Quick Summary
- The absence of a double eyelid crease (“single eyelid”) is common in some East Asian populations
- The cause of absent eyelid creases is the lack of attachments from the eyelid elevator muscle to the skin, most commonly congenital, followed by aging changes
- Absent double eyelid creases can create the appearance of smaller eyes and may contribute to a tired and sleepy look. Individuals with double eyelid creases are often perceived as alert, bright and attractive
- There are different shapes of upper eyelid folds: the hidden fold, the tapered fold and the parallel fold
- There are two main types of crease creation double eyelid surgery: minimal-incisional (suture) and incisional double eyelid surgery, and two main methods of skin excision for accentuation of double creases
A Brief History Double Eyelid Surgery in Asians
The first description of surgical double crease creation was by Mikamo in 1896, where Mikamo described his suture technique in a patient who did not have an eyelid crease in one eye. He estimated the incidence of the single eyelid in Japanese women to be approximately 17 to 18% and regarded the double eyelid as the typical eyelid appearance. In this article, Mikamo described how he used three sutures passed through the full thickness of the eyelid, placed approximately 3 mm apart, 6 to 8 mm above the lid margin (the eyelash line), and these were removed after 4 to 6 days. Interest in this procedure started building, and Uchida published his experience in 1926. The first publication of the incisional technique was by Maruo (1929), in which he performed an incision 7 mm above the lid margin, and created a connection between the the eyelid skin (superior tarsal border of the skin edge) and the underlying tarsal plate using sutures that passed through the conjunctiva (a membrane lining the inside of the eyelid) . Subsequently, publications by Hayashi, Inoue, Sayoc, Mitsui, Fernandez and Boo-Chai described incisional techniques that permitted more controlled crease formation and the ability to perform other simultaneous modifications.
The Asian vs Western Upper Eyelid
The Asian differs from the Western upper eyelid in the following aspects:
- The Asian upper eyelid often lacks a double eyelid crease. This is due to the lack of muscle fiber adhesions from the eyelid elevator (“levator palpebrae superioris”) muscle to the skin, which is present in the majority of Westerners
- Asians with double creases often have a lower crease height (“pretarsal show”) than Westerners
- Asians with double eyelid creases usually have tapered crease configuration; Westerners often have a parallel crease
- Asians often have an excess of droopy skin on the inner aspect of the eyelid (“epicanthal fold”)
Creation of the beautiful upper eyelid crease requires knowledge of the anatomy and appreciation of ethnic norms. Contrary to popular myths, creation of a beautiful Asian upper eyelid is not simply putting a Western-style crease on an Asian face.
The Perennial Debate Amongst Plastic Surgeons: Incisional or Non-incisional?
Plastic surgeons have debated for decades on which technique is better: the incisional or non-incisional technique. My personal experience has taught me that the real debate is not which technique is better, but rather, which technique is more appropriate for the particular individual sitting in front of me. To summarize what would otherwise be a very long and technical discussion, no one technique produces satisfactory results in all patients. Hoping to achieve a good outcome with all patients with a broad range of different anatomy often yields disappointment. An experienced surgeon identifies the individual’s unique anatomy and applies the appropriate method to achieve the desired results.
In the professional plastic surgery literature, the reported long-term failure (i.e. loss of crease) of minimal incision techniques range from 0.5 to 5.0%, whereas the figure is 0.12 to 2.2% with the incisional technique. The reason for variability in results depends on each surgeons’ patient selection (for the particular technique that they have published on) and the length of their follow-up. As expected, those with longer follow-ups will see a higher failure rate over time.
Patients who are ideal for minimal-incision techniques include:
- Young patients with no or minimal skin excess
- Do not require any other eyelid modification procedures, e.g. removal of excess fat
- Are able to accept possible loss of crease, requiring further surgery in the future
Patients who are ideal for incisional techniques include
- Older patients with some skin excess, which is concurrently removed during the crease-formation surgery
- Require other eyelid modifications, such as removal of excess upper eyelid fat, or correction of the epicanthal fold
- Patients who desire a stable double-eyelid crease with longer-lasting results
- Failure of previous minimal-incision technique blepharoplasty
What is the Difference in Scarring Between Minimal-Incisional (“stitch”) and Incisional Blepharoplasty?
