13 Double-Eyelid Surgery: Incisional Techniques

10.1055/b-0036-135525

13 Double-Eyelid Surgery: Incisional Techniques

Jae Woo Jang

Pearls

The East Asian upper eyelid has several distinct anatomic characteristics, including a low, poorly defined, or absent eyelid crease; narrow palpebral fissure; and epicanthal fold.
The goal of upper blepharoplasty for the Asian patient is to make eyes fresh, youthful, and attractive while maintaining their ethnic appearance by surgically creating a supratarsal crease.
The indications for the incisional technique are redundant skin, bulky eyelids due to soft tissue and fat, disappearance of the eyelid crease after suture or partial incisional technique, and reoperation due to various complications after eyelid crease surgery. Scarring is not a problem if the technique is delicately performed.
The eyelid crease height in East Asians is 6 to 8 mm in females and slightly lower in males. A 2- to 3-mm pretarsal show, 20 to 30% of the length of the interpalpebral fissure, is optimal in East Asians.
The height and shape of the eyelid crease should be individualized depending on a patient’s eyelid fissure or epicanthal fold. The favorite types of eyelid creases are the inside crease and outside crease—fan type or mixed type—in East Asians, especially Koreans.
Proper removal of the orbicularis muscle and orbital fat is necessary to create a more secure eyelid crease. Sometimes retro-orbicularis orbital fat (ROOF) removal is required depending on the puffiness of the individual’s eyelid.
Appropriately designed doubleeyelid height and proper fixation result in a natural and aesthetically pleasing double eyelid.

Introduction

Upper lid blepharoplasty is the most common cosmetic surgical procedure in East Asia (Korea, Japan, and China). Asian blepharoplasty, also known as “doubleeyelid surgery,” involves the surgical creation of a supratarsal crease. However, because the creation of a supratarsal crease does not actually involve the formation of another eyelid, the term double eyelid is actually a misnomer.1,2,3

It is generally agreed that ~ 50% of Asians are born with naturally occurring upper eyelid creases. However, for most of this population, the height of the doubleeyelid crease is low, and well-defined double eyelids are present in only ~ 10% of Asian men and 33% of Asian women. The goal of blepharoplasty for Asians, with or without related procedures, is fresh, youthful, and attractive eyes that retain their ethnic appearance. The Asian upper eyelid has several distinct anatomic characteristics, including a low, poorly defined or absent eyelid crease; narrow palpebral fissure; and epicanthal fold. The upper eyelid margin of a single eyelid in East Asians is in most cases covered by upper lid skin. Therefore, when doubleeyelid surgery is performed, the upper eyelid skin is pulled upward, resulting in an apparent increase in the size of the eyes. Doubleeyelid surgery is considered by East Asians to make the eye appear larger and more aesthetically pleasing.4

Eyelid crease surgery is performed not only for aesthetic purposes, but also for the correction of problems such as entropion, lash ptosis, pseudoptosis, and ptosis. Most patients tend to want the surgeon to perform eyelid crease surgery simultaneously while correcting these other problems. When patients with blepharoptosis undergo eyelid crease surgery, the palpebral fissures become wider and can create a more pleasing eye shape.5

It is important to recognize that Asian upper blepharoplasty is not a Westernization procedure, and the aim is to create an upper eyelid crease similar to a naturally occurring one.

Anatomy of the East Asian Eyelid

The most obvious characteristics of the Asian eyelid are the absent or very low lid crease, and fuller upper eyelid. Asian eyelids with no lid crease are referred to as “single eyelids.” Although not visible, a small fold commonly exists under the overhanging eyelid skin. Caucasian eyelids typically have an eyelid crease, but Asian eyelids can be categorized into three types: single eyelid, low eyelid crease, and double eyelid.

The causes of an absent or lower crease in an Asian upper eyelid include the following: (1) The orbital septum fuses to the levator aponeurosis below the superior tarsal border. (2) Preaponeurotic fat pad protrusion and a thick subcutaneous fat layer prevent levator fibers from extending toward the skin near the superior tarsal border. (3) The primary insertion of the levator aponeurosis into the orbicularis muscle and into the upper eyelid skin occurs closer to the eyelid margin in Asians (Fig. 13.1).6,7 Asian single eyelids have more prominent subcutaneous and retro-orbicularis fat in the supratarsal region. Several components, such as a submuscularis fibro-adipose tissue layer and a lower-positioned transverse ligament, have been identified and are found exclusively in the Asian eye.

