes outside San Jos¿, offering a private and intimate way to recover from plastic surgery, cosmetic dentistry, and eye surgery. All surgical procedure packages include transfers, accommodation, meals and post-operative care. Contact info@healthcostarica.com for pricing and further information about procedures.
If it's just buttocks or breasts you are after, Venezuela may be your destination. The Caribbean International Plastic Surgery Centre (tel. + 58/295/267-2955; www.internationalsurgery.com) specializes in implants and augmentation for these two areas, but will also throw in additional procedures at discounted and "package deal" rates. It lists prices like Buttocks Augmentation (their signature procedure) starting from $6,600, Breast Augmentation from $3,500, Abdominoplasty (tummy tuck) from $3,000 to $4,800 (obviously depending on the size of your tummy), Rhinoplasty (nose jobs) from $2,500 to $3,000, Rhitidectomy (face lifts) from $3,500 to 5,000, Liposuction from $2,500 to $3500, Reduction Mammoplasty (Breast reduction) from $3800 and even Intimate Feminine Corrections (I won't put in all the details here, this is a family website) from $1,500 to $2,000.
When visiting for buttocks augmentation as your main surgery, any of the above procedures that are compatible will have a 20% discount. They also offer special packages involving up to three compatible procedures. The center will assist you with accommodations, travel information and post-operative care.
Asia represents the cheapest cosmetic surgery solutions and countries such as Thailand have thriving aesthetic industries, dominated by its gender reassignment procedures. Cosmetic Surgery Travel (www.cosmeticsurgerytravel.com) is a travel company dedicated to planning your cosmetic or dental surgery vacation in Thailand and can arrange every aspect of your trip. They also facilitate orthopedic, cardiac and gastric bypass surgery, featuring an extensive menu of possibilities for those considering going under the knife. You make your surgery and travel plans with your own personal assistant, called a medical concierge. They develop a program and an estimated cost for everything plus arrange a pre-departure consultation with your doctor. Upon arrival at the airport in Bangkok you are greeted by a company representative, and your entire stay in Thailand is managed including post-surgery recovery and rejuvenation, based on your doctor's recommendations and your preferences. They feature five "packages," for example the "Tummy Tuck Package" which includes general anesthetic, cosmetic procedure, two to three-day hospital stay, six to12-day hotel or resort recovery and all transfers for $7,300. Or how about the "Eyelids lift with Under Chin Liposuction Package" which includes general anesthetic, cosmetic procedure, one-day hospital stay, three-day hotel or resort recovery and all transfers for $3,800. Airfares to Bangkok are additional.
The St. Carlos Cosmetic Surgery Clinic (tel. + 662/975-6700; www.stcarlos.com/en/carlos_medical_spa/cosmetic.asp) located in Thailand is alternative that offers everything from cosmetic procedures to non-invasive holistic healing and spa services. Business is booming with the Center now boasting five clinics, two hospitals and the main center in the Bangkok area. The standard procedures are all offered, mammoplasty, rhinoplasty, face lifts, eye lifts and hair transplants, but alternative treatments are also available like weight loss programs. Accommodation starts at $86 per night in a deluxe room or $288 in a suite -- cheaper than any hospital bed in this country. Even meals prices are offered ranging from $8 to $12 for full meal room service. Procedure prices are provided on application.
Cosmetic Surgery Philippines (tel. 632/374-6092; www.cosmeticsurgeryphil.com/beauty_travel.htm) is a clinic located in Quezon City, Philippines. Its surgeon, with the ironic name of Dr. Lasa, is the only Filipino plastic surgeon ever accepted for advanced fellowship training by the Foundation for Education in Aesthetic Plastic Surgery, at the Institute of Aesthetic Plastic Surgery in Atlanta, Georgia. Although not ASPS registered, he does have significant US training. You name it, Dr. Lasa does it, and all at super low prices. He even offers you the option of getting the budget implants made in China rather than the more expensive European versions. Some examples of pricing include:
-Breast Augmentation (China-made implants): $2,000
-Face and Necklift: $2,700
-Liposuction (one area): $800
-Reduction Rhinoplasty: $2,200
-Tummy Tuck (abdominoplasty): $3,300
The "package" prices include operating room expenses in our outpatient surgery facility, all medications, cost of surgical implants (if any), the professional fee of plastic surgeon and the professional fee of anesthesiologist for major operations.
