Asian Double Fold Surgery Because many Asians have single eyelids or very small double eyelids, shallow orbit, Mongolian fold and slanted eyelid fissure, their eyes look small, tired, sleepy, stinging and sometimes violent. So, double eyelid surgery with medial epicanthoplasty is the most popular and the most effective cosmetic surgery among Asians. Asian double fold surgery is totally different from Caucasian one. Not only physical but also cultural differences should be taken into consideration in Asian double fold surgery. Incision vs. Non-incision Double fold surgery is largely classified into two; incision and non-incision. Non-incision double fold surgery (suture method) is recommended to whom has thin eyelid skin, little eyelid fat and tight eyelid skin. Eventhough non-incisional technique has spot scar and minimal recovery period, the fold can be disappeared. Incision double fold surgery is recommened to whom has thick eyelid skin or puffy and fatty eyelid or redundant skin I mostly recommend young patients partial incisional technique (or called minimal incisional technique). Advantages : - 1. short(1 week ) recovery period - 2. minimal chance(below 0.1%)of disappearance of double fold - 3. faint and innoticeable scar - 4. more natural result - 5. easy in revisional surgery - 6. minimal tissue trauma.

Scar from partial incisional double fold surgery (dynamic fixation). When they close their eyes, the scar from partial incisional technique is flat and innoticeable. Because the incision is located in central portion only, scar is innoticeable even when the patient look downward and the line of double fold can be altered easily in secondary revisional surgery.

Dynamic vs. Static fixation
Incisional double fold surgery can be classified into two according to the method of fixation; dynamic and static.
Dynamic fixation attach skin of doule fold to shallow dynamic structure of eyelids; eye elevating (levator) muscle or its aponeurosis.
Resulting scar is even, flat and innoticeable because fixation is movable, shallow and at rest when they close eyes.
The shape of double fold is more natural of course.
But it is difficult to make double fold symmetric because not only the height of incision but also the tension between two mobile structure should be controlled.
So, it needs many experiences and delicate technique and recommendable to Asian double fold surgery.
Static fixation attach skin to deep tarsus and resulting scar is uneven, depressed and noticeable.
But it is easier to make double fold symmetric because double fold is symmetric if only the height of incision is symmetric.
So, it is recommendable to inexperienced surgeon and Caucasian blepharoplasty.

Various unsightly scar from static double fold surgery. Scar from static double fold surgery is depressed, irregular when they close their eyes. Double fold is also deep and unnatural even when they open their eyes.

Why natural and fast healing double fold ?
Many patients ask me why double fold at OZ is natural, heals fast and has innoticeable scar and simple and fine line.
But it is not easy to answer briefly because this is very complex and delicate.
I'll exemplify some important principles of double fold at OZ eventhough these are very professional and hard to understand.

1. Double fold line : If double fold line follow natural skin fold in eyelid and is placed in lower thin skin, resulting scar is even and fine.
2. Local anesthesia : If local anesthesia is injected slowly with thinnest needle, pain is minimized and postoperative swelling and bruise is lessened.
3. Incision and dissection : If incision is right angled to skin, tissue is handled cautiously, bleeding is coagulated meticulously and subcutaneous tissue including blood and lymphatic channels are preserved, tissue trauma is minimized. So, resulting scar is minimized with no irregularity and wound healing is fastened.
4. Redundant skin and fat : Redundant skin makes double fold concealed, small and makes eyes puffy, dull.
   Excess skin and fat should be excised but not too much of course.
5. Fixation : If skin is attached to loose movable levator muscle aponeurosis with appropriate tension, resulting double fold is shallow and natural. The tension in fixation is the key in dynamic double fold fixation.
6. Closure : Both ends of skin edges are approximated with fine threads and this skin closure is seperated from deeper double fold fixation.

Medial Epicanthoplasty
Medial epicanthoplasty means removal of Mongolian fold which obstruct the medial corner of eye and make eyes look apart.
Among my patients who undergo double fold surgery, about 80% of patients also undergo medial epicanthoplasty.

Effects of medial epicanthoplasty : These effects are very complex and delicate.
- 1. It decreases intercanthal distance (eyes become closer) and the ratio between length of eyes and intercanthal distance becomes closer to ideal ratio of 1:1.
- 2. It reveals medial half of eyes more by turn aside the redundant drooping Mongolian fold and eyes look bigger and brighter.
- 3. It reveals medial half of double fold more also and make the line more natural and softer.
- 4. It moves medial canthus not only medially but also upward and eyes look less slanted and impression becomes softer.

Magic Epicanthoplasty :
The technique of medial epicanthoplasty has developed a lot in recent 10 years.
The result becomes more natural and the scar becomes less noticeable.
Magic epicanthoplasty (sometimes called No Scar Epicanthoplasty) blow away the worry about scar and made medial epicanthoplasty more popular.

