Episode 43: Sunday June 27

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

S02E14 Show 43 - DR. LAWRENCE TONG - Double lid (double fold or "Asian") Blepharoplasty Part 2

So basically I break this surgery down into three steps. First step is the incision and dissection down through the Vader. So you're making the skin incision and then removing tissue to get down to the level of the elevator. The next step is placing those anchoring sutures, which will connect the skin to the Vader after diagnosis. And then the last step is to check the symmetry by having a patient open their eyes, make adjustments as necessary. And then closure of the skin.
So when we do the incision and that dissection hemostasis is critical. So you have to minimize the amount of bleeding. Once you start getting a lot of bleeding and things swell up, that's when you can start having issues with kind of be able to judge the symmetry because you have, might've done the procedure fine, but because of the swelling, the creases are going to look off.
And if that happens is it's just very difficult to know sometimes what is the end results going to be like Isaac caller, Colorado tip cautery on local regulation. All right. So this is a animation. Let's see if this will go. Okay. Okay. So that's basically making the skin incision. And the next is going to be removal of the of the strip of skin. So removal of the strip of skin, you can see, 
I haven't really removed any of the muscle underneath and I've done that on purpose just so that it doesn't bleed as much. It takes a little bit more time, but it's worthwhile. So after the skin is removed, then we will get the little bleeders. So that's the Colorado tip cautery buzzing the vessels.
So it stops bleeding. And then the next thing we'll do is we're going to start to remove the tissue. So when we remove the tissue, we're doing it right along where the incision has been made and the goal is get down from a level of the skin, down to the innovator. So you can see that we've removed the strip of the orbicularis there. And as we continue to go deeper,
So you could see that as you go deeper, you start seeing some fat and that fat is either the fat that's just underneath the orbicularis muscle, or it's possible that we have broken through the septum already and are at the level of the pre-AP and neurotic fat or preceptive Fadiman. And. 
And that's, it's important to be very incremental in your excision because, you can go through the levators possible to go through the levator if you're not careful.
All right. So once you think you're near the right level, then the way I, the thing that I like to do is do something called what I call them. I've coined it, the poll test, which is distracting them vid by pulling on the base of the wound to see if the lid comes with it.
So you could see what, when I was doing that distraction test, the lid came up directly with it. If you're not deep enough, but it's going to happen as you pull on the wound and the lid won't really move. So you're looking for a one-to-one correspondence with with the movement of your forcep and the lid itself.
Once you see that, then you can be pretty confident that you're at the right level. It's interesting to note that it doesn't have to be right at the level of the vader to be able to do that. Meaning that the section you don't have to necessarily get to the levator once you see the pull test work like that, you can be pretty confident that it's been studied. Your stitches in, and you can also see that when I was doing that section, I would bias the the removal right at the edge of where my incision face. So it's very important to try to do removal and place your stitches right at that level. So that you can have your crease 
set at the crook level.
Dr. Sam Rhee: [00:31:00] You don't actually have to see levator fibers or anything like that. You're just pulling and that you're in that correct plane, then.
Dr. Lawrence Tong: [00:31:06] That's right. And I find that it's notoriously difficult sometimes to actually see what is the levator at that point in Asian lids in Caucasian patients is actually very easy, but in that area, there's so much, what I find is so much variation is that you can get yourself into trouble by, going through the late enough to go through the elevator at certain points. There's so much width of attachment that it's not really a big deal. If you go through certain pumps, you're not going to get a ptosis, but if you are very aggressive in the it all the way across, then you could run into some problems. In that dissection, I didn't show it on the videos, but the, there was some fat that's removed as well. And sometimes there's so much fat in the list that we have to remove more fat than just at the level of the, so I'm talking about above the crease, this video shows, dissection of the fat pocket. It doesn't show the removal, but the removal could have been done in this case. It's just not shown there.
Okay. So there's that fat Patsy's lifted and there, you can see the elevator after neurosis that white structure.