To help ensure optimal results and to limit risks and complications, consider the following before deciding to have cosmetic surgery in a foreign country: Do your research. You need to research the procedure, its benefits, risks and possible complications. You also need to research the clinic you choose, its surgeons and the country's certification laws. Most surgeons will be board certified in their own country, but requirements may not be as stringent as those in the US or Europe. Ideally you would want to find a surgeon who is American Board of Plastic Surgery (ASPS) or International Society of Aesthetic and Plastic Surgery (ISAPS) certified. Try www.plastic surgery.org for information on plastic surgery procedures plus referrals to international ASPS Member Surgeons. Make sure you know all the costs up front, what the expected recovery time is and when you will be able to fly home. Ask to speak with former patients for referral and don't be afraid to ask questions -- surgery is serious business and you don't want to enter into any decisions lightly.
Friday, May 9, 2008
Face Lift (Rhytidectomy)
The Goal of every face lift surgeon is to give every patient happy after surgery. The quest is for maximal results with a minimum of risk.
Before surgery you should come to NEO PSC. for preoperative consultation since thoughtful and honest preoperative approach that is realistic will avoid future misunderstanding and disappointment.
The gains may be remarkable but there are definitive limitations and risks. Rhytidectomy is a surgical procedure that remove excess skin to eliminate skin sag. It does little to improve fine lines which is often treated by another nonsurgical method.
You may be a good candidate if you consist one or more of the followings.
1.forehead and brow ptosis , feel heavy or hanging upper eyelids
2.sagging cheek
3.jowls, absent lower jaw contour
4.deep nasolabial fold
5.neck skin laxity, " turkey gobbler fold "
Face lift surgery can be divided into three parts according to facial area
1.The upper component consist of the temporal , forehead and brow
2.The middle consists of the cheeks and jowls
3.The lower third consists of the neck and submental area
4.Each section of the face need separate evaluation and different procedure.
How should you prepare yourself before surgery ?
At the time of consultation if you wish to proceed with this kind of surgery you must bear in mind all of these facts.
1.sun damaged actinic skin does not heal well as normal skin.
2.smoker have a much greater tendency for skin death compare to nonsmoker . Basically you
should halt smoking at least two weeks prior to your facelift schedule day.
3.excessive bleeding usually occur for the poor controlled hypertensive patient.
4.underlying serious medical disease such as diabetes mellitus, severe anemia etc.. may jeopardize your capacity of wound healing.
How do I perform the face lift ?
For single area of the face lift surgery ( either upper, middle or lower ) I prefer to have it done at the NEO PSC. under local anesthesia with preoperative heavy oral sedation with the free standing ambulatory basis.
With regards to more comprehensive full face lift I advice you to have it performed in the hospital under the general anesthesia or standby intravenous or twilight anesthesia.
Through the entire procedure at the hospital, the anesthesiologist will monitor your vital parameters as his routein.
Each side of your face will be infiltrated with 2% lidocaine with 1 : 1000 adrenaline 50 cc diluted with normal saline 50 cc. or more depending which type of anesthesia being used.
The incision
For the upper third lift, I will place the upward curve incision from the root of your ear staying about 3 cm . behind the temporal hairline.
The length of this incision vary from 7 - 10 cms. For the midface lift, The incision is made in the preauricular crease extending downward sweeping around the earlobe .
For the lower third , the incision is continued upward on the back of the ear to the point at which the top of your ear overlies the postauricular hairline then turns posteriorly following the posterior hairline.
The facial dissection
There are many varieties how the facial skin and soft tissue structure is raised. My personal technic is creation of two planes of dissection ; the skin and the SMAS. ( submusculocutaneous aponeurotic system ) plane.
