"Without adequate fat,
a true crease cannot exist."
Asian skin is legendary for its ability to hide aging changes and wrinkling for a decade or two longer than Occidental skin. However, there's more to an eyelid than just its outer layer.
Most young Asian eyelids are noticeably fuller than their Occidental counterparts due to an abundance of fat in the lid, orbit, and sub-brow areas.
Most of this added volume is provided by the orbital fat (yellow) that extends further downward in the Asian lid and the sub-brow fat (green) that is larger in size and also lower in position.
Sub-Brow Fat Pad
It is now known that the dominant factor in facial aging is a gradual loss of fat. Such change may begin during the early thirties and progress at a variable rate based primarily upon inhertied tendencies.
Unfortunately, fat loss in the eyelid and surrounding structures (collectively known as the "periorbita") is more noticeable at earlier ages in many Asian patients. In some patients, relative fat shortage is already present by the late twenties.
As fat loss increases, the overlying skin begins to deflate. A growing concavity or depression appears midway between the brow and eyelid and then gradually deepens.
Since, as a rule, young Asian lids are full while older lids are noticeably more hollowed, the net effect of this fat loss is to make the face appear prematurely old.
By age forty (although sometimes by as early as the twenties), a sinking eyelid can generate real cosmetic concerns that cannot be addressed by either double eyelid surgery or traditional blepharoplasty since neither operation restores fat.
Asian orbital and periorbital fat deficiency can cause other undesirable effects:
• Early on and when still mild, the eyelid's natural crease may be weakened and instead turned into an arrary of dents and folds
• In advanced stages, the depth of the hollow may "pull in" so much skin that an objectionable depression (sometimes confused with a high crease) becomes the dominant facial feature.Without adequate fat, however, a true crease cannot exist. Instead, this depression signifies only a progressive collapse of the overlying skin and muscle against a hollowed interior.
• For reasons not well understood, a hollowed upper eyelid is more commonly associated with ptosis, or a drooping eyelid. Ptosis makes the vertical opening between the eyelids more narrow and causes the eye to appear smaller. Since ptosis is more commonly seen in the elderly, its appearance in younger patients further ages the face.
• Results after standard double eyelid surgery in a patient with even a mildly hollowed lid can be much more unpredictable. The final crease may form unexpectedly high, and full healing may take substantially longer. Fat preservation (video below) is crucial in all such patients. In some, orbital fat grafting may be indicated.