And so if I want to move the fat, it would just open up the septum here and remove the fat. If you're going to approach this fat pad, we always approach it laterally because it's much easier to find sometimes when you get lost and you don't know where you are finding this path fat and elevating it, flipping it up will help you identify with a motivator is if you can't just remove it directly from that area where you're unsure, the next step is anchoring. So I use 6 0 9 1. And what I'm doing is grabbing a bite of the innovator or Perry tarsal tissues. So where we make the incision, it's usually still a long, the width of the Tarsus. It's usually not above grab a little bit of that tissue and then catch the dermal edge of the lower incision flat.
And as I said before, it's very important to get the correct height so that it is in line with your pre-marked incision. And it's important to do this the same on both sides and to be consistent. So you don't have one stitch higher and lower and higher and lower. You just want to have a smooth arc when we place these incisions.
And it's also important to alternate between the eyes I find. So that means you do one stitch on one side, then you go to the other instead of finishing one and then go to do the other Indian society. I find that if you wanted me to think symmetry it be much more consistent. If you placed, let's say the central stage on one side, then the same thing on the other side, then you'll maybe do the meetup stitch on one side and the same thing on the other side that will help keep the pump here.
Dr. Sam Rhee: [00:34:00] Do you do your regular upper lid Bluffs like that? Where you're doing them simultaneously? 
Dr. Lawrence Tong: [00:34:04] No. Maybe just before, before closure of foreclosure. Yeah, just to check. Yeah. So this is a schematic of the anchoring. So you can see here's the incision. We grab a bite of the Vader app in the analysis, and then we grab a bite of the inferior skin flap was a sort of slowed that down.
Do you ever run into wound healing issues with a permanent stitch in an area where their skin is so thin? No permanent issues sometimes because it's so superficial, you'll have the the end of the stitch poke through a little bit. So to come through these incisions and if that happens we can try to clip it so that it'll stink down and get buried again. Or sometimes we have to end up removing. If that happens, sometimes the patient gets like a little  and give them a bit of antibiotic in it and it goes away. We try to leave those anchoring stitches in for at least 10 weeks, if possible, so that there can be some scar formation before we take it out. So sometimes this dish does become exposed, but it usually doesn't cause really any major issues at all.
It's a minor thing. So that's one stitch placed. So on the other side, we're doing it at the same location, so super grabbing the base and you can see there's that one-to-one correspondence and we're putting the stitch through that and then grabbing the underside of the dermis and using Castro, Vale, needle drivers is important for precision and then we're just. Tie it down. And so when you're doing this, you're also looking at the other side to make sure that it's a similar height. As on the other side, do you ever worry catching the tarsal plate or that's not even close to where you are depth wise, so you can actually catch the tarsal plate.
That is actually one of the methods that is described. The main downside of that is that when you catch the tarsal plate, then you end up with a crease that's more static as opposed to dynamic. What that means is when the eyes are closed, you should not see a crease. You should not see this indentation or a line there.
If you catch a parcel plate, then it becomes more increased, becomes more stuck. And then you see a line that's owns there, so you can do it that way, but aesthetically it's just better to To catch the intimidator on a pair of Tafaro tissues only. But in general, the tarsal plate is so tough. It's not easy to sink a stitch through that and that's usually not an issue.
All right. So then going back to the other side we'll do the next medial and groom suture we'll tie that down. So then, it goes back and forth until both sides have done. As I said before, it's usually four to five anchoring points, per side. 
And then if you've made an incision, that's a little bit off on one side or the other, you can correct for that when you place this stitches, put a little bit more stretch on the flat to account for that. So there are some things you can do with it. The incision isn't exactly perfectly. We've made it. All right. So we've seen that one already. Okay. So the last step is to check for symmetry and then close. So I don't have a video of this, but I ask patients to open their eyes.
This was before closure. And then I look to see what the creases look like. I used to sit them up and do this whole thing that made it very complicated. And I just asked them to open their eyes. 
And from experience, I'll just know if it's going to be symmetric enough. If it's not, let's say one crease doesn't high enough that I'm maybe take a stitch or two out and readjust, so then it does look symmetric. At this point. I might also move a little bit of extra skin from the upper flap as well to make everything. As possible. So once everything was good, then we through the closure of the scan and this specific. So I use a running set of help. 