SMAS lift is mandatory to uplift the underneath structure laxity and also serves as the good foundation for the final tightened skin to rest upon.
After the SMAS is pulled and the excess removed I will add the extra special suspending nonabsorbable sutures which will anchor the SMAS to the more stabilized structures in the upward and backward directions
Then the bleeding is checked , skin is draped and the excess is resected following the previous incisional line. Meticulous skin suturing gives rise to unsightly final scar outcome. I use the stapler to close the hair baring skin.
Finally I will apply nonadhesive dressing with few layers of fluff gauze and light pressure wrap around elastic bandage over all the operative areas.
Post operative recovery and care
If the vaccuum drain is used, I will discard it on the next 24 hours.
At Day 3, I will remove all the dressing. You may shampoo your hair, wash your face and dry the surgical wound. Please paste the antibiotic ointment over the wound. I usually instruct all the patients to let the wound air dried ( exposure technic ) except in some particular reason.
At Day 5, all the skin sutures are removed.
At Dat 8-10 withdraw the stapler Swelling, bruising and temporary numbness are usually expected for the face lift, however severe pain is uncommomly anticipated. The swelling may last for few weeks post op. and it gradually subside afterwards.
Understanding risk
Face lift complication is greately reduced by the well trained plastic surgeon. Any attempt to reach perfection must be tempered by conservatism. Some of the potential complications are,
1.blood collection
2.skin necrosis
3.infection
4.facial nerve paralysis
5.sigthly scar
6.earlobe malposition
article by: http://thailandplasticsurgery.com/en/m_face.php
Before surgery you should come to NEO PSC. for preoperative consultation since thoughtful and honest preoperative approach that is realistic will avoid future misunderstanding and disappointment.
The gains may be remarkable but there are definitive limitations and risks. Rhytidectomy is a surgical procedure that remove excess skin to eliminate skin sag. It does little to improve fine lines which is often treated by another nonsurgical method.
You may be a good candidate if you consist one or more of the followings.
1.forehead and brow ptosis , feel heavy or hanging upper eyelids
2.sagging cheek
3.jowls, absent lower jaw contour
4.deep nasolabial fold
5.neck skin laxity, " turkey gobbler fold "
Face lift surgery can be divided into three parts according to facial area
1.The upper component consist of the temporal , forehead and brow
2.The middle consists of the cheeks and jowls
3.The lower third consists of the neck and submental area
4.Each section of the face need separate evaluation and different procedure.
How should you prepare yourself before surgery ?
At the time of consultation if you wish to proceed with this kind of surgery you must bear in mind all of these facts.
1.sun damaged actinic skin does not heal well as normal skin.
2.smoker have a much greater tendency for skin death compare to nonsmoker . Basically you
should halt smoking at least two weeks prior to your facelift schedule day.
3.excessive bleeding usually occur for the poor controlled hypertensive patient.
4.underlying serious medical disease such as diabetes mellitus, severe anemia etc.. may jeopardize your capacity of wound healing.
How do I perform the face lift ?
For single area of the face lift surgery ( either upper, middle or lower ) I prefer to have it done at the NEO PSC. under local anesthesia with preoperative heavy oral sedation with the free standing ambulatory basis.
With regards to more comprehensive full face lift I advice you to have it performed in the hospital under the general anesthesia or standby intravenous or twilight anesthesia.
Through the entire procedure at the hospital, the anesthesiologist will monitor your vital parameters as his routein.
Each side of your face will be infiltrated with 2% lidocaine with 1 : 1000 adrenaline 50 cc diluted with normal saline 50 cc. or more depending which type of anesthesia being used.
The incision
For the upper third lift, I will place the upward curve incision from the root of your ear staying about 3 cm . behind the temporal hairline.
The length of this incision vary from 7 - 10 cms. For the midface lift, The incision is made in the preauricular crease extending downward sweeping around the earlobe .
