Hong Kai Lim, BA, MB BChir¹ _Contact

¹Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK.

Conflicts of Interest and Source of Funding: The author has no financial or conflicts of interest to disclose. No funding was sought or received for this work.

Abstract

Asian blepharoplasty is a well-established and popular surgical procedure among individuals of East Asian descent, primarily concerned with creating a well-defined upper eyelid crease. The academic literature on this procedure has been mainly dedicated to surgical techniques and anatomical considerations. However, the popularity of this procedure that purports to modify race-typical features among Asians has generated debates on its wider social implications. This review discusses the anatomy of the Asian upper eyelid as well as ethnocultural and ethical implications of the Asian blepharoplasty.

Introduction

Asian blepharoplasty, also known as double eyelid surgery, typically refers to surgical procedures primarily concerned with creating a well-defined upper eyelid crease or supra-palpebral fold (SPF) (1). These procedures are commonly performed in individuals of East Asian descent such as those from Korea, Japan, and China, in whom the SPF is frequently absent, in contrast with Caucasians (1). Asian blepharoplasty is increasingly accessible and is the most popular cosmetic surgery in East Asia (2), particularly among women, with Japan contributing over 150,000 cosmetic eyelid surgeries in 2019, the highest number of these procedures performed worldwide (3). The academic literature on the Asian blepharoplasty has largely focused on technical surgical considerations. This review discusses the unique anatomy of the Asian upper eyelid, the ethnocultural motivations underpinning the decision to undergo Asian blepharoplasty, and ethical issues surrounding the alteration of characteristic racial features that the surgery potentially offers.

Anatomy of the Asian Upper Eyelid

The SPF is an invagination of the eyelid skin along the superior tarsal border. It occurs when the skin-orbicularis over the pre-septal region rolls over passively as a lid fold when the posteriorly located levator muscle and Muller’s muscle glide up against pre-aponeurotic fat on eyelid elevation (4).

Asian upper eyelids demonstrate significant differences compared to Caucasians: low tarsal height, abundant pre-septal fat, thicker orbicularis oculi, fewer levator aponeurosis fibres terminating along the superior tarsal border, medial epicanthal folds, and the resulting absence of an SPF – the so-called single eyelid found in at least 50% of Asians (2). This can give the appearance of puffy eyelids and pseudoptosis (5). Asian blepharoplasty aims to address this by creating an SPF using diverse techniques that can be broadly classified into external incisional techniques and non-incisional or suture ligation techniques (5).

Ethnocultural Motivations

Critics argue that the popularity of Asian blepharoplasty stems from pathologisation of non-Caucasian features in cosmetic surgery (6), in reference to Western norms and claims of objectivity derived from the so-called golden proportion of Greco-Roman ideals (7). The motivation of Asian women within Western communities who sought these procedures has been reported to be partly derived from a desire to conform to mainstream appearances and associations between distinctively Asian features and negative physical or personality traits, with this inferior branding being additionally adopted in their countries of origin (8). However, others report the desire for the more expressive, energetic appearance thought to be conveyed by a SPF predates Western influences (9). Furthermore, there is a tendency for Asian women to avoid noticeably obvious alterations, often defined as an unnatural Western appearance that surgeons may not necessarily aim for, as demonstrated in 1896 by Japanese surgeon Mikamo through his double eyelid technique, who reportedly sought to eliminate the look of a traditional Japanese woman to reflect the newly emancipated feminine beauty (10). Thus, cosmetic alteration of Asian features might be reconciled with Oriental beauty standards.

The perceived socioeconomic and interpersonal value of cosmetic surgery is also a strong motivator for women to undergo Asian blepharoplasty. Gendered constructions of cosmetic surgery are prominent in Korea, including ‘marriage cosmetic surgery’ and ‘employment cosmetic surgery’ which describe the ‘right face’ to improve marriage and economic prospects, respectively (11). This has led to the willingness of some Asian families to fund their children’s cosmetic surgery for its perceived value as a social credential (12). Therefore, seeking blepharoplasty may be seen as a relational endeavour or a means to improve social standing as part of a larger neoliberal community (12).

Ethical Implications

Asian blepharoplasty is argued to establish the notion that the Asian eyelid is akin to an abnormality warranting correction, in comparison to supposed Western ideals (6). This misconception can perpetuate negative stereotypes and racial norms of appearance that already marginalise Asian minority groups in Western societies (8). It can be seen as from of racial oppression justified by supposedly scientific appearance evaluations (6). Furthermore, the pathologisation of racial features to legitimise specialist surgery can be regarded as ethically problematic by generating incentives to discover or create new problems, stemming from surgeons wanting to distinguish themselves from their competitors (6). The practice may increase anxieties that patients might have with their appearance, directly contradicting the traditional goals of medicine (13).

Asian blepharoplasty is inherently linked to gendered discourses as the uptake is disproportionately higher among women than men (11). Due to many complex socio-cultural factors, throughout history women have been subjected to practices purported to improve physical attractiveness (6). In cosmetic surgery, this is often framed as medical advice of significant authority. Critics argue that this displaces women’s control over their appearance and affirms the notion that expertise in this regard lies with medical professionals (6), which conflicts with modern patient-centred care. Furthermore, the socioeconomic utility of Asian blepharoplasty has been questioned. Its popularisation does not guarantee equitable access to the improvements in beauty that it supposedly offers as the surgery is often unfunded under universal healthcare systems and most women may not be able to afford it privately (14). Thus, Asian cosmetic surgery as a means of empowerment may not address the institutionalised social structures that motivate women to conform to particular beauty standards that cause distress (8).

Future Directions

Asian blepharoplasty is a well-established surgery and its popularity suggests that it will continue to be an important component of the oculoplastic surgeon’s operative toolbox.  A key debate on ethnocultural attitudes towards Asian blepharoplasty continues to be whether it is an ethically problematic practice that involves patients aligning their appearance to so-called Western ideals or a means of self-improvement compatible with their culture of origin (5). Given the significance of these issues, surgeons should be encouraged to explore in detail the motivations and expectations of patients requesting Asian blepharoplasty. In tandem, high-quality research studies employing validated patient-reported outcome measures will be needed to satisfy increasing demands for robust evidence to enhance shared decision-making (15). Ultimately, this will facilitate balanced patient-clinician discussion and a mutual understanding of the wider social issues surrounding cosmetic surgery, in line with modern ethical clinical practice.

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