Dr. Sam Jejurikar: [00:38:35] How often do you find that you actually have to do what you're describing and actually make those alterations? Is that a common occurrence? 
Dr. Lawrence Tong: [00:38:41] No, I would say maybe 10% of the cases. Usually if you get, enough experience, you'll know if it looks when you're doing it, you'll have a very good sense. It looks very symmetric with feel that everything is working nicely. 
So I always, then we use a subcuticular closure, same 600 nylon. So with this operation, you can actually do the entire surgery, usually with one 600 nylon suture. 
Dr. Sam Rhee: [00:39:10] Very economical. 
Dr. Sam Jejurikar: [00:39:12] Yeah, exactly. 
Dr. Lawrence Tong: [00:39:16] So let's take a look at some results. This is a before and after. And you could see the patient did not have much of a super tussle crease afterwards, and it's a higher reference. This is a more of a close-up of that same patient. 
Dr. Sam Jejurikar: [00:39:34] And did you, and did she select that parallel fold? Like you, you sit down with them and that's amazing. That's amazing. It looks just like your drawing. 
Dr. Lawrence Tong: [00:39:41] So when we do, you saw how I did the simulation with the instrument, usually that will let you know, let the surgeon know how the crease is going to behave as it goes medially. So what that means is it'll either look parallel or look tapered and then depending on what the patient wants, then you can advise them further. You can say, okay, this is it's probably going to look parallel. Is this okay? If they're not okay with that, you can actually design the operation by making the incision taper in a little bit more to grade that tapered incision on the flip side though.
Dr. Sam Rhee: [00:40:21] Yeah, go ahead, sir. No, go ahead. I was just, no, go ahead. And then I was going to comment on this particular patient on the flip side. 
Dr. Lawrence Tong: [00:40:27] On the flip side, if you do that and the patient has a tapered cruise, but they want a parallel crease. Then we have to go into some discussions about whether or not they want to do in epic capital plastic. And the reason is most of the time if a patient has a tapered crease that occurs when you're simulating it's because they have an epic capital fold that forces the crease fold in a certain way as it gets towards the. And if you don't relieve those tight forces that are there, , you're generally not going to be able to get a parallel crease or it's not as likely. So then I tell them, okay, if you want a parallel Greece, I would recommend to do the other capital plasty. But if you don't want to do the epic capita plasty, I can try to get parallel crease by altering how the incisions are made basically to make them higher and bring them beyond the epicanthal fold, but just don't guarantee if that, so they just have to be aware of what the potential outcomes are, who did that. 
Dr. Sam Rhee: [00:41:35] How many patients are really aware about the change in epicanthal fold in terms of their appearance? Because I feel like that's, it's a dramatic change, but I think it's something that not that many patients would actually be aware of knowing to bring up. 
Dr. Lawrence Tong: [00:41:53] That's right. In general, it depends on your patient patient population. Generally, I find like really young patients know about this, but if they don't, you can just do the simulation and say, okay, this is what it's gonna look like. And that's, they're assuming they're just going to come into the double fold. They're not thinking about it, but capital, plastic or anything like that. And so if you show them that and they're happy with it, then you don't have to go further with the discussion. 
If it's a patient who you think might want to do that, or do you think it would look much better with it, then you can simulate an epic Capitol plastic, with them. And what you do is after you put the paperclip in with your other fingers, draw you shut a pull, pull the medial lid skin immediately post the notes and instantly you'll be able to see what the what the pair with be. So that's very handy for them to see. And maybe from that, they can decide whether or not they wanted to do an epicanthal pasta or they want a parallel cruise.
You can also send it presented. So percentage of patients who do epicanthal plasty, I would say like 10 to 20%. Okay. And you can also do an epicanthal plasty without a pair cruise. Why would somebody do that? Mostly because they don't necessarily want a parallel crease, but the epicanthal fold is so significant. It makes the eyes look rounded. Sometimes asian patients look cross-eyed, I don't know if you've ever seen that. Because of that that skin sort of making the horizontal of the lids much shorter 
Dr. Sam Rhee: [00:43:35] in this particular case, this patient, it was more of a challenge because she has a asymmetric asymmetry, which you can actually see here. And so was that more of a challenge in terms of address? How common is that where you see some sort of asymmetry? 
