Abstract
Background
Recent studies on postoperative measurements for upper blepharoplasty utilized static photographs, which fail to accurately reflect the postsurgical dynamic naturalness of the eyelids.
Objectives
In this study we aimed to analyze dynamic naturalness after double-eyelid blepharoplasty with a simple smartphone method involving slow-motion videos.
Methods
In this prospective observational study we enrolled patients who underwent double-eyelid blepharoplasty with the flexible suspension technique (FST) and rigid fixation technique (RFT), and individuals with congenital double eyelids. Demographic information was collected, and ultra-slow-motion videos of the eye-opening processes were recorded with a smartphone. Four keyframes were selected from each video, from which several parameters were measured. A third party evaluated the degree of naturalness of the photographs and eye-opening videos.
Results
Sixty females (20 per group) were enrolled. The fold-emerging delay (FED) score showed a linear correlation with the mean third-party dynamic naturalness rating (DNR) (R2 = 0.71, P < .0001). The puffy score showed a linear correlation with the mean third-party static naturalness rating (SNR) (R2 = 0.53, P < .0001). For the congenital, FST, and RFT groups, respectively, the FED scores were 62.9 ± 18.9, 52.2 ± 17.7, and 26.3 ± 18.3 (all P < .05); the puffy scores were 49.8 ± 11.9, 55.9 ± 11.0, and 62.6 ± 12.4 (congenital vs FST, P = .055; others P < .05); the mean third-party DNRs were 3.21 ± 0.67, 2.47 ± 0.62, and 1.78 ± 0.74 (all P < .0001); and the mean third-party SNRs were 3.01 ± 0.78, 2.61 ± 0.55, and 2.14 ± 0.69 (all P < .05).
Conclusions
The 2 new indices obtained from the analysis of smartphone-captured ultra-slow-motion videos are good indicators of the dynamic naturalness of double eyelids created with upper blepharoplasty.
Level of Evidence: 4 (Therapeutic)
The eyes of East Asians are characterized by a single eyelid and epicanthus. Therefore, upper blepharoplasty, especially double-eyelid surgery, is the most common aesthetic surgery conducted in China that has garnered considerable attention.1
Upper blepharoplasty is performed for upper eyelid rejuvenation more often in Caucasians, whereas “double-eyelid surgery” is more commonly performed in East Asians. Double-eyelid surgery can be classified by the incision and burial suture methods.1 Double-eyelid surgery involves connecting the palpebral skin to the up-lifting power system to create a palpebral furrow.2 The ideal objective of this surgery is to mimic the appearance of natural-looking double eyelids. Based on the different anatomical structures involved in the connection, the incision method can be divided into the flexible suspension technique (FST), rigid fixation technique (RFT), and combination technique.3,4 Our previous studies have shown that double eyelids created by FST surgery are more in line with the innate physiological way of opening the eyes, that is, “natural” or congenital double eyelids, whereas double eyelids created by RFT surgery tend to appear stiff, leading to “unnatural” double eyelids.
Previous research on upper blepharoplasty focused on the measurement of certain distances or angles in the resting state with the eyes open or closed, such as marginal reflex distance (MRD)1 and MRD2.5-7 These studies verified whether upper blepharoplasty improved the height of the palpebral fissure and sagging eyelids; however, it was difficult to determine whether the postoperative eye-opening process was natural or unnatural mainly due to the fact that still photographs inherently failed to meet the requirements for recording eye movements.8
In this study, we devised a simple and effective method that utilized the ultra-slow-motion function of a smartphone to capture a video in which the eye-opening action was slowed down by 256 times and several keyframes were selected and measured. We proposed 2 new parameters to judge the degree of naturalness after blepharoplasty, followed by comparison with third-party evaluations to determine their reliability. With these results, we verified the degree of natural double-eyelid formation with FST and RFT.
METHODS
Patients and Surgical Techniques
At Zhejiang Provincial People's Hospital, 1 senior researcher (S.W.) performed double-eyelid surgery with the FST for 424 patients and another senior researcher (H.S.) performed double-eyelid surgery with the RFT for 611 patients between January 2017 and May 2022. The inclusion criteria for this study were as follows: (1) patient's age at the time of surgery was between 18 and 35 years, (2) the skin of the upper eyelid showed no obvious relaxation, and (3) photographs and videos were obtained more than 6 months after the operation. We received IRB approval from the Ethics Committee of the Zhejiang Provincial People's Hospital, and consent from all patients was received to include the patient images in this paper.
