Episode 42: Sunday June 20

Drs. Sam Jejurikar @samjejurikar, Salvatore Pacella @sandiegoplasticsurgeon, and Sam Rhee @bergencosmetic welcome guest Dr. Lawrence Tong, MD, FACS, FRCSC. We talk to Dr. Tong about his expertise regarding double lid (double fold or "Asian") blepharoplasty, the most popular aesthetic plastic surgery procedure in the world.

Lawrence Tong, MD, FACS, FRCSC, at the Yorkville Institute of Plastic Surgery (https://www.myplasticsurgerytoronto.com/), is a certified specialist in Plastic Surgery by the Royal College of Physicians and Surgeons of Canada and is Board Certified by the American Board of Plastic Surgery. Dr. Tong specializes exclusively in Cosmetic Plastic Surgery of the Face, Breast, and Body. Dr. Lawrence Tong attended medical school at the University Of Toronto, and he completed his training in Plastic and Reconstructive Surgery at the University of Michigan, in Ann Arbor.

We catch up with Dr. Tong, who reviews his technique and approach to double lid ("Asian") blepharoplasty and demonstrates multiple example cases. If you are interested in double this episode is a MUST

#podcast #plasticsurgery #cosmeticsurgery #rheeplasticsurgery #boardcertified #plasticsurgeon #beauty #bergencosmetic #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bergencosmetic #doublefoldsurgery #doubleeyelidsurgery #asianblepharoplasty #torontoplasticsurgery ⁠#bestplasticsurgeon

S02E13 Show 42 - DR. LAWRENCE TONG - Double lid (double fold or "Asian") Blepharoplasty Part 1
Dr. Sam Rhee: [00:00:00] And welcome again to another episode of three plastic surgeons and a microphone where I am joined as always with Dr. Sam Jejurikar who's Instagram handle is @samjejurikar. Our fellow third plastic surgeon, Dr. Sal Pacella is recovering from arthroscopic knee surgery. And so he will be missing this episode unfortunately, but we wish him a speedy recovery and he will be back shortly.
I'm Sam Rhee, and my Instagram handle is @bergencosmetic, and we are joined by our fellow former resident, my former, our former chief resident, actually Dr. Lawrence Tong, whose website is myplasticsurgeryToronto.com. A little background on Dr. Tong. Dr. Lawrence Tong was born and raised in Toronto and he attended University of Western Ontario and medical school at University Toronto.
He then went and trained with us at university of Michigan medical center in Ann Arbor and plastic surgery. And. Since then he's transitioned after practicing in the United States for awhile stateside, he went back to Canada and now he has an exclusive cosmetic surgery practice in Toronto in the Yorkville neighborhood.
Dr. Tang is board certified by the American Board of Plastic Surgery. 
He is a certified specialist in plastic surgery by the Royal College of Physicians and Surgeons in Canada. And he specializes exclusively in cosmetic plastic surgery of the face, breast and body. And we've known Larry for many years, and he is an amazing surgeon.
He is meticulous. He is super laid back and probably out of the chiefs that I've had one of my favorite because he was he didn't brow beat you. He just showed you how good things could be by the way he did it. And you'd even have to show you didn't have to tell you what to do. He just showed it and then you could see what excellence look like just by what he did on a daily basis.
So with that I was, we would like to go ahead and put our disclaimer, our verbal disclaimer in for our show before we can, Sam .
Dr. Sam Jejurikar: [00:02:02] Yes, just the the necessary legal business we have to get out of the way. This show is not a substitute for professional medical advice, diagnosis or treatment. This show is for informational purposes, only treatment and results may vary based upon the circumstances, situation and medical judgment after appropriate discussion, always seek the advice of your surgeon or other qualified health providers with any questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because of something on the show.
And I just want to echo what Dr. Sam in New Jersey says about Larry. Amazing surgeon. And in many ways, just watching him as a more junior resident got me really interested in aesthetic surgery and in many ways was influential in my career. So I'm so excited to talk to Larry as well today, back to you, Sam.
