What is an Upper Lid Crease and Historical Consideration: 双眼皮与手术历史

In common usage, the eyelid crease is often meant to describe a natural inward creasing of the skin seen in the upper eyelid, typically dividing it into a lower segment adjacent to the upper eyelashes, and an upper segment of skin that runs from the crease to the border of the eyebrow.

The upper eyelid crease is present in about 50% of the Asian population, and found to be more prevalent in non-Asians. The presence of a crease in an Asian subject is what differentiates a double eyelid (with a crease dividing the lid into two unequal sections, hence “double”) from a single eyelid (or mono-lid).

Double-eyelid crease surgery (procedures) is a form of surgery to add or supplement an eyelid crease to an individual who seeks it. This is often for an individual who does not have a crease, or who finds their crease is insufficient, or in whom the crease is unbalanced between the two sides.

The configuration of the upper lid crease in Asians varies greatly. The terminology used to describe these configurations also varies, depending on the ethnic group and language concerned. Figure 1-1 illustrates the Chinese characters for the words “double-eyelid fold”. Figure 1-2 shows the Japanese Kanji writing for “single [one] lid eye” and “double [two] lid eye”. The characters common to Chinese and Japanese for the operation to construct a lid crease are illustrated in Figure 1-3 .


Chinese written characters for “double eyelid [skin]”.


Japanese Kanji characters for “single eyelid” (left) and “double [two] eyelid” (right).


Characters common to Chinese and Japanese for the procedure to construct an eyelid crease, or “double-eyelid procedure”.

As described in previous publications by the author, the crease may be asymmetric in its presentation or be absent in one eye and present in the other. It may be continuous or segmented (fragmented).

Figure 1-4 shows the various configurations of the Asian eyelid.


Chen has previously described the various forms of Asian eyelids, as illustrated. (A) Single eyelid without crease. (B) Same size eyelid fissure with crease. (C) Segmented or non-continuous crease. (D) Partial or incomplete crease. (E) Multiple creases. (F) Asian eyelid with a nasally tapered crease; in a small percentage of cases it shows some lateral flare. (G) Asian eyelid with a parallel crease. (H) Typical Caucasian semilunar crease.

Figure 1-5 illustrates the visual expansion of the eye size when a natural crease is added. From the original eye size of Width (W 1 ) and Height (H 1 ), the apparent fissure size is expanded to W 2 , and H 2 when a crease is there, either through surgery, eyelid tape, glue or attached thin strings or fibers.


The addition of a crease that is appropriate in nature adds to the apparent width (W 2 ) and height (H 2 ) of the eyelid fissure.


Publications in early Japanese medical literature favored the suture ligation method. The first description of this method, by Mikamo, was published in 1896 (see Appendix 1 , and Appendix 2 under Shirakabe, 1985). Mikamo performed the procedure on a Japanese woman who did not have a crease in her right upper lid ( Figure 1-6 ). The crease was designed to be 6–8 mm from the ciliary margin. Three 4-0 braided silk sutures were used, passing through the full thickness of the lid from the conjunctiva to the outer layer of skin. The depth of the crease was adjusted by the number of days the sutures were left in place, the range being 2–6 days.


Mikamo’s first case in 1896. He performed lid crease enhancement via translid suturing on the right eye of a woman. His drawing showed preoperative view (right of drawing) as well as 21 days’ postoperative view (left of the drawing).

From Mikamo K: A technique in the double-eyelid operation. J Chugaishinpo 1896; 396:9.

As early as 1926, Uchida described his suture ligation method for the double-eyelid operation. He performed the procedure on 1523 eyelids in 396 male and 444 female patients. Uchida described the crease configuration as a fan shape, that is, a somewhat rounded crease. The crease was designed to be 7–8 mm from the ciliary margin. Three buried catgut sutures were used on each lid, encompassing approximately 2 mm of eyelid tissue horizontally. The sutures were removed 4 days after placement.

The first mention of an external incision method dates to 1929, when Maruo reported on both his suturing technique and his incision technique. Maruo’s incision technique required a crease incision across the lid, designed to be 7 mm from the ciliary margin. The wound closure technique was a translid passage from the conjunctival side just above the superior tarsal border to the anterior skin surface. One 5-0 catgut suture was used to imbricate four throws along the superior tarsal border, attaching the skin edges to the underlying tarsal plate. The spacing between each throw of the stitch was about 5–6 mm. Maruo also discussed subcutaneous dissection 5 mm superior and inferior to the incision line.