Patients were excluded if they had undergone revisional surgery, concomitant levator palpebrae superior muscle surgery, concomitant lower blepharoplasty, had a history of botulinum toxin injection around the eyes within half a year of photograph and video acquisition, or could not cooperate during the photograph and video acquisition sessions. Patients who met the criteria were contacted and asked whether they would visit our hospital for the photographs and videos. Eventually, the first 20 patients of each group who were willing to visit the hospital to be photographed were enrolled in this study. In addition, 20 patients with congenital double eyelids were chosen according to the inclusion and exclusion criteria.
The FST entailed fixing the orbicularis oculi muscle under the incision to the superficial aponeurosis of the levator palpebrae superior muscle, as described in our previous study.3 The RFT entailed fixing the skin or orbicularis oculi under the incision on the tarsal plate (Figure 1).
Figure 1.
Diagram of the up-lifting system in congenital double eyelids, flexible suspension technique–created double eyelids, and rigid fixation technique–created double eyelids. (A) The power of the congenital double eyelid is dispersed from the end of the levator muscle fiber to the skin around the double-eyelid line. (B) Power transmission of the FST double eyelid originates from the superficial aponeurosis of the levator muscle, going to the orbicularis oculi muscle and then to the skin of the upper eyelid. (C) The power of RFT double eyelids moves directly from the levator muscle to the tarsus and then to the skin of the upper eyelid. FST, flexible suspension technique; RFT, rigid fixation technique.
Video and Photographic Analysis
Video recording was performed in a specific clinic room with all indoor lights turned on and the patient facing the window. All patients were asked to look straight ahead at the photographer during the procedure, then the photographer moved their phone position until a complete eyebrow appeared in the frame. Videos were filmed with a Huawei Mate 30 Pro (Huawei Corporation, Shenzhen, China) in the ultra-slow-motion mode (1/256, 7680 fps, 1× optical lens). Patients were instructed to relax the facial mimetic muscles, close their eyes, and open them quickly. The camera's motion-detection feature automatically recorded the eye-opening movements as a slow-motion video (Videos 1-3). The movements of each eye were recorded with these steps. The video was imported to a computer, and images of the following keyframes were selected: when the eyes were closed gently, when the double eyelid fold was first fully present, when the upper edge of the pupil was first fully exposed, and when the eyes were open to the maximum extent (Figure 2). The images were analyzed with the ImageJ software (ImageJ 1.53e, National Institutes of Health, Bethesda, MD). The selected keyframes were evaluated by a second investigator to ensure image quality and accuracy.
Figure 2.
Keyframes selected from ultra-slow-motion videos and measurement method for Area 1, Area 2, PFH1, and PFH2. (A-D) Eye-opening process of a 32-year-old female patient with congenital double eyelids. (A) With the eyes gently closed; (B) with the double-eyelid fold first fully present; (C) with the upper edge of the pupil first fully exposed; (D) with the eyes open to the maximum extent. (E-H) Eye-opening process of a 25-year-old female patient with double eyelids created with FST. (I-L) Eye-opening process of a 30-year-old female patient with double eyelids created with RFT. Area 1 (red outlined area in A, E, I: the area between the double-eyelid fold and palpebral margin when the eyes are closed; Area 2 (red outlined area in D, H, L): the area between the double-eyelid fold and palpebral margin when the eyes are opened fully; PFH1 (white double-arrow line in B, F, J): height of palpebral fissure when the double-eyelid fold has just emerged completely; PFH2 (white double-arrow line in C, G, K): height of palpebral fissure when the pupil is first fully exposed; yellow-dotted circle: external pupillary contour. FST, flexible suspension technique; PFH, palpebral fissure height; RFT, rigid fixation technique.
Fold-Emerging Delay Score and Puffy Score
Palpebral Fissure Height
The palpebral fissure height (PFH)1 was calculated as the height of the palpebral fissure at the moment when the double-eyelid fold had just completely emerged (Figure 2B). The PFH2 was calculated as the height of the palpebral fissure when the pupil was just fully exposed (Figure 2C). The fold-emerging delay (FED) score was calculated with the formula: PFH1/PFH2 × 100.
Area 1
This denotes the area between the double-eyelid fold and palpebral margin when the eyes are closed (Figure 2D).