Compare these two cases of double fold surgery with or without medial epicanthoplasty.

Double fold surgery with medial epicanthoplasty Her eyes becomes bigger, brighter and less slanted. The width of eye and length between eyes become similar. Her impression becomes softer.	Double fold surgery without medial epicanthoplasty Eventhough double folds were created, she still looks stinging and her eyes look more slanted. Remained Mongolian folds seem to pull double fold inferiorly, block medial half of eyes, conceal the medial portion of double fold.

Lateral Canthoplasty
Many people misunderstand that lateral canthoplasty can make their eyes elongated horizontally at lateral end because medial epicanthoplasty really make their eyes elongated horizontally at medial end..
But that' not true ! Lateral canthoplasty is not a counterpart of medial epicanthoplasty at lateral end. They are totally different.
Lateral canthoplasty moves lateral canthus backward, not laterally.
This is only recommendable to whom has narrow and close lateral canthus.

Lateral Canthoplasty Lateral canthoplasty moves lateral canthus backward about 1 or 2 mm. Eventhough eyes look bigger in side view, there is little change in front view. Elongated portion has no eyelash and sometimes may look weird on close inspection.

Secondary (Revisional) Double Fold Surgery
Because double fold surgery is the most popular surgery in Korea, revisional double fold surgery also becomes one of the most popular surgery.
The most common causes of revision are too high, deep and unnatural fold, deep and uneven scar, asymmetry, too small or too shallow fold.
Revisional surgery is more difficult than primary surgery because of scar and adhesion.

Revisional double fold surgery Too high or too deep double fold not only make eyes look smaller and unnatural but also interfere with complete eye opening. By making double fold smaller and shallower and releasing eye opening muscle, eyes can look larger, brighter and the patients can open their eyes completely.

Ptosis
Ptosis (also known as Blepharoptosis) refers to an eyelid which is droopy. A person with ptosis is not able to lift one or both upper eyelids to uncover the eye completely and pupil is not exposed more than 70 to 80% in straight forward gaze.
This may cause sleepy appearance, early forehead wrinkle and headaches in mild cases and loss of vision in severe cases.
Nowadays, plastic surgeons have a tendency to recommend ptosis correction to mild cases who have more than 70% pupil exposure.
Surgery usually shorten eye elevating muscle and double fold is created.

Bilateral ptosis after 2 weeks

Unilateral ptosis after 5 days

Upper Blepharoplasty and Brow Elevation
As you get old, eyelid skin and eyebrows sag, which makes you look tired, sleepy and older.
Redundant skin is excised in upper eyelids and eyebrows are elevated.
Position of eyebrows is very important.
If eyebrows are low, upper eyelid skin sags more, eyelids look puffy, they look tired or angry.
After eyebrow elevation, they look brighter and younger.
There are several ways in eyebrow elevation ; scalp brow elevation, endoscopic brow elevation, suprabrow excision, subbrow excision, transblepharoplasty eybrow elevation.

• Scalp brow elevation : Through scalp incision, forehead and brows are elevated.
  Accurate control and secure fixation, but long scalp scar.
• Endoscopic brow elevation : Through small holes in scalp, brows are elevated and fixed with Endotine (self resolving fixation plate)
  Fast operation with minimal scar, but expensive. Recommendable to young patients.
• Suprabrow excision : Suprabrow skin and muscle are excised.
  Simple operation, but suprabrow scar. Recommendable to whose brows are very low and who wants simple surgery.
• Subbrow excision : Subbrow skin and muscle are excised.
  Simple and fast operaton, but subbrow scar. Recommendable to whom has thick and puffy upper eyelids and who wants simple surgery..
• Transblepharoplasty eybrow elevation : Through blepharoplasty incision, eyebrows are elevated and fixated into periosteum.
  No scar but insecure fixation
  

Upper blepharoplasty after 1 month Redundant skin was excised and double fold was created. Because she had thin eyelid skin and normal eyebrow position, subbrow excision was not needed.

Upper blepharoplasty with subbrow excision after 1 month Because she had thick skin, puffy eyelids and low eyebrows, blepharoplasty and subbrow excision was done simultaneously. Take note thin crisp double fold and elevated eyebrows with brighter impression. Scar becomes innoticeable after 3 months.

Subbrow excision If the patient just want to remove redundant skin without makind double fold, subbrow excision alone can be performed.

Suprabrow excision If the patient's eyebrows are low and want simple surgery, suprabrow excision can be performed. Take note change of the eyebrow shape and brighter and younger impression after brow elevation.

Lower blepharoplasty (Eye Bag Removal) after 3 months If the patient has redundant skin and muscle, external approach is performed. Lower lid fat is redistributed or removed.

Transconjunctival Fat Removal after 7 days If the patient has lower fat bulge without redundant skin, transconjunctival fat removal is performed. There is no external wound and recover much faster.