Asian Blepharoplasty (Double Eyelid Surgery)

Although about half of the Asian population does have a fold in the area above the eyelashes, the other 50% of the population does not. For those without a fold, a blepharoplasty procedure can create a natural-looking crease. Known as “Asian double eyelid surgery,” this procedure aims to surgically create creases in the eyelids of Asian patients. Generally, the lid starts at the crease very close to the eyelashes. As the crease becomes further away from the nose, it gets larger until it reaches the midpoint of the pupil. In effect, the fold runs parallel to the eyelash origin.

Before & After Eyelid Photos
See additional eyelid photos

At his practice, Dr. Lee offers the DST Double sutures and twisting method (DST) technique, which is a sophisticated version of the traditional suture (non-incision) methods of double eyelid surgery. Contrary to the relatively high breakage rate and indistinct folds associated with the traditional method among Asian patients, this innovative technique not only addresses these disadvantages, but also maintains the benefits of the traditional method, including:

  • Virtually scarless folds
  • Naturalness to the creases
  • Fast recovery

Asian vs. Caucasian Eyelids

The difference between Asian and Caucasian eyelids is in the position of the eyelid fold. Asians who do have a crease above their eye have very different looking eyelids than Caucasians. The Asian eyelid typically starts at the crease very close to the eyelashes. As the crease gets further away from the nose, it gets larger and larger until the midpoint of the pupil, at which point the fold runs parallel to the eyelash origin.

A Caucasian lid crease is slightly different in both shape and size. It typically tapers closer to the eyelashes as the fold goes out laterally so that it is more of an upside-down “U” shape, rather than a parallel shape to the eyelash lid. The Caucasian lid crease is also about 20% larger than an Asian eyelid crease. When considering the blepharoplasty techniques that will be used to place a crease, it is important for both the patient and the surgeon to understand that the goal of double eyelid surgery is not to westernize an Asian face, but to create a crease that looks natural.

Asian Double Eyelid Surgery Methods

DST Double sutures and twisting method (DST) technique is the most sophisticated of the suture (non-incision) methods of double eyelid surgery. The traditional suture method has been criticized for its relatively high breakage rate and indistinct folds, which fade over time. The DST technique addresses these disadvantages while maintaining the benefits of a suture technique, such as the virtually scarless fold, a supreme naturalness to the crease, the potential reversibility and the quick recovery, which takes just a few days instead of weeks. In a suture method eyelid procedure, a crease is created by burying permanent non-reactive sutures (prolene, used in heart valve surgery) pinching a bit of the undersurface of the eyelid skin to the deep soft tissue of the eyelid.

An analysis of fold failure in such cases reveals that sutures do not usually break, but rather the sutures cheesewire through the soft tissue of the upper eyelid. The DST technique rectifies this problem by securing the sutures to firmer structures less likely to allow the sutures to tear through. This is accomplished by first securing one end of the sutures to the firmest structure of the upper lid, the tarsal plate, which is made of strong cartilage.

The other end of the suture is interlinked to an adjacent suture, much like two links on a chain. A bit of the underbelly of the eyelid skin is pinched into the suture before tying the knot. This results in a firm interlocked fold which is tremendously resistant to tearing through or breaking.

The published report for breakage or loss of fold is approximately one percent per year (ten year follow up). This statement is remarkable for two reasons. One is that a claim of superior results has been supported by scientific data, a rare accomplishment in and of itself in aesthetic surgery. Secondly, an extraordinarily low failure rate has been established, comparable to an incision method. We hope to dispel some common misconceptions. First and foremost is the notion that the DST technique frequently fails or disappears over time. This has been repudiated by published study, our extensive personal experience with hundreds if not thousands of cases, and a reasoned explanation of why this procedure works. In anecdotal comments we have received, the most common source of misinformation has been in confusing the DST technique with traditional suture techniques that are unreliable.

Another misconception is that the DST technique results in more scarring than an open procedure. Because no significant incisions are made, there is virtually no scarring. This lack of scarring allows the procedure to be reversed by simple removal the sutures. In addition, we have confirmed during the occasional re-surgery that DST patients have much less scarring than those that have had prior incisional surgery. The ease with which re-surgery can be performed is reflected by the fact that we have always been able to revise DST procedures without difficulty.

Anchor incisional crease surgery before and after photo #2
Fold failure after prior incisional surgery elsewhere (left) corrected with DST suture technique (right)

As a practical matter the DST procedure continues to have tremendous appeal and secure reputation in the Beverly Hills and other Southern Californian communities. The majority of patients have referred themselves to our office after their friends have had the procedure done and have witnessed.

We consider the DST technique the procedure of choice for the ideal candidate, as described below. The best candidates for the DST technique have: A) thin skin that is not excessive and do not have a lot of upper lid fat, have not had prior eyelid surgery; B) whose brows are not low or heavy; C) who do not have complex eyelid problems such as ptosis (“sleepy eye”) or retraction (overly pulled upper lid). Other candidates for the procedure include A) men, who generally cannot conceal the incisions with makeup, B) smokers (more than ten cigarettes per day), who are at higher risk of prominent scar. C) Patients with a fear of incisional surgery. D) Those in need of quick recovery period, who have a few days, not weeks.

Risks of surgery Debate continues regarding the preference of incisional vs. suture method crease formation. Although suture techniques are sometimes disparaged as inferior surgery, patients resistant to the incision technique know something on an instinctive level – that the risks of an incisional surgery are more significant. The main risk of suture technique is fold failure. This is an annoying, embarrassing, but ultimately a readily correctable problem. The significant major risk of incisional surgery, on the other hand, is damage to the levator mechanism, which can result in ptosis (sleepy eye) or retraction (lid stare). Inexperienced surgeons can also create havoc by over removing fat and/or skin, resulting in an uncorrectable, permanent deformity. Finally there is on occasion the poor scarring and permanent puffiness of the upper lid, overwhelmingly which occur in smokers, cigarettes or otherwise.