Area 2
This denotes the area between the double-eyelid fold and the palpebral margin when the eyes are fully open (Figure 2A). The puffy score was calculated with the formula: Area 2/Area 1 × 100.
Third-Party Evaluation
Three clinicians who did not participate in the surgery and did not know the treatment methods participated in the third-party blinded evaluation. This included:
1. Dynamic naturalness rating (DNR): This entailed evaluation of the degree of naturalness from videos of the patient's eye-opening process (very unnatural = 1, unnatural = 2, close to natural = 3, and very natural = 4).
2. Static naturalness rating (SNR): This entailed evaluation of degree of naturalness from static photographs of patients when patients opened their eyes fully (very unnatural = 1, unnatural = 2, close to natural = 3, and very natural = 4).
Correlation Analysis
We analyzed the correlation between all patients’ mean third-party DNR and FED scores, and between third-party SNR and puffy scores to verify whether the 2 new parameters could reflect the degree of naturalness of the double eyelids based on other clinicians’ subjective findings.
Statistical Analysis
Statistical analyses were performed with the GraphPad Prism version 9.0 software (GraphPad, San Diego, CA). One-way analysis of variance was performed to compare the FED scores, puffy scores, and third-party evaluation across the 3 groups. Spearman's correlation coefficient and simple linear regression were performed to calculate the correlations among the FED scores, puffy scores, and third-party evaluations. Differences were considered statistically significant at P < .05.
RESULTS
Twenty patients who underwent double-eyelid surgery with the FST (age ranging from 21 to 31 years, mean 28.1 ± 4.4) and 20 patients who underwent double-eyelid surgery with the RFT (age ranging from 21 to 34 years, mean 27.8 ± 3.8) met the inclusion criteria and were photographed and videotaped at the hospital with a smartphone. The remaining 20 patients who were born with double eyelids (age ranging from 19 to 32 years, mean 28.5 ± 3.8) and met the exclusion criteria were enrolled. All patients were female, and their demographic characteristics are enumerated in Table 1.
Table 1.
Patients’ Demographic Characteristics
| Characteristic | Congenital group | FST group | RFT group | P value |
|---|---|---|---|---|
| No. of patients | 20 | 20 | 20 | — |
| Mean age ± SD, years | 28.5 ± 3.8 | 28.1 ± 4.4 | 27.8 ± 3.8 | .837 (Congenital vs FST) .956 (Congenital vs RFT) .956 (FST vs RFT) |
| Mean postoperative time ± SD, months | — | 12.6 ± 5.4 | 14.0 ± 5.4 | .978 |
FST, flexible suspension technique; RFT, rigid fixation technique; SD, standard deviation.
Correlation Analysis
There was a significant positive correlation between the FED score and third-party DNR (r = 0.84, P < .0001). The FED score showed a linear correlation with the third-party DNR (y = 3.16 * x + 1.00, R2 = 0.71, P < .0001). These findings indicated that the FED score reflected the dynamic natural state of the eye-opening process. The puffy score also showed a positive correlation with the third-party SNR (r = −0.75, P < .001). The third-party SNR showed a linear correlation with the puffy score (y = −4.35 * x + 5.03, R2 = 0.53, P < .0001) (Figure 3).
Figure 3.
(A) Scatter plot of the FED score and third-party DNR. The third-party DNR increased with the FED score (y = 3.16 * x + 1.00, R2 = 0.71, P < .0001). (B) Scatter plot of the puffy score and third-party SNR. The third-party SNR decreased with the puffy score (y = −4.35 * x + 5.03, R2 = 0.53, P < .0001). DNR, dynamic naturalness rating; FED, fold-emerging delay; FST, flexible suspension technique; RFT, rigid fixation technique; SNR, static naturalness rating.
Fold-Emerging Delay Score and Puffy Score
The mean FED scores were 62.9 ± 18.9, 52.2 ± 17.7, and 26.3 ± 18.3 in the congenital, FST, and RFT groups, respectively, and the differences between them were statistically significant (congenital group vs FST group, P = .026; congenital group vs RFT group, P < .0001; FST group vs RFT group, P < .0001; Table 2, Figure 4A). This finding indicated that the degree of dynamic natural-looking double eyelids created by FST was worse than that of congenital double eyelids but better than that of the double eyelids created by RFT.
Table 2.