**Fig. 13.1** Differences in upper eyelid anatomy between **(a)** East Asians and **(b)** Caucasians. In Asians, the orbital septum fuses with the levator aponeurosis below the superior tarsal border. The protruded preaponeurotic fat and thick subcutaneous fat layer disturb extension from the levator aponeurotic fibers toward the skin.

The primary goal of doubleeyelid surgery is not simply to create a supratarsal crease but to create a crease that is consistent with the natural configuration present in the general East Asian population.

When Should the Incisional Technique for Double-Eyelid Surgery Be Performed?

The types of doubleeyelid surgery include the simple suture technique, the partial incisional technique, and the incisional technique. The choice of technique is based on patient preference, skin quality, and the volume of fat tissue in the upper eyelid. There are advantages and disadvantages to the incisional technique and nonincisional techniques. The advantages of nonincisional techniques are that patients recover more quickly with no scarring, while the disadvantages include the inability to remove preaponeurotic fat and soft tissue, which leads to the disappearance of the double fold.

The indications for the incisional technique are (1) redundant skin, (2) bulky eyelid due to soft tissue and fat, (3) disappearance of the eyelid crease after the use of a nonincisional suture technique or partial incisional technique, and (4) an additional operation due to various complications after eyelid crease surgery (Fig. 13.2).

**Fig. 13.2** A typical indication for the incisional technique for eyelid crease surgery. The eyelids show puffiness, skin laxity, and an epicanthal fold in a 25-yearold woman.

The major disadvantage to the incisional technique is the long recovery time (usually 1 week is required to reduce postoperative swelling and edema). Scarring is not a problem when the procedure is performed precisely and delicately. The incision line is more prominent with the partial incision technique compared with the incisional technique because there is an apparent abrupt ending with the more limited incisional method.8

Patient Evaluation

Most patients desire permanent and naturallooking eyelid creases. At the initial consultation, the patient’s goals and expectations should be identified. The eyelid crease height usually depends on the interpalpebral fissure size and tarsal plate height. The proper eyelid crease height in East Asians is 6 to 8 mm in females and slightly lower in males.

The first step is to simulate the estimated eyelid crease in front of the mirror by pushing the eyelid skin with devices such as a forceps, a lacrimal probe, a paperclip, or a wooden cotton-tipped applicator; the different shapes and widths of the eyelid crease can be created and visualized using these tools. The height and shape of the eyelid crease required for a natural look should be decided via discussion with patient. Should the patient request a height and shape that do not match the eyelid shape, a more thorough explanation will be required to assist in the decision making process. Some patients may not fully express their desires, which can make these cases very difficult to manage. As mentioned previously, most Asians want a crease that is consistent with those that occur naturally in the population.

Ptosis of the upper eyelid is assessed by measuring the palpebral fissure width and margin reflex distance 1 (MRD1, from the light reflex on the patient’s cornea to the central upper eyelid margin). Lash ptosis or downward angulation of the lashes owing to relaxation of the anterior lamella of the eyelid should also be noted and corrected during upper lid blepharoplasty.9 Early myasthenia gravis symptoms are similar to those of ptosis and require a differential diagnosis.

Periorbital fat is important for blepharoplasty, especially when subbrow fat (retro-orbicularis orbital fat, or ROOF) is distributed up to the orbital septum level and fullness in the upper eyelid can be seen; this is distinguishable from orbital fat herniation.7 The orbital fat of the upper eyelid is divided into two groups: central and medial. Central orbital fat has a yellow, butter color, while medial orbital fat is whitish in color and is composed of smaller lobules.

Blepharoplasty may be adapted according to the quality of the eyelid skin. The surgeon will consider eyelid skin thickness (thin or thick), dehydration of the skin, and the loss of elastic and collagen fibers, depending on the degree of aging. With a greater degree of aging, blepharoplasty for thick eyelid skin requires that the skin incision be made at a lower level and the procedure not involve excessive skin removal.

Before surgery, the patient’s eyebrow shape and position, the appearance of the eyelids and degree of sagging, and the degree of fat bulging should be recorded using paintings or photographs. These records can also play an important role in resolving any complaints or conflicts that may occur following surgery.

What Is the Favorite Type of Double Fold in Asians in Relation to the Medial Epicanthal Fold?