Dr. Lawrence Tong: [00:43:50] So it's very common. Maybe you don't always see, like one side has no fold and one side has some fault. But it's very common for there to be a very tiny fold that you can just barely see and then nothing on the side. This one is a little bit more noticeable. So it's challenging in that sometimes you have to tell the patient that it's in the best interest to do both sides, even if they don't want to change. The crease that they feel aside, that they feel is more. And the reason for that is because when we create these creases, the the definition is very, it's a very defined flipping appearance.
Whereas natural creases as you guys are probably seeing, can sometimes be very, spanked and not very noticeable. And if you have that situation and you just to one side and the other side is faint, you're going to have a symmetry not maybe because of the height, but just the the other characteristics, the depth of the full little bit different.
So usually when we have something like this, we also ask them, do you want to change your quote unquote, good side? We can, make it a little bit higher, want to get more? Pre-trial. And if that's if that crease looks very faint, then I'll make a general recommendation yet you should do it like this, or else you could end up with sending assymetry afterwards and you should, patients would be fine with that once they understand the reasoning behind it.
All right. So next, so again, another patient with asymmetry. Okay. And you can see that without the crease, it even looks like the eye aperture is actually smaller on her right side. And that's 
I think partly because of the illusion that the crease is to make the eyes bigger, partly it may be because she has skin that hangs over the lid margin without actual TOSAs.
As I said before, we called that pseudoptosis or Intellis. And so this is afterwards and you can see that it looks like the aperture is bigger. Afterwards, I don't remember in this patient funded one or both sides. I think I might've done both sides.
Just another example, no super tarsal crease. Pre-op and then super tarsal crease. Afterwards. Another example. See this one has a very sort of faint, super Tunsil crease on his left then afterwards. Nice creases.
This patient had Asian blepharoplasty plus low left for plasty done at the same time. And so this is a little bit closer up of the, appearance.
Another patient sees very long line creases. And then afterwards, a bit of elevation there what's the distribution of age and your patients. So usually most patients who do this, I would say on the younger. So it starts at 18 years old and the average goes up to maybe the thirties and then after thirties, it starts to diminish a bit. Yeah. Cause you can see most of these patients are pretty young. This patient, you see how her creases are. Very well-defined. And so that is that is another indication. Silver creases are much more defined afterwards. Plus their increases are actually higher, but because she's wearing a little bit of makeup it's it's not as easy to see.
That's another thing that we discuss if a patient plans to wear a lot of eye makeup or wears eyeliner specifically, that usually makes the pretarsal show a little bit smaller. So they have to decide when they're figuring out what height they want as to, they usually wear makeup or are not wearing makeup because that will impact on the paints. Just another patient's sort of faint folds and the extra skin, another asymmetry. 
Dr. Sam Rhee: [00:48:02] What is the gender breakdown? 
Dr. Lawrence Tong: [00:48:05] 90% female, 10% male, which is similar. Usual cosmetic surgery. It's another male patient more of a conservative crease, but better symmetry afterwards. And then now we'll get back to that first patient that I showed you. So this is her on the front view and I think that's it.
Yeah. All right. So hopefully, you gained some perspective. I left out a lot about the post and the planning and all the things about epicanthal plasty. And so it's just correction, but it's a lot of material that could be covered, but I think this is generally fairly decent overview of what the surgeon does.
Dr. Sam Jejurikar: [00:49:00] That is a, those are phenomenal results. Larry, just the precision that you show. And the level of detail I think is very is very just eye opening. I think most plastic surgeons don't do this operation. Myself, I've never done an Asian blepharoplasty. And after watching this, I'm just going to send them to you because you do an amazing job and you truly do a lot of us, and I'm just, I'm blown away by your results.
Dr. Sam Rhee: [00:49:27] Yeah it's really amazing. When I first started in practice in private practice, I did some, and like you said, this was something and only because I'm Asian and there were a couple of drawbacks. One was I never learned like you at Michigan to do a formal, I never formally learned how to do an Asian bluff.