Dr. Sam Rhee: [00:02:47] Thank you. So today this is a talk actually I listened to Larry give a couple of years ago at our alumni meeting at University of Michigan in Ann Arbor. And it went over really well. It was probably the best talk that I've ever heard of or seen or read about this subject. And I feel that it was really a value for everyone.
Not just surgeons, but patients and anyone who has a passing interest in upper lid blepharoplasty particularly Asian upper lid blepharoplasty, which is a pretty specialized topic. And certainly there are literally thousands of providers out there that do this. But. It's like everything else, there are probably, I think about a million people who know how to prepare a steak, but there are only a few people out there who make it amazingly well.
And it's one of those things. Everyone thinks they know how to do an Asian upper lid blepharoplasty, but there are only a few people out there that know how to do it amazingly well. So I'm really happy and honored that Larry decided to agree to come on our show and talk about it a little bit. So thanks very much, Larry.
I really appreciate it. 
Dr. Lawrence Tong: [00:03:55] Thanks guys. It's a pleasure and honor to be here. Good afternoon to Sam in New Jersey and Sam in Texas. Sal, sorry, you couldn't be here. Hope you get better soon and wishing you a rapid recovery. But you know, very glad to be with friends. This was a great show and hopefully you guys will be able to get something at my talk.
And this talk is a talk, as Sam had said before one that I'd given at one of the Dingman meetings a couple of years ago, and I've simplified it a bit, taking out a lot of the very technical things and I've shortened it, but hopefully it will still give a very nice overview of what this procedure is about.
And what did this all right. If you guys want me to start, we can start going over things. 
Dr. Sam Jejurikar: [00:04:43] Yeah, absolutely. 
Dr. Lawrence Tong: [00:04:46] Great. So first of all, what is Asian blepharoplasty? It's basically a constellation of aesthetic procedures performed on the upper lid with creation of a super tussle crease as the central objective in the procedure. It's interesting to note that this is probably the most common cosmetic surgical procedure that is performed in the world. But because because it's not as performed often in north America, it's less well understood. And that was certainly something that I was never really formally taught during my residency program.
Just because there weren't very many patients who were demanding it. And so when I moved back to Toronto, there's a very large asian population here. And that's when I started doing all that to have to learn and to do a lot more of these procedures. And the Asian population is increasing in north America.
Affluence of that population is also increasing. So there's going to be increasing demand of this procedure going forward. All right. So why do agents perform performance suit procedure? Basically because it's it gives an aesthetically more desirable appearance. 
And specifically patients will say that the lids look more expressive after it's done the size of the lid. That's the aperture size looks larger. Now, sometimes that is a true enlargement of the aperture. Sometimes it's an illusion the ideals of Western beauty have also had an influence. That's one of the reasons why this procedure I think was originally invented. 
But it's important to note that the procedure is not to mimic, an Asian eyelid.
Exactly. But just to take some of the characteristics, which are thought to be attractive to the nation a super tarsal crease occurs in about 50% of asians. So that means that there's a very large population of patients who could potentially benefit from this procedure. 
So this is a illustration that I've done, which you just look at the surface anatomy of the lid for.
So this is a patient illustration of someone who actually has a super tarsal crease. So let's see if I can. Okay. So this dotted line right here is a super tussle crease. So what is that? That is the horizontal skinfold that occurs when somebody opens the eyes and when somebody opens their eyes, there's going to be a flap of skin that hangs over that crease. And that flap is skid is called. The supercharge will fold. So a lot of people get super tarsal, fold and superficial. Mixed up when they describe it, but the crease is actually where the skin bends. And then this fold is the skin that flips over flops over it. The most inferior aspect of the fold is called the double eyelid line.
So that's this line right here. And that's the basically the hanging out mostly for your hanging portion of that super jealous with full. And so the distance between the super tarsal fold and the lid margin, this space here is called the pretarsal show and pretarsal space. So when we do non-Asian blepharoplasty and we were moving skin from the upper mid, that is one of the things we're trying to increase or create because as a person ages that skin stretches and sits down, and then you're going to have less pretarsal show.
