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
Asian double fold surgery is totally different from Caucasian
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
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
I mostly recommend young patients partial
incisional technique (or called minimal
- 1. short(1 week ) recovery period
- 2. minimal chance(below 0.1%)of disappearance of double
- 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
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.
Incisional double fold surgery can be classified into two according
to the method of fixation; dynamic and static.
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.
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
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
I'll exemplify some important principles of double fold at OZ eventhough
these are very professional and hard to understand.
- 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.
- Local anesthesia : If local anesthesia is injected slowly with
thinnest needle, pain is minimized and postoperative swelling
and bruise is lessened.
- 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.
- 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.
- 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.
- Closure : Both ends of skin edges are approximated with fine
threads and this skin closure is seperated from deeper double
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
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
Compare these two cases of double fold surgery with or without medial
Double fold surgery with
Her eyes becomes bigger, brighter and less slanted. The width
of eye and length between eyes become similar. Her impression
Double fold surgery without
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
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
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
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.
(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
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.
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 (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
- 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
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
Scar becomes innoticeable after 3 months.
If the patient just want to remove redundant skin without
makind double fold, subbrow excision alone can be performed.
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.
Blepharoplasty, Dark Circle Correction and Fat Graft
Lower eyelid fat bulge is caused by excess lower lid fat, skin &
muscles, loosened fascia which block lower lid fat bulge, absorption
of bone along nasojugal groove. So, removal of excess fat, skin &
muscles, tightening of fascia, redistribution of lower lid fat, augmentation
of nasojugal groove can be helpful to make the patients look younger
According to the causes of lower lid fat bulge, the exact method can
Dark circle can be improved also by lower blepharoplasty.
In young patients who need only lower fat removal, we recommend transconjunctival
In some patients with dark circle, fat graft can be recommended.
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
If the patient has lower fat bulge without redundant skin,
transconjunctival fat removal is performed. There is no external
wound and recover much faster.