Incisional technique The ideal candidate for Incisional technique include patients who are A) older than the latter 20′s, B) have excess skin or fat, C) desire a larger, dramatic fold who have a preference for an Incisional technique. Some of the less ideal candidates for this technique include: A) Smokers (more than ten cigarettes daily), B) who will scar more prominently C) Excessively saggy brows or deep forehead wrinkles, whose correction would lead to too much removal of upper lid skin. D) Multiple prior upper lid surgeries, whose scarring results in limited eyelid function, and who probably should limit themselves to correcting eye problems related to function, not appearance enhancement.

Surgeons differ in two major areas: the crease markings which will determine the shape and size of the fold, and technique of surgery, namely which deep eyelid structure will the skin be secured to. Although many types of folds have been described, the most natural (hence, ideal) shape of the fold is a tapered fold and the parallel fold, referring to the shape in relation to the margin of the inner half of the eyelid. The ideal size of the fold allows 2 – 3mm of skin above the eyelashes to show on direct frontal view with the eyes open. This also usually corresponds to a crease set at 10mm from the lash line when the eyes are closed (with the skin on light tension). This height is modified based on whether the eyeball is slightly deep set (larger crease) or overly shallow (smaller crease). This height also corresponds to the size of the tarsal plate, the cartilaginous skeleton of the eyelid. Skin excision is usually needed, determined by the sagginess of the brow – more skin removal being required for saggier brows. Skin excision is limited to 3 or 4mm in order to maintain the naturalness of the eye area and prevent risk of dry eyes. Patients over age 40 and those who require more correction than this are strongly encouraged to consider a brow lift. An advantage of undergoing an evaluation from a plastic surgeon certified by the American Board of Plastic Surgery is that such surgeons are trained to evaluate and treat not only your eyelids but your face in its entirety, whether it is the eyebrows or the midface.

25-year-old woman with incisional anchor eyelid surgery. As seen on the Dr. Phil Show.
More dramatic folds result from an incisional “anchor” blepharoplasty with a brow lift.
Technical differences between surgeons involve the structure to which the eyelid skin-muscle is secured. One structure preferred by some surgeons is the septum, lying deep to the skin-muscle. The advantage of securing the fold to this structure is that there is minimal swelling due to the limited dissection. The disadvantage is that any excess fat, which lies just deep to the septum is not addressed. Also the limited dissection leads to a higher rate of crease failure. Perhaps the most popular technique today is securing the skin to the levator aponeurosis, the structure just deep to the fat and which is responsible for pulling the eyelid open. This technique, developed in the 1960′s by plastic surgeon Leabert Fernandez, is considered the first modern technique for double eyelid surgery. Although probably used by more surgeons than any other, a drawback is the not-insignificant rate of fold failure and imprecision in the crease. This phenomenon is due to the fact that the levator aponeurosis is a structure with a glossy, teflon-like surface, necessary for gliding motion as the levator aponeurosis lifts and lowers the eyelid. This slippery surface, unfortunately, also can resist attempts to attach the skin-muscle to it when creating a surgical fold. This can result in imprecise folds that “slide” around. This also accounts for the occasional fold loss.

Prior incisional surgery with skin fixation to levator aponeurosis performed elsewhere resulting in multiple creases, indistinct fold, and left eyelid ptosis (droopage) (left photo).

Asian eyelid surgery
Correction using anchor technique with fixation of skin to tarsal plate and correction of detached levator aponeurosis (right photo).

The most precise, permanent folds result from securing the skin-muscle to the tarsal plate, lying beneath the levator aponeurosis. Fat and other slippery soft tissues are removed to allow the muscle and skin to attach to the rough raw surface of the tarsus. The result is a secure permanent crease. This technique is known as an “anchor blepharoplasty”. One drawback of this technique is the complexity of the operation which has limited the number of surgeons who feel comfortable with this technique. Performed properly, however, the procedure results in a highly stylized precise, permanent crease.

Eyelid Surgery

S = Skin
F = Fat
LA = Levator aponeurosis
TP = Tarsal Plate
In the “anchor” technique, the crease is secured to the Tarsal Plate rather than the Levator Aponeurosis resulting in a more secure fold. The levator aponeurosis has a slippery, shiny surface which is a less secure structure than the tarsal plate for suturing.

Medial epicanthoplasty The medial epicanthus (ME), or Mongolian fold, covers the inner corner of the eyelid. The degree of severity can be categorized as non existent or mild, moderate and severe, depending on how much of the caruncle (the pink “bump” inside the eye corner) is exposed. The severe cases should be corrected; for moderate folds, correction is optional. One popular technique for correction is to remove a crescent of skin along the ME. The location of the incision is parallel to the edge of the fold, in an attempt to hide it. Our observation is that this frequently leads to a widening of the scars due to the stretching forces resisting against the incision. In addition. the crescent removals are frequently performed as one long incision connected to the double-eyelid incision. We find that the continuous incision contributes to an undesirable appearance of the scar. Instead, our preference is what is called a “v-w plasty” in which incisions are placed not parallel but perpendicular to the edge of the ME. 7 sutures carefully placed with the aid of magnifying loupes usually results in barely detectable scars. However, we limit this procedure to non smokers.

Anchor incisional crease surgery
Double sutures and Twisting (DST) method Asian eyelid surgery with v-w medial epicanthoplasty (ME)

For a technical description of the procedures described above geared to physicians, please go to:

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