When we do this in an asian patient who does not have a crease, we're actually creating some degree of pretarsal show, we'll know a precocial show existed previously.
So this is a photograph of a patient who has no super trustable crease. This is also variously termed, a single fold or single island. So in comparison, when we look at somebody the same patient after they've had the Asian bleph done with the crease. Now you can see that the pretarsal show exists. She has about 1, 1, 2, 1 and a half millimeters of pretarsal show. And in general, the eyes look more expressive. And they even look a little bit bigger. Now, in this case, they might, the eye aperture size might be actually slightly bigger because. In the pre photo, hung over the lid margin a bit, making them, they didn't look like it has some grouping of ptosis there wasn't true ptosis.
So we call this pseudoptosis a, the skin sort of hangs over, but them they'd functions normal. And overall the effect is a sort of a brighter, more expressive appearance. 
So as I said before, this surgery has several different names. So double fold surgery, double eyelid surgery, that before blepharoplasty, those can be generally used interchangeably. So when we look at the surface anatomy or the anatomy of the either, there are some differences with Asians versus Caucasians. So with agents I've already mentioned that 50% do not have a super tarsal crease. So this line right here is not present. In this Asian patient, 
There's something called an ethic capital fold, which is this little flap of skin right here which starts from the upper lid and ends up. So when the load that flap is skin is also something that's almost only exclusively seen in Asian patients and is almost never seen in Caucasian patients. And then finally the upper Leeds Asians oftentimes look a little bit more puffy than Caucasian patients. And that's because in some part the eyes with less deep-set in Caucasian patients, but also there are anatomic factors within the lid itself that contributed to the pumping okay.
Of why does a crease occur? And this is a, it's a cross section of an upper lid on this side, the left side, there's an Asian lid. And on the right side, there's a Caucasian lid. So you see there are these fibers that come from the Veda. So this area right here is the muscle. That's the levator muscle.
The levator elevates the lid. So when you open your eyes, that muscle contracts, and from a point on the levator, which is the fusion of the septum to the levator, it gives off these attachments. These attachments are anatomical attachments that Pierce through the particulars and end up joining to the dermis or joining through the skin outstanding of the lid.
And. The Vader contracts, those attachments because of connected along the horizontal line on the lid, create spec priests in Asians. Those fibers are usually they're not present in patients who do not have a super trustful cruise. So that's one difference, the presence or absence of the fibers. 
I had mentioned the septum in the previous slides. So the septum is this right here and it holds a pocket of fat. So this area right here is a pocket of fat. And in a Caucasian lid is fusion point occurs relatively higher than in than the Asian rate. So what that means is that the fat stays in other patient that's higher up on the lid, whereas in an Asian patient, you see the fusion point is right down near the tussle plate. That means that the fat that's below, behind the septum can sit and whatever spot. And when that happens, the lid can take on a puffier appearance. And oftentimes just underneath the the muscle layer, there's also a little pad of fat and that is often a little bit thicker than in a Caucasian. And so those things contributed to the prints on the positiveness.
So in summary here, the differences basically in the Caucasian lid, the septum sits at a higher point and therefore the fat consider the higher point, making them look less puffy. And also there are the fibers, those fibers attachments that come from the vader that go into the skin. And that's, what's responsible for the out of the crease.
Whereas the Asian lid fusion points it's much lower the fat, so it's much lower. So it looks more puffy. And this. Absent or very few fibers of the fiber sit, very low causing the crease. That looks very low. Sometimes when I look at Asian patients they'll have a crease, but it's very short distance from the edge of the lid. Some people think that the presence of the fat because of this location is what obscures the formation of these fibers.
Finally something called the capital fold is present on nation, but so this is a flap of skin that starts from the upper lid and comes down and joins to the lower lid. 
And that can make the they'd have a characteristic appearance. So can you give a rounded or a blunt appearance? Sometimes it's stronger or less, a more severe or less severe on the patient.