In 1933, preference for a higher placement of the crease became evident when Hata reported his suture ligation method. The crease line was placed 10 mm from the ciliary margin. Hata used three double-armed 5-0 braided silk sutures, passing them from tarsus to skin and fixing them to the skin surface using small beads. Each arm of the suture required 1 mm spacing for the bead to be tied. Stitches were removed after 8–10 days.

In a comprehensive and scholarly article in 1938, Hayashi described the two methods of crease formation. His suture ligation technique was modeled after Mikamo’s method but was novel in that it was designed for a nasally tapered crease. Three sutures were used on each lid. The central and lateral sutures were applied superior to the crease line or tarsal plate, whereas the medial suture was deliberately applied below the crease line or tarsal plate. Hayashi’s incision method was also revolutionary, in that he advocated excision of the pretarsal orbicularis oculi muscle at the area of the incision. He also advocated the use of interrupted skin–tarsus–skin sutures, and in between skin–skin stitches consisting of 4-0 silk for wound closure. The crease was designed so that medially it was 5 mm from the ciliary margin, centrally 6 mm from the margin, and laterally 7 mm from the margin; in essence it was a nasally tapered crease. The sutures were removed after 4 days.

Inoue in 1947 proposed dissecting the “connective tissues” in the subcutaneous plane between the incision line and the ciliary margin. Sutures of 5-0 braided silk were used for skin–tarsus–skin closure; sutures were removed after only 2–3 days.

In 1950, Mitsui continued the evolution of the double-eyelid crease procedure when he described the dissection and removal of pretarsal connective tissue, including pretarsal orbicularis muscle and pretarsal fat pads. Wound closure was carried out in two steps. First, five separate nylon sutures were used to stitch the inferior skin border to the anterior surface of the superior tarsal border and were tied individually. Second, 5-0 braided silk was used to close the incision site skin to skin. The nylon sutures were removed after 2–3 days, the silk sutures after 7–8 days.

Ohashi described a double-eyelid crease operation using an electric coagulator. The cautery needle was applied vertically to the skin surface along the crease line until the skin blistered; two more rows of cauterization below the crease line followed. Hirose and Ikegami in 1951 briefly discussed incision methods but did not offer any new information.

The foregoing procedures were described only in the Japanese literature and were not readily available to Western readers. As a result, the publication of articles on this procedure in Western medical journals in the 1950s made the procedure seem new (and Western) in concept. Between 1896 and 1950, 11 articles relating to the suture ligation methods and eight articles on external incision methods were published in the Japanese medical literature (see Appendix 1 for selected articles).

Much of the later Western literature on this subject described techniques quite similar to those described in the early Japanese publications (see Chapter 4 for a continuation of historical publications from the 1950s onwards).

Figure 1-7 shows an eyelid without a crease. There is a mild degree of upper lid hooding, causing secondary downward rotation of the lashes. Figure 1-8 is an eyelid in which a portion of the crease has been obliterated. An eyelid with an incomplete or partial crease is shown in Figure 1-9 . The crease originates in the medial canthus and medial upper lid fold (supracanthal web) and extends halfway across the upper lid. Multiple creases are illustrated in Figure 1-10 , where two well-defined creases run parallel to each other. Figure 1-11 shows a nasally-joining crease (NJC). The lateral third of the crease may be the same distance from the eyelash margin as the central third, or it may rise slightly to form a laterally-flared crease, in which the lateral third of the crease is further from the lash margin than the central third. A Caucasian upper lid crease is shown in Figure 1-12 , where the central third of the crease is farthest from the lash margin.


Asian lid without crease. This patient has moderate upper lid hooding causing downward rotation of the lashes. Note the apparent upper lid hooding (fold) that overshadows the smaller palpebral fissure laterally. Strategic placement of a crease would make the palpebral fissure seem larger.

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Apr 6, 2024 | Posted by in General Surgery | Comments Off on What is an Upper Lid Crease and Historical Consideration: 双眼皮与手术历史

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