The shape of an eyelid crease can be characterized as nasally tapered, parallel, or semilunar. Asians rarely have a semilunar shape, which is common in Caucasians. Asians with a natural crease have either a nasally tapered crease or a parallel crease, as described in various reports. Chen noted that inside fold and outside fold are less appropriate terms; however, in Korean populations, the inside crease is well matched with the nasally tapered crease, but the parallel crease does not exactly match the outside fold.2 Therefore, in this chapter, the author will use the terms inside crease and outside crease instead of nasally tapered crease and parallel crease.

Inside crease. A natural, lower crease that converges toward the medial canthus and runs parallel across the ciliary margin, over the central portion, and flares away from the ciliary margin as it approaches the lateral canthus (fan type) (Fig. 13.3a).
Outside crease. The crease runs fairly parallel to the lash margin from the medial canthus to the lateral canthus. The outside crease is divided into three types: (a) fan type, (b) fan-parallel or mixed type (the eyelid crease gradually flares away from the lid margin toward the center portion and then runs parallel to the ciliary margin toward the lateral canthus), and (c) parallel type (the crease runs at the same width from the medial to the lateral canthus) (Fig. 13.3b,c).

**Fig. 13.3** Variations of East Asian creases. **(a)** Inside crease. **(b)** Outside crease, fan type. **(c)** Outside crease, parallel type.

Usually an inside crease becomes a fan type and an outside crease becomes a fan, fan-parallel, or parallel type. In general, there is a greater tendency to create an inside crease than an outside crease in patients with a strong medial epicanthal fold. The inside fold is considered to be more natural and conservative, whereas the outside fold is considered to be more modern and outgoing. Although the higher outside-crease eye was once trendy, it is unnatural-, artificial-, and Western-looking (Fig. 13.4), East Asians, especially Koreans, prefer the inside crease and outside crease fan type or outside crease mixed type. Moreover, it is now uncommon for East Asians to choose a semilunar crease like that of Caucasians.

**Fig. 13.4** The higher outside crease. The high outside creases may look cool, but they also look unnatural, artificial, and Western.

It is reported that epicanthal folds are found in 50 to 80% of South Koreans. Due to the epicanthal fold, in 70% of eyelids the caruncle and lacrimal lake are not overtly visible. The shape of the eyelid crease depends on the height, the degree, and the shape of the epicanthal folds. The eyelid crease may be two lines at the medial canthus and be operative in appearance if the outside crease is made without medial epicanthoplasty (Fig. 13.5 ). To make eyes larger and more attractive, medial epicanthoplasty is recommended at the same time as the doubleeyelid surgery, especially for moderate to severe epicanthal folds.

**Fig. 13.5** Webbing of the crease. Webbing is noted at the medial canthus because the outside crease was made without epicanthoplasty.

What Is the Best Height of the Double Eyelid?

The eyelid crease height usually depends on the interpalpebral fissure size and tarsal plate height. The eyelid crease height of East Asians is 6 to 8 mm in females and slightly lower in males. In patients with a large interpalpebral fissure or thin eyelid skin, making a higher-set eyelid crease is better. Otherwise, a lower-set eyelid crease is preferable for patients with a small interpalpebral fissure.

Eyeball protrusion and vertical/horizontal interpalpebral fissures are important for determining the height of the eyelid crease. If the horizontal fissure of the eye is small, the high eyelid crease will appear unnatural and artificial. A higher eyelid crease looks natural in patients with a large horizontal fissure of the eye. However, high eyelid creases do not look natural in patients with thick eyelid skin and a large amount of pretarsal soft tissue. East Asians often have protruding eyeballs; a high eyelid crease is strong-looking in these cases.

With regard to Asian eyelid creases, the crease is partially covered by the fold of skin that overlays it. The width of the eyelid crease during eye opening is called the pretarsal show (Fig. 13.6a).10 The height of the eyelid crease (or designed incisional line) is determined from the pretarsal show. The pretarsal show in East Asians is optimal at ~ 2 to 3 mm or 20 to 30% of the interpalpebral fissure, but it may depend on the height of the supratarsal fold and the laxity of the supratarsal skin draping the crease and pretarsal skin (Fig. 13.6b).11 The amount of redundant skin excision depends on the pre-determined pretarsal show when the incisional technique is performed. Even though designed at the same height as the eyelid crease, the height of the crease is determined according to the amount of skin. If the amount of excised skin is large, the eyelid crease will be high after eyelid crease surgery. The doubleeyelid crease can be created with or without a pretarsal show by managing the excised amount of the skin as per the patient’s desires.