It hides the Caro gum, which is the Medial portion of the eye. So that makes the eye look rounded and what we do as your blepharoplasty. Sometimes we alter this epic capital fold to make it look less visible because it also has implications on how the crease travels as it goes towards the nose.
All right. So what is the goal of Asian blepharoplasty? As I said before, it's not to westernize the lid which means that the super tussle crease is created, but it's not usually going to be as high as a Caucasian instead of in this photo, you can see that this patient it might be a little bit too small to see on the screen, but she has a crease is very low compared to Caucasian link, which is typically much higher.
So how do we create the crease? Basically what we're doing is because patients do not have these attachments or they sit very low, we're actually creating those attachments. And how do we do that? We're making an incision on the skin, we're dissecting down to the Vader and then we're taking stitches to attach the skin to the levator.
So we're surgically creating these attachments, and this can be done through the open method, which uses an incision. And that's the method that you'll see described in this presentation to other multiple methods that can be done with just using sutures and minimal incisions. But the open method is generally the more preferred method because it's permanent and it gives you more flexibility in what you can do with these procedures.
All right. So other goals, as I said, created super tunnel increase, but other goals maybe remove skin, correct asymmetry, which is a big thing that we see very often improve the epicanthal folds. If the patient has ptosis, we can stop. We will combine ptosis correction at the same time. Ptosis is drooping.
So when plan for these procedures, basically the consultation is very important because the patient has to communicate to the surgeon as to what they actually want. How high do you want the crease? How high do you want the Creek show? If you want the priest to run in a certain, tapered fashion or a parallel in fashion, as it goes towards the nose and what do you want it to do when it comes to the side?
So all these things on important. In my consultations, I'll use an instrument to stimulate a crease for the patient so that they can see what it would look like and give her, give me some feedback as to what you know, what they're actually looking to achieve. And from that, I can formulate a, formulate, a plan, figuring out if I have to move into fat.
If I have to do that. But capital plasty, if I have to remove some skin, how, where should I make the decision? So I'm glossing over the planning, but that's actually very important. And the consultation, that's actually a very important part of the of the process because if you don't have a good idea of what the patient wants, you're going to be having a lot of problems after this.
Dr. Sam Rhee: [00:17:00] Larry quick question. If they ask, they bring in a picture and that person does not look. Like a result that you can achieve in that particular patient due to anatomy or because the, every physically the characteristics are super different. Is that are you able to reconcile that with patients?
Dr. Lawrence Tong: [00:17:18] Yes. So that's actually a very important point. And I'm sure that you guys see that a lot when people come in and they show you somebody's nose for rhinoplasty. Basically what I tell them is you can, if you want to show me a picture, I'm happy to look at it and go over with them. But 
The main thing is that I always tell them we're not going to be able to get a lid that looks exactly the same as that, and because of that we're just looking at some of the, the features that a patient might like. If there's a certain height to the crease or the pretarsal show, then I will. Use that as a guide for for the planning purposes. 
If they'd like a certain way that the puppet capital form looks, then I'll use that as a guide, but you were correct Sam, that we can't always get exactly the same. In fact, we cannot can never get exactly the same as the patient shows us to know. We just tell him, we'll use this as a guide. Don't look at it as something we're going to be able to get. 
All right. So moving on. So I had talked about, I'd made some terms like tapered crease and parallel. So this is an illustration of some of those things. So this is a tapered crease so that the nose is over here. Tapered crease means that the crease travels medially and then joins in at some point with the edge of the lid margin. This is a parallel crease where the. As it moves towards the nose never touches. And this is a hybrid crease. Some people call it an en fold where it comes and doesn't touch until the very end.
So we asked them about that laterally, sometimes the crease can just follow exactly the shape of the lid, or sometimes it can widen a bit. So we have to talk about that. And then we talk about, the amount of pretarsal show that a patient wants to achieve. Generally those three parameters can have a rough framework of what we want to achieve with that thing. So now we're going to go on to the surgery itself. So these are done immediately preoperatively. So I'll say hello to a patient. I will know what the patient wants from a preoperative assessment and consultation. We'll just reinforce that. And then we'll take a bit of time to draw the lines on this.