For the lower third , the incision is continued upward on the back of the ear to the point at which the top of your ear overlies the postauricular hairline then turns posteriorly following the posterior hairline.
The facial dissection
There are many varieties how the facial skin and soft tissue structure is raised. My personal technic is creation of two planes of dissection ; the skin and the SMAS. ( submusculocutaneous aponeurotic system ) plane.
SMAS lift is mandatory to uplift the underneath structure laxity and also serves as the good foundation for the final tightened skin to rest upon.
After the SMAS is pulled and the excess removed I will add the extra special suspending nonabsorbable sutures which will anchor the SMAS to the more stabilized structures in the upward and backward directions
Then the bleeding is checked , skin is draped and the excess is resected following the previous incisional line. Meticulous skin suturing gives rise to unsightly final scar outcome. I use the stapler to close the hair baring skin.
Finally I will apply nonadhesive dressing with few layers of fluff gauze and light pressure wrap around elastic bandage over all the operative areas.
Post operative recovery and care
If the vaccuum drain is used, I will discard it on the next 24 hours.
At Day 3, I will remove all the dressing. You may shampoo your hair, wash your face and dry the surgical wound. Please paste the antibiotic ointment over the wound. I usually instruct all the patients to let the wound air dried ( exposure technic ) except in some particular reason.
At Day 5, all the skin sutures are removed.
At Dat 8-10 withdraw the stapler Swelling, bruising and temporary numbness are usually expected for the face lift, however severe pain is uncommomly anticipated. The swelling may last for few weeks post op. and it gradually subside afterwards.
Understanding risk
Face lift complication is greately reduced by the well trained plastic surgeon. Any attempt to reach perfection must be tempered by conservatism. Some of the potential complications are,
1.blood collection
2.skin necrosis
3.infection
4.facial nerve paralysis
5.sigthly scar
6.earlobe malposition
article by: http://thailandplasticsurgery.com/en/m_face.php
Wednesday, April 30, 2008
Eyelids Asian blepharoplasty
Asian blepharoplasty, commonly termed double-eyelid surgery, refers to surgery designed to place a pretarsal crease in Asian eyes that are absent a fold. Patients typically desire to look more bright-eyed and want to make applying eyeliner easier. Patients also seek to remove the puffy and tired look associated with a fatty upper lid. In current American society, Asian patients almost never seek to westernize their appearance, and surgeons should be wary of modifying a patient's ethnic appearance, even in the rare case when it is requested.
Problem
Asian patients with a puffy upper lid and an absent crease may dislike such an appearance. The patient may report difficulty applying eyeliner because of the overhanging fat and may wish to have a crease similar in appearance to Asian friends who were born with such a crease. Patients generally do not want to change their ethnic appearance.
Frequency
Approximately 50% of people of Pacific Asian descent (eg, Korean, Japanese, Chinese) have a pretarsal crease.
Etiology
Traditional theory states that the pretarsal fold represents the insertion of the levator aponeurosis expansion into the dermis. Presumably, Asians have a lower insertion point than white persons, leading to smaller or absent folds. An alternative theory is that the fold corresponds to the level of the septoaponeurotic sling. Lower height of the sling in Asians allows the fat to sit lower in the eyelid, leading to a smaller fold.
Pathophysiology
Traditional approaches to placing a pretarsal crease involve suturing the dermis to the levator expansion at the appropriate height. Alternative approaches attempt to create a septoaponeurotic sling at the desired lid height.
Clinical
Most commonly, the patient for this procedure is female and presents in mid adolescence with her mother or is female and is in her early 20s. Male patients, seen occasionally, tend to be slightly older, aged in the late 20s to early 30s. Female patients may report difficulty applying eyeliner. Not infrequently, females may apply cellophane tape to create a fold as part of the daily makeup ritual; the patient desires surgery to spare herself this inconvenience.
Occasionally, an older patient presents to report problems related to the aging upper eyelid and/or periorbital area. The patient may have had prior pretarsal crease placement.