There is a plethora of techniques, as you mentioned out there. So it's really hard to settle on something. If you're just trying to learn this was probably like 10, 15 years ago. And then the third thing is my patients assume many of them assumed I spoke either Mandarin or Korean or something and I, I don't speak anything like in this area, especially there were a lot of immigrants, there are a lot of people coming from overseas.
And and so at that point it was a a moot point. Cause it's, you are familiar with the landmarks. If you've done upper lid blephs which, all of us do regularly, but the, as Sam said that the precision and dialing in the consistency is what's key for doing this well. And the fact that there are conditions here, you can actually see whether it's actual or not.
Whether the aperture looks different, size wise, like the eye. It, there are a lot of things which dramatically affect eye appearance. And it, and as you said, it's not just a straight westernization of an Asian, upper lid. There are specific aesthetic values that are being addressed here, which are specific to the Asian eyelid.
And it's not just doing something that makes an Asian lid look. Western. And that the fact that you also incorporate the patient's preferences significantly, you, you say that at every step of your procedure or your processes you're taking in the patient's preferences. You're asking them about their makeup, their lifestyle, their overall aesthetic values.
That's crazy important because of the people that are not, I don't, I'm not going to denigrate anyone, but there are a lot of people who are very cookie cutter do it the same way all the time. And we know people like that for any procedure, probably. And I think the key here is how you customize it.
So there's no doubt that if there's anyone that I know who is looking for this type of procedure, I'm going to just have them drive up to Toronto or fly up to Toronto and see you about it. Cause it's that's truly amazing. 
Dr. Lawrence Tong: [00:51:49] That's a very kind of you to say it, it is true. If you just watch the videos. You can really understand the procedures, not that difficult of a concept, but it's just like you said, execution is very important for success and inconsistency and the only way that you can get that is by doing cases. So that's the sort of conundrum, right? 
If you don't do a lot of cases, then you'd never get as comfortable with it. And so just as a starting point that everybody has to go through. But I think that any of our co-residents would be able to perform this operation very well. If you just take a little bit of time to understand what the surgery is about and just, take it slow and be careful when we're doing this we'll do the surgery.
The surgery does have a revision rate. That's a little bit higher than what you would see in a regular blepharoplasty. I would put that maybe about five to 7% and that's meaning patience to eventually come back to do a little bit of a touch-up. So whether it's like no removal, most common would be like removal of a little bit more skin just to get the symmetry to be perfect because it's sometimes it's just hard, but it's very important for patients to be understanding that it takes time, right after the surgery, as you probably know, the crease looks super high. And if you don't tell them that beforehand, they're going to freak out when you take out, take up to 10. So very important to educate them beforehand, then it's gonna have a Cod and maybe even look and even swelling can occur differentially. And when I do the surgery, I put a very thin Steri-Strip on the incision.
And so wherever you put that Steri-Strip is going to affect the swelling. And you might know that patients use, I would take to create creases. Non-surgically and that's like having eyelid tape there for a week before before it comes off. So you're going to get this, what I call a false crease for at least a few days before it returns to normal.
So it's very important to tell people. It's been a look, I might look at an event, but don't worry about it because if it looked even during the procedure, but I checked you check the symmetry, then it should work out in the end. It might take a few weeks. Sometimes it takes a few months. But just for them to be patient.
Dr. Sam Rhee: [00:54:26] Wow that was amazing. Larry, I really appreciate you spending the time. And I again, would encourage anyone who is interested to go to Dr. Tong's website. It's myplasticsurgeryToronto.com. Again, thank you to Dr. Sam Jejurikar in Dallas, Texas, our recovering colleague, Dr. Sal Pacella out in La Jolla, who is recovering from his knee surgery.
And I am Dr. Sam Rhee @ bergencosmetic in New Jersey and we will see you all very soon. Thanks again, Larry. And have a great day. 
Dr. Lawrence Tong: [00:54:56] Thank you very much. And Sal, I'm sorry, couldn't be here. I have a message for you Sal. You've got to come in. .