Now, this is important because if you don't draw the lines properly, then you're flying blind when we do the the surgery. So making the lines very accurate is very important for the process. So I usually do the markings with the patient on the stretcher and the supine position. Usually have them elevated a bit, maybe 45 degrees, and then, to make things consistent. I apply some lightning upward stretch on the lid that's to reduce the redundancy, because if the students vary from patient to patient and you just mark whatever five millimeters or whatever, it's going to be different from patient to patient. So you have to get rid of that redundancy.
Mark the the incision, just like I remember, samir had said that just Stamets it from a previous abdominoplasty podcast that you guys did of lift up on the skin or traction on the skin while you're making the mark for the plastic. So this is the same sort of idea for a little bit of traction on the skin so that where the incision is going to go.
And you have consistency between patients who would admit the markets. We elevate the skin and the first put a vertical mark. So an up and down mark at the center of the pupil. So we'll have the patient book straight ahead and I'll make them. At the center of the pupil and then with the skin on stretch, then we'll mark the height of where we want the crease to be.
So I put some numbers on the screen here. This is not not set in stone, but in general, a smaller crease you'll start at about five or six millimeters above. The margin media is somewhere around seven to eight, and then beyond eight is a larger cruise. 
Dr. Sam Rhee: [00:21:26] What do you use to mark like boys? 
Dr. Lawrence Tong: [00:21:30] So I use a surgical marker. I think it's by, from vis Scott. 
I have no conflicts of interest saying that it's just a very thin marker. It just works well. It's important to clean the lids, with alcohol before you do the marketing, because if you if you don't do that and the marker spreads all over the places. It just can be a mess once it's all parked and you can't figure out, where your incisions should be made. All right. So this is an example. So in this photograph, there's a instead of something, I usually use a ruler, but this is with a caliper. So we mark a certain height and then just gradually go laterally immediately to make the line at the height that has been pre discussed. 
If you have extra skin, especially in older patients, you have to incorporate some skin removal. And in general, you should try to remove skin such that once the skin is removed, you're going to have a slight amount of eyelash version. I do a similar thing when I do, upper blepharoplasty, but you have to have a set end point where you do the markings so that you can be consistent between patients because remove off the skin has an effect on the amount of pretarsal show.
And if you're just making the crease at a certain height, but not regarding or taking into a cat, how much skinnier than the move, you're not going to get a consistent result. So I usually try to remove skin so that there was a small amount of lash version. And that's how I know that when I make the incision at certain Heights, I can get a certain result. So it's not just marketing, be insufficient to make the certain marketing precision height that will determine for a show. It's also necessity for move on. Skin if needed, usually have one or two millimeters is all that's needed. 
Dr. Sam Jejurikar: [00:23:29] As is the inferior aspects of your skin excision, where your fold is going to be. Is that how you design it? 
Dr. Lawrence Tong: [00:23:34] That is correct. So the first slide is going to be a where I'm gonna base the circuit tussle crease. And then above that line, the small Crescent is the skin removal. So here's an example of somebody who had their marketing stuff. And, it's a little bit hard to maybe discern in this photo, but it's usually wider laterally and immediately you don't want to take too much skin. And then there's these central cross hatch. Cheer which delineates the central pupil. And then usually there's three or four more around the lid. And that helps me to distribute where the the spitters are. We call those the anchor and stitches or the anchoring sutures that will attach to the skin.
So I do this procedure under sedation. So I do that because I want the patient to be able to open their eyes at some points during the surgery, usually near the end. So I can take a look at the symmetry and make adjustments. I use a local anesthetic in addition to that half percent usually about half CC per side. So you don't want to distort. That's a very important thing too. You don't want to distort the lid. And when you put the local and you want to put the same amount on both sides and then it's important to wait for the epinephrin effect, which is to reduce the amount of bleeding. Wait for that effect to occur, which is about seven minutes or more so that you have the least amount of bleeding during the procedure, leading in the procedure really can affect your ability to perform this procedure.