Fold-Emerging Delay Score, Puffy Score, and Third-Party Dynamic Naturalness Rating and Static Naturalness Rating of the 3 Groups
| Congenital group | FST group | RFT group | P value | |
|---|---|---|---|---|
| FED score ± SD | 62.9 ± 18.9 | 52.2 ± 17.7 | 26.3 ± 18.3 | .026 (congenital vs FST); <.0001 (congenital vs RFT); <.0001 (FST vs RFT) |
| Puffy score ± SD | 49.8 ± 11.9 | 55.9 ± 11.0 | 62.6 ± 12.4 | .055 (congenital vs FST); <.0001 (congenital vs RFT); .032 (FST vs RFT) |
| Mean third-party DNR ± SD | 3.21 ± 0.67 | 2.47 ± 0.62 | 1.78 ± 0.74 | <.0001 (congenital vs FST); <.0001 (congenital vs RFT); <.0001 (FST vs RFT) |
| Mean third-party SNR ± SD | 3.01 ± 0.78 | 2.61 ± 0.55 | 2.14 ± 0.69 | .026 (congenital vs FST); <.0001 (congenital vs RFT); .007 (FST vs RFT) |
DNR, dynamic naturalness rating; FED, fold-emerging delay; FST, flexible suspension technique; RFT, rigid fixation technique; SD, standard deviation; SNR, static naturalness rating.
Figure 4.
(A) Comparison of the FED score in different groups. There were statistical differences across all groups. (B) Comparison of the puffy score in different groups. There was no significant difference between the congenital group and FST group, but the difference between the congenital group and RFT group and that between the FST group and RFT group were statistically significant. (C) Comparison of the third-party DNR in different groups. There were statistically significant differences across all groups. (D) Comparison of the third-party SNR in different groups. There were statistical differences across all groups. DNR, dynamic naturalness rating; FED, fold-emerging delay; FST, flexible suspension technique; ns, not significant; RFT, rigid fixation technique; SNR, static naturalness rating.
The mean puffy scores were 49.8 ± 11.9, 55.9 ± 11.0, and 62.6 ± 12.4 in the congenital, FST, and RFT groups, respectively. There was no statistically significant difference between the congenital and FST groups (P = .055), but the difference between the congenital and RFT groups was statistically significant (P < .0001). The puffy score significantly differed between the FST group and RFT group (P = .032; Table 2, Figure 4B). This finding suggests that the degree of static natural-looking double eyelids created by FST was similar to that of congenital double eyelids and better than that of double eyelids created by RFT.
Third-Party Evaluation
The mean DNR of the videos of the patients’ eye-opening process was 3.21 ± 0.67, 2.47 ± 0.62, and 1.78 ± 0.74 in the congenital, FST, and RFT groups, respectively, and the differences among the 3 groups were significant (congenital group vs FST group, P = .0001; congenital group vs RFT group, P < .0001; FST group vs RFT group, P < .0001; Table 2, Figure 4C). The mean SNR of the static photographs when the eyes fully opened were 3.01 ± 0.78 in the congenital group, 2.61 ± 0.55 in the FST group, and 2.14 ± 0.69 in the RFT group, and the differences among the 3 groups were significant (congenital group vs FST group, P = .026; congenital group vs RFT group, P < .0001; FST group vs RFT group, P < .007; Table 2, Figure 4D). These results showed that, whether dynamic or static, the degree of naturalness of the FST group was inferior to that of the congenital group but was superior to that of the RFT group.
DISCUSSION
Despite being one of the most common plastic surgeries in the world, research on postoperative measurements after blepharoplasty has not made significant progress in recent years. The current methods involve static measurements based on photographs, which cannot accurately reflect the changes of some dynamic characteristics after upper blepharoplasty.9 In previous clinical observations, we found differences in the eye-opening process between patients with double eyelids due to surgery and congenital double eyelids. Compared with congenital double eyelids, double eyelids formed after surgery appear more blunt or unnatural.10 We found that slow-motion video had a great advantage over traditional photometric measurements when describing this natural or unnatural state. In the past, the frame rate of hand-held cameras or mobile phones generally did not exceed 60 fps. This speed could not meet the needs of studying eye-opening motion. However, the slow-motion technology of current smartphone cameras has considerably advanced and can theoretically reach 7680 fps. This technical progress allowed the current research to be conducted conveniently and cost effectively.