Surgeons should consider the maturity of patients when they request such surgery. Occasionally, a mother brings a young teenaged daughter in for surgery. Patients should be mature enough to participate in oral or intravenous sedation for surgery and should understand and accept the risk of complications.
In Asians with a fold, the height of the normal lid fold lies 8-10 mm from the lash line with the skin gently stretched. Nasally, it begins close to the lash line and then reaches a maximum height at mid pupil. It stays at this height, extending to the orbital rim laterally. In contrast, folds in non-Asians tend to be larger and have less orbitopalpebral fat.
The primary difference between the non-Asian versus Asian eyelids is that the prelevator fat lies in a more inferior level; ie, the septo-aponeurotic sling hangs lower. In non-Asians, the supratarsal fold marks the inferior limit of the prelevator fat. This inferior limit is also the point at which the levator aponeurosis attaches to the dermis, creating an upper lid crease. In the Asian eyelid, this dermal attachment rests lower, resulting in a smaller crease, or it does not attach to the skin at all, resulting in an absent fold.
The surgical strategy for creating an Asian eyelid fold is either to recreate the dermal attachment of the levator aponeurosis or to prevent the fat from descending below the desired eyelid fold height. The nonincision suture method of eyelid surgery creates the fold by recreating this dermal attachment using nonabsorbable sutures. The incisional method of Asian eyelid surgery recreates the fold by removing the inferior portion of the prelevator fat and sealing off this area. A hybrid version, the semi-open method, combines aspects of both techniques by using buried nylon sutures to recreate the fold but also removing a portion of the prelevator fat through a small incision. The incisional method and semi-open method are described in Surgical therapy. In any case, the surgeon should not remove too much fat from the Asian eye because this results in a westernized appearance, which should be avoided.
The nasal area of the fold bears a variable relationship to the medial epicanthus. A fold may begin on the undersurface of the epicanthal fold or on the visible outer surface. These are referred to as an "inside" fold or an "outside" fold, respectively. When the fold is set relatively high, the crease usually folds on the outside.
The medial epicanthal fold can be variable in configuration. The Flowers classification is based on the how much of the caruncle is visible. In type I, the caruncle is visible and resembles a white person's anatomy. In type II, the caruncle is partially obstructed, while in type III, the fold is prominent and has an inversus component. Type IV resembles type I, except that the medial epicanthal fold is thick. A medial epicanthoplasty is recommended for patients with type III or IV and is optional for patients with type II.
Consider the maturity level of the patient, especially if he or she is young. At age 15-16 years, many teenagers do not have adequate coping mechanisms for potential complications. For these patients, consider the simplest and least morbid procedure.
Surgical Therapy
The 2 general categories of repair include the open method and the suture method. The suture method is preferable for patients with thin skin or Asian eyelids so thin that they fold spontaneously on an intermittent basis. If the patient has some excess fat, this fat can be removed through a small stab incision. The fat in the central portion of the eyelid should be preserved, but the portion near the lateral orbital rim can be removed to yield better definition. The open technique is preferred for patients with thicker skin, thick pretarsal orbicularis muscle, or excess skin, or for those for which permanence is a premium. Both techniques are described in Intraoperative details.
Preoperative Details
Consider upper eyelid position in conjunction with the forehead. The visible amount of pretarsal skin on straightforward gaze depends on the degree of brow ptosis and upper lid skin redundancy. Even young patients may have a congenitally low brow position, as evidenced by frontalis strain. Set the lid height higher in these patients.
For a natural looking fold, the ideal amount of pretarsal show with the eyes open and at straight gaze is 2-3 mm. The rest of the pretarsal skin should be hidden behind the overhanging upper lid skin. This height is usually obtained by creating an incision at 7-10 mm above the lash line at the mid pupil with the skin slightly stretched (see Image 1). This measurement corresponds to the tarsal height. Although this is a general guideline, a patient with brow ptosis should have the incision set slightly higher because the brow drops in the postoperative period, decreasing the amount of pretarsal show. On the other hand, patients who are slightly exophthalmic should have the crease set slightly lower, closer to 6 or 7 mm.
