COSMETIC
Vertical Enlargement of the Palpebral Aperture
by Static Shortening of the Anterior andPosterior Lamellae of the Lower Eyelid: ACosmetic Option for Asian Eyelids
FootToshitsugu Hirohi, M.D.
Kotaro Yoshimura, M.D.
Tokyo, Japan

Background: Although double eyelid plasty, levator aponeurotic surgery, andepicanthoplasty are well-accepted cosmetic treatments for Asian eyes, somepatients are incompletely satisfied with the outcomes and request further surgery. Although lower eyelid descent is generally recognized as a symptom ofaging or a complication after blepharoplasty, the authors propose a perceptionalchange: a lowering the lower eyelid procedure to vertically enlarge the palpebral
aperture in selected Asian patients.
Methods: A total of 125 Japanese patients underwent the lowering the lower
eyelid procedure between 2005 and 2009. The main indications were patientswith vertically narrow palpebral aperture or an up-slanting appearance. The
lowering the lower eyelid procedure is performed by a combination of theremoval of approximately 4 to 6 mm of the subciliary skin (usually the lateral
one-third to two-thirds of the lower eyelids) and static shortening of the lowereyelid retractors (posterior lamella) through a transconjunctival approach. The
middle lamella was not touched during the procedure.
Results: The up-slanting lower eyelid margin was lowered and the lateral partof the palpebral aperture was enlarged by the procedure in all cases. Cosmetic
outcomes were encouraging and satisfying to most patients. Three complications occurred (2.4 percent): lagophthalmos in one patient (0.8 percent) andentropion in two patients (1.6 percent). These minor complications resolved
within 1 month. Eight revision operations were required for undercorrection.
Conclusions: The lowering the lower eyelid procedure offers Asian patientsdesiring large oval eyes a novel surgical option. The procedure proved to be areliable and consistent technique that provided satisfactory results in carefully
selected patients. (Plast. Reconstr. Surg. 127: 1, 2011.)

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number of previous reports focus on retraction of the lower eyelids, but always from negative points of view. Not only the aging process but also lower blepharoplasty can cause descentof the lower eyelid (occasionally along with medial
migration of the lateral canthus), resulting in rounding of the palpebral aperture.1–3 Because these unFrom the Ritz Cosmetic Surgery Clinic Tokyo and the Department of Plastic Surgery, University of Tokyo School ofMedicine.
Received for publication March 15, 2010; accepted June 22,
2010.
Presented at the 32nd Meeting of the Japanese Society ofAesthetic Plastic Surgery, in Yokohama, Japan, on September
25, 2009.
Copyright ©2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181f95b09

favorable situations are generally candidates forsurgical treatment, a considerable volume of theliterature describes how to treat and how to avoid
lower eyelid malposition such as inferior scleral show
and cicatricial ectropion.4 –9
Typical characteristics of the Asian eyelid include puffiness, single (nonfolded) upper eyelid,
epicanthus, up-slanting appearance, vertically narrow palpebral aperture, and deep-set eyes (Fig. 1).
These distinctive features sometimes project animpression of tiredness, maliciousness, or anger.
Although a youthful palpebral aperture has been

Disclosure: The authors declare that they have nocompeting financial interests.

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