The mobile phone, Huawei Mate 30 Pro (Huawei Technologies, Shenzhen, China), was chosen because it can shoot slow-motion videos with a high fps rate; however, it has some disadvantages compared with professional slow-motion cameras. Its ultra-slow-motion mode is a fast motion detection trigger mode; therefore filming cannot be started manually when in ultra-slow-motion mode; only when it detects fast movement (such as blinking) will the process of fast motion automatically be recorded, and the video will be processed as a 35-s short video in the order of normal speed, ultra-slow speed, and normal speed. Because this short video was not uniform, it was difficult to employ time as a parameter for measuring the process of eye opening. Furthermore, keyframes could only be extracted to measure the height of palpebral fissure to reflect the difference of opening movements between congenital and surgical double eyelids. This choice is not optimal, but the proportion of distance in space can also reflect the change of eye opening. The present study also identified some meaningful parameters to reflect whether the upper eyelid changes naturally during the eye-opening process.
As mentioned above, we found in the clinical observation that the eye-opening process of the surgically formed double eyelids was different from that of congenital double eyelids. Specifically, we observed a delay from the opening action of the congenital double eyelids to the appearance of the total double-eyelid line, whereas the surgically formed double eyelids often have a significantly shorter delay or do not have this delay; that is, the double-eyelid line appears at the same time as the eye-opening action, giving people a stiff and unnatural feeling. As we can see in Video 1 of the ultra-slow-motion eye-opening process of congenital double eyelids, the levator muscle started to contract in the first second, then the eyelid margin began to lift at the eighth second. Nevertheless, we can see in Video 3 of the ultra-slow-motion eye-opening process of double eyelids formed by RFT that the eyelid margin began to lift almost as soon as the levator muscle started to contract. To quantify this delay, we analyzed the videos. Generally, delay should be quantified as time, however, as mentioned, the slow-motion videos were not at a uniform speed, therefore, it was unrealistic to utilize time to describe the delay. Instead, we found that the more obvious the delay the later the double-eyelid line emerged, and the bigger the palpebral fissure was when the double-eyelid line first appeared completely. Therefore, we selected 2 typical keyframes of the eye-opening processes, the complete appearance of the double-eyelid line and the complete exposure of the pupil, and proposed the parameters of the FED score. The more the eye-opening delay, the later the double-eyelid line appears, and the greater the FED score. The results showed that the FED score of the congenital double eyelid was larger than that of the surgically formed double eyelid, indicating that the delay in the appearance of the double-eyelid line was an important indicator of whether the double eyelid was natural.
Our results revealed that the FED score of the FST group was between that of the congenital double eyelid and the RFT groups, indicating that the dynamic conduction of the levator muscle was directly related to the FED score. The power of the congenital double eyelid was dispersed from the end of the levator muscle fiber to the skin around the double-eyelid line, and that of the FST double eyelid was from the superficial aponeurosis of the levator muscle to the orbicularis oculi muscle and then to the upper eyelid skin.3,11 The power of the RFT double eyelids was directly from the levator muscle to the tarsus, and then to the skin of the upper eyelid. Among the groups, the eye-opening power of congenital double eyelids and FST double eyelids was transmitted to the skin through its elastic structure, whereas the power of RFT double eyelids was transmitted to the skin through the hard tarsal plate. Therefore, the time from eye opening to the formation of double-eyelid line was significantly shortened, which may be the root cause of the difference in FED score among the 3 groups. Because this delay occurred during the eye-opening process, we believe that the FED score is an important indicator of dynamic naturalness, and the linear correlation between the FED score and the third-party DNR also supports this idea.