Most patients have some degree of brow asymmetry, with 80% of patients having a right brow lower than the left. This asymmetry should be compensated for by setting the crease slightly higher or removing slightly more skin from the lower eyebrow. Failure to compensate for the asymmetric brow is one of the frequent causes for crease asymmetry.
Although much discussion has been made about the different shapes of the crease fold, a natural crease will present itself when a key point has been placed just medial to the pupil, roughly corresponding to the medial edge of the tarsal plate. As the patient opens his or her eyelid, a fold will present itself medial and lateral to this key point. The crease can then be carefully marked out.
The medial epicanthal area should be addressed in discussion with the patient. If the patient has no preference, the author generally prefers to avoid a medial epicanthoplasty unless the patient is of the Flowers type III or IV. As for placing the fold on the inside or outside of the epicanthus, this author prefers a very small outside fold. This can be hard to control, but in general, the larger the fold at mid pupil, the more likely it is to fold on the outside. A very small fold usually folds on the inside. The patient often makes his or her preference clear on this matter, which of course influences the size of the fold the surgeon needs to create in order to accomplish the desired result.
Problem
Asian patients with a puffy upper lid and an absent crease may dislike such an appearance. The patient may report difficulty applying eyeliner because of the overhanging fat and may wish to have a crease similar in appearance to Asian friends who were born with such a crease. Patients generally do not want to change their ethnic appearance.
Frequency
Approximately 50% of people of Pacific Asian descent (eg, Korean, Japanese, Chinese) have a pretarsal crease.
Etiology
Traditional theory states that the pretarsal fold represents the insertion of the levator aponeurosis expansion into the dermis. Presumably, Asians have a lower insertion point than white persons, leading to smaller or absent folds. An alternative theory is that the fold corresponds to the level of the septoaponeurotic sling. Lower height of the sling in Asians allows the fat to sit lower in the eyelid, leading to a smaller fold.
Pathophysiology
Traditional approaches to placing a pretarsal crease involve suturing the dermis to the levator expansion at the appropriate height. Alternative approaches attempt to create a septoaponeurotic sling at the desired lid height.
Clinical
Most commonly, the patient for this procedure is female and presents in mid adolescence with her mother or is female and is in her early 20s. Male patients, seen occasionally, tend to be slightly older, aged in the late 20s to early 30s. Female patients may report difficulty applying eyeliner. Not infrequently, females may apply cellophane tape to create a fold as part of the daily makeup ritual; the patient desires surgery to spare herself this inconvenience.
Occasionally, an older patient presents to report problems related to the aging upper eyelid and/or periorbital area. The patient may have had prior pretarsal crease placement.
Surgeons should consider the maturity of patients when they request such surgery. Occasionally, a mother brings a young teenaged daughter in for surgery. Patients should be mature enough to participate in oral or intravenous sedation for surgery and should understand and accept the risk of complications.
In Asians with a fold, the height of the normal lid fold lies 8-10 mm from the lash line with the skin gently stretched. Nasally, it begins close to the lash line and then reaches a maximum height at mid pupil. It stays at this height, extending to the orbital rim laterally. In contrast, folds in non-Asians tend to be larger and have less orbitopalpebral fat.
The primary difference between the non-Asian versus Asian eyelids is that the prelevator fat lies in a more inferior level; ie, the septo-aponeurotic sling hangs lower. In non-Asians, the supratarsal fold marks the inferior limit of the prelevator fat. This inferior limit is also the point at which the levator aponeurosis attaches to the dermis, creating an upper lid crease. In the Asian eyelid, this dermal attachment rests lower, resulting in a smaller crease, or it does not attach to the skin at all, resulting in an absent fold.