In both cases, the scars are sited at the intended double crease, approximately 5 to 8 mm above the eyelashes. When the eyelid is open, the skin folds over the incision line and conceals the scar, regardless of whether a minimal-incisional or incisional technique is performed, i.e. the scar is not visible. When the eyelid is closed, the scar is more visible with the incisional technique, usually only for the first 2 months. With appropriate treatment, this scar fades quickly and is almost imperceptible at about 3 to 6 months postoperatively. It is extremely uncommon for individuals to have unsatisfactory upper eyelid scars from either procedure.
Illustrative Cases
We have included some illustrative cases below.
*Direct comparative pre- and post-operative photographs are prohibited by the Healthcare Services Act (Advertising) in Singapore
Case 1
A 32 year old female came for consultation, requesting for double eyelid creation as her crease was absent/very faint since childhood, causing her eyes to appear small and sleepy. Examination showed her to have good skin quality without laxity or drooping, good eye opening (no ptosis) and a thin skin-muscle layer covering the eyelid.
She was suitable for minimal-incision and incisional upper blepharoplasty. She opted to proceed with minimal-incision blepharoplasty.
Case 2
A 30 year old female presented 3 months after a road traffic accident, noting that the left eye had difficulty opening and was associated with a loss of the inner portion of the double eyelid crease. Physical examination noted symmetrical position of the eyebrows but reduced eye opening on the left side (moderate-to-severe ptosis), as evidenced by the reduced MRD1 distance (distance between the pupil and upper eyelid margin). There was a loss of the inner third of the upper eyelid crease. She required repair of the eyelid elevator (levator palpebrae superioris) muscle and crease formation. Her eyelid skin-muscle layer was also thicker and heavier than the example in Case 1, and a minimal-incision crease formation procedure would have been likely to be less effective. As the eyelid drooping was moderate-to-severe, repair through a full upper eyelid incision was required, and the crease was re-created by suturing the orbicularis muscle to the levator-tarsus complex.
Case 3
A 71 year old male presented with bilateral eye droopiness and loss of the double eyelid over the past few years, worse following his cataract operation 5 years ago. Close examination showed bilateral reduced eye opening (moderate ptosis) and significant skin laxity (dermatochalasis) that was covering the double eyelid (pretarsal skin), creating the perception of a single eyelid. He required upper eyelid skin excision, repair of the eyelid elevator (levator palpebrae superioris) muscle and crease reinforcement. This was achieved by a full upper eyelid incision, and the crease was reinforced by suturing the orbicularis muscle to the levator-tarsus complex.
The Picasso Plastic Surgery Advantage
The upper eyelid is anatomically complex and delicate. Successful outcomes demand accurate preoperative assessment, appropriate planning, precise execution, and meticulous postoperative care. Our Singapore board-certified surgeons are experienced in aesthetic and functional eyelid surgery and have a deep understanding of cultural aesthetic norms. Picasso Plastic Surgery also has European Board-certified plastic surgeons who are familiar with Western eyelid anatomy and related surgery. We carefully customise every procedure with precision and artistry to ensure natural, elegant outcomes that enhance each individual’s authentic beauty. Our clinic has an en-suite operating room that promises maximal comfort and privacy, and permits scheduling flexibility. Our surgeons are regarded for their work on eyelid surgery and frequently present their experience as invited faculty at international plastic surgery conferences and have written book chapters as well. Picasso Plastic Surgery has a strong reputation amongst peers and attracts regional and local plastic surgeon observers. Our highly trained support staff are attentive and skilled, and will partner you through your entire journey to attain a beautiful and bespoke outcome.
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