Patients who have undergone double-eyelid surgery often complain that the double eyelids formed by the operation feel puffy and fleshy and the soft tissue below the double-eyelid line is bloated and prominent, which is unnatural relative to congenital double eyelids. After observation, we found that because the soft tissue below the double-eyelid line of natural double eyelids is relatively thin, the skin above the double-eyelid line will more easily cover the skin below when the eyes are fully opened, which means that the skin below will be less exposed. However, for double eyelids formed by surgery, because the soft tissue below the double-eyelid line is more swollen and less elastic, it is more difficult for it to be covered by the skin above the double-eyelid line, and a sense of puffiness will be formed below the double-eyelid line when the eyes are open. Nevertheless, there is still no good clinical indicator to reflect the degree of puffiness. Here we put forward another parameter, the puffy score. We defined puffy score as the area between the double-eyelid fold and the palpebral margin when the eyes are naturally fully open (Area 2) divided by the area when the eyes are naturally closed (Area 1) (Figure 2). Therefore, the puffy score is a ratio rather than a value of the area, for the following reasons. First, the length and width of the double eyelids of different people are obviously different, so it is unreasonable to measure the area size for horizontal comparison. Although Area 2 of the patient in the congenital group (Figure 2D) looks larger than that of the FST (Figure 2H) and RFT groups (Figure 2L), the puffy score is still lower than that of the patients of the FST and RFT groups. Second, generally speaking, congenital double eyelids should have good elasticity and contraction ability. The purpose of the proposed puffy score is to measure the elasticity and contraction ability of the soft tissue below the double-eyelid line. That is, the greater the degree of skin contraction below the double-eyelid line when the eyes are closed relative to when eyes are open, the more natural it appears. For the measurement of this parameter, we chose another 2 keyframes: eye closure and routine eye opening to the maximum palpebral fissure to measure the area between the double-eyelid line and the upper eyelid margin, respectively. The ratio of these 2 areas can largely reflect whether the tissue of the lower edge of the double-eyelid line is bloated after surgery. In the present study, the puffy score was greater in the RFT group than the FST group, which had a score greater than the congenital double eyelids group. Combined with the results of the third-party evaluation, these outcomes indicate that the higher the puffy score, the more likely that feelings of puffiness or swelling will be reported. There are 2 main reasons for the puffy sensation.12 First, the removal of excessive tissue during double-eyelid surgery affects the tissue, veins, and lymphatic reflux, resulting in swelling. Second, excessive residual tissue below the incision during the operation leads to the appearance of swelling. According to the results of this study, the former may be a more important cause of the puffy sensation.
Our research started in 2020. At that time, we tried several common brands of smartphones on the market (Apple [Cupertino, CA], Huawei, Xiaomi [Beijing, China], etc.) when selecting mobile phones for video shooting. All mobile phones have slow-motion photography functions. However, Huawei can shoot videos with the highest fps. Perhaps thanks to its special frame insertion algorithm, the definition of slow-motion videos is also the highest. Therefore, the mobile phone we finally chose for this research was the Huawei Mate 30 Pro. However, with the advancement of smartphones, at present (2024) we have learned that some smartphones of several brands (Huawei, Honor, Xiaomi, Samsung [Suwon-si, South Korea], etc) have similar functions, which meet the parameter measurement needs of this research.
The 2 novel parameters proposed in this study can reflect to a large extent whether the double eyelid appears natural. However, the limitations of this study should be acknowledged. First, we initially planned to describe “delay” more reasonably in terms of time. However, the ultra-slow-motion videos shot by the mobile phone in this study were not uniform, like those captured by professional slow-motion cameras. Therefore, we were forced to utilize distance instead of time to describe the delay. After observation, it was found that the more obvious the delay in eye-opening process, the greater the height of the palpebral fissure when the double-eyelid line fully appeared. Nevertheless, because the palpebral fissure height of different patients cannot be compared horizontally, we chose the ratio of the palpebral fissure height when the double-eyelid line fully appeared to the maximum palpebral fissure height to express comparison. In short, describing delay as a ratio of palpebral fissure height was a compromise approach. We will endeavor to find professional slow-motion cameras that accurately measure eye-opening delay to verify our research in a subsequent study, but the portability and economy of smartphones in outpatient work are unmatched by professional cameras, so the measurement method proposed in this study is still worth promoting. Second, the sense of puffiness mainly manifests as swelling and soft tissue prominence under the double eyelid, which in fact reflects a change in volume, but it was expressed as a change in area in our study, leading to some errors. We plan to conduct research with a 3-dimensional camera to obtain more accurate results regarding the sense of puffiness after double-eyelid blepharoplasty.
In this study, we proposed 2 parameters to quantify the naturalness of double eyelids formed by surgery, then with them compared the 2 double-eyelid methods frequently performed in our department with natural double eyelids. Due to the popularity of smartphones, other doctors can also measure these 2 parameters to evaluate the dynamic and static naturalness of other double-eyelid surgery results in the future.
CONCLUSIONS
The FED and puffy scores can be utilized as quantitative indicators of the degree of natural appearance after double-eyelid surgery with an ultra slow-motion video captured by a smartphone. The degree to which double eyelids created with FST could mimic the natural state was better than that achieved with RFT.
Supplementary Material
Acknowledgments
Dr Zhang and Dr Gu contributed equally to this work as co-first authors.
Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research, authorship, and publication of this article.
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