The surgical strategy for creating an Asian eyelid fold is either to recreate the dermal attachment of the levator aponeurosis or to prevent the fat from descending below the desired eyelid fold height. The nonincision suture method of eyelid surgery creates the fold by recreating this dermal attachment using nonabsorbable sutures. The incisional method of Asian eyelid surgery recreates the fold by removing the inferior portion of the prelevator fat and sealing off this area. A hybrid version, the semi-open method, combines aspects of both techniques by using buried nylon sutures to recreate the fold but also removing a portion of the prelevator fat through a small incision. The incisional method and semi-open method are described in Surgical therapy. In any case, the surgeon should not remove too much fat from the Asian eye because this results in a westernized appearance, which should be avoided.
The nasal area of the fold bears a variable relationship to the medial epicanthus. A fold may begin on the undersurface of the epicanthal fold or on the visible outer surface. These are referred to as an "inside" fold or an "outside" fold, respectively. When the fold is set relatively high, the crease usually folds on the outside.
The medial epicanthal fold can be variable in configuration. The Flowers classification is based on the how much of the caruncle is visible. In type I, the caruncle is visible and resembles a white person's anatomy. In type II, the caruncle is partially obstructed, while in type III, the fold is prominent and has an inversus component. Type IV resembles type I, except that the medial epicanthal fold is thick. A medial epicanthoplasty is recommended for patients with type III or IV and is optional for patients with type II.
Consider the maturity level of the patient, especially if he or she is young. At age 15-16 years, many teenagers do not have adequate coping mechanisms for potential complications. For these patients, consider the simplest and least morbid procedure.
Surgical Therapy
The 2 general categories of repair include the open method and the suture method. The suture method is preferable for patients with thin skin or Asian eyelids so thin that they fold spontaneously on an intermittent basis. If the patient has some excess fat, this fat can be removed through a small stab incision. The fat in the central portion of the eyelid should be preserved, but the portion near the lateral orbital rim can be removed to yield better definition. The open technique is preferred for patients with thicker skin, thick pretarsal orbicularis muscle, or excess skin, or for those for which permanence is a premium. Both techniques are described in Intraoperative details.
Preoperative Details
Consider upper eyelid position in conjunction with the forehead. The visible amount of pretarsal skin on straightforward gaze depends on the degree of brow ptosis and upper lid skin redundancy. Even young patients may have a congenitally low brow position, as evidenced by frontalis strain. Set the lid height higher in these patients.
For a natural looking fold, the ideal amount of pretarsal show with the eyes open and at straight gaze is 2-3 mm. The rest of the pretarsal skin should be hidden behind the overhanging upper lid skin. This height is usually obtained by creating an incision at 7-10 mm above the lash line at the mid pupil with the skin slightly stretched (see Image 1). This measurement corresponds to the tarsal height. Although this is a general guideline, a patient with brow ptosis should have the incision set slightly higher because the brow drops in the postoperative period, decreasing the amount of pretarsal show. On the other hand, patients who are slightly exophthalmic should have the crease set slightly lower, closer to 6 or 7 mm.
Most patients have some degree of brow asymmetry, with 80% of patients having a right brow lower than the left. This asymmetry should be compensated for by setting the crease slightly higher or removing slightly more skin from the lower eyebrow. Failure to compensate for the asymmetric brow is one of the frequent causes for crease asymmetry.
Although much discussion has been made about the different shapes of the crease fold, a natural crease will present itself when a key point has been placed just medial to the pupil, roughly corresponding to the medial edge of the tarsal plate. As the patient opens his or her eyelid, a fold will present itself medial and lateral to this key point. The crease can then be carefully marked out.
The medial epicanthal area should be addressed in discussion with the patient. If the patient has no preference, the author generally prefers to avoid a medial epicanthoplasty unless the patient is of the Flowers type III or IV. As for placing the fold on the inside or outside of the epicanthus, this author prefers a very small outside fold. This can be hard to control, but in general, the larger the fold at mid pupil, the more likely it is to fold on the outside. A very small fold usually folds on the inside. The patient often makes his or her preference clear on this matter, which of course influences the size of the fold the surgeon needs to create in order to accomplish the desired result.
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