A Method for Precisely Designing the Form of Double Eyelid in Double Eyelid Plasty

Abstract

Background:

Given the high prevalence of monolids in Asians and challenges in achieving natural-looking symmetrical folds in blepharoplasty, this study introduces a precise double eyelid design method to improve surgical outcomes. This study aimed to introduce a method of precise designing of double eyelid shape in double eyelid blepharoplasty.

Methods:

After removing the orbicularis oculi muscle and orbital septum fat properly in the operation, the same double eyelid marker line was drawn on the anterior tarsal tissue as that designed before operation, and then the skin-anterior tarsal tissue skin was sutured along the marker line.

Results:

We followed up 160 patients who had this method applied for 6–12 months, using a questionnaire named self-evaluation of the postoperative form of double eyelid. The satisfaction rate of double eyelid morphology was 92.5%.

Conclusions:

This method simplifies the repeated adjustment of suture operation, enables precise surgical operations, and has high satisfaction with the shape of double eyelids after operation, thus deserving popularization.

Takeaways

Question: To present a novel technique for precise double eyelid contour design in full-incision blepharoplasty, addressing common postoperative issues of asymmetry, irregularity, and unnatural appearance.

Findings: In a 6- to 12-month follow-up study of 160 patients using a standardized postoperative evaluation questionnaire, the technique achieved a 92.5% satisfaction rate for eyelid morphology outcomes.

Meaning: This innovative approach streamlines surgical execution by eliminating repetitive suture adjustments, enhances procedural precision, and delivers superior aesthetic results with high patient satisfaction, making it worthy of widespread clinical adoption.

INTRODUCTION

Monolids are present in up to 50% of Asians, and double eyelid surgery (blepharoplasty) has become the most common procedure in plastic surgery.^1,2 There are currently 3 main surgical approaches for blepharoplasty, namely, buried suture, minimally invasive partial incision, and full incision. Among them, full incision is most widely used in blepharoplasty because it allows intraoperative removal of excess skin and fat tissue and clear intraoperative visualization of the tissue structure, as well as solving eye aesthetic problems such as poor levator palpebrae superioris strength.³ The double eyelid fold should appear natural, smooth, and symmetrical. How to achieve bilaterally symmetrical and smooth double eyelid creases remains a challenge for plastic surgeons. Unaesthetic double eyelid is not only a common problem in incisional blepharoplasty but also a common postoperative complication. Therefore, in this study, we proposed a method for precisely designing the double eyelid shape which effectively solves the problems of having unnatural, unsmooth, and asymmetrical double eyelid folds. All patients included in this study underwent incisional blepharoplasty using this method and achieved good clinical outcomes.

Clinical Data

A total of 160 patients (320 eyes) who sought blepharoplasty between May 2022 and May 2024 were included in this study, including 5 men and 155 women. All patients underwent incisional blepharoplasty using the method proposed in this study and were followed up for 6–12 months after surgery.

METHODS

Preoperatively, the double eyelid line was designed, and the most prominent point of the upper eyelid was marked according to the effect of the double eyelid simulation design accepted by the beauty seeker (the distance from this mark to the upper eyelid margin is the width of the double eyelid) (Fig. 1). The shape of the double eyelid is simulated through this marked point, and the medial and lateral ends of the double eyelid line are determined by the natural flexibility of the upper eyelid skin, ultimately completing the full double eyelid line (Fig. 2). The double eyelid line is drawn as described earlier, simulating the shape of the double eyelid based on the design line, and marking the line at the edge of the skin fold. Generally, a second line is drawn 2 mm below the marking line, parallel to the middle of the double eyelid line; then, the skin between the two marking lines is pinched, using the slight curl of the eyelashes as a gauge, and repeatedly tested to finally determine the amount of skin to be removed (Fig. 3). The 2 lines gradually converge at the medial and lateral corners, eventually forming a complete incision line for the full-cut double eyelid surgery.Through repeated testing, the final amount of skin to be excised is determined, generally between 2 and 5 mm. The medial end of the crease line should not exceed the medial canthus point, and the lateral end should not exceed the lateral canthus point on the outside by more than 5 mm. Other preoperative tests include upper eyelid muscle strength, corneal exposure, extraocular muscle function, and the Bell phenomenon. Local anesthesia was used in all patients, an incision was made along the marker lines, and excess upper eyelid skin was excised. The upper eyelid skin at the lower margin of the incision was separated from the orbicularis oculi muscle, and the orbicularis oculis muscle within the designed range and at the lower margin of the incision was excised to expose the pretarsal tissue. The orbital septum was opened to remove prolapsed adipose tissue, and then the intraoperative marking was made. As shown in Figure 4, during surgery, the marked line on the upper eyelid skin was replicated in front of the tarsal plate and the lower margin skin, pretarsal tissue, upper margin skin, orbital septum, and orbicularis oculi muscle were intermittently sutured with 7-0 monofilament nylon suture along the marker line. (See Video [online], which displays the secondary line marking process in blepharoplasty. The final result is shown in Fig. 4.) Regular cold compresses and hot compresses should be applied postoperatively. The wound should be kept clean and regularly changed, and the sutures removed.

Fig. 1.

Distance marked by calipers is the width of the blepharoplasty.

Fig. 2.

The double eyelid line is drawn from the medial end to the lateral end. A, The process of regulating the blepharoplasty line in the open-eye state. B, The process of plotting the natural connection smooth curve in the closed-eye state.

Fig. 3.

The arrow in the figure indicates 2 mm below the natural fold line.

Fig. 4.

The intraoperative caliper measurement line will be redrawn on the eyelid.

Video 1. This video demonstrates the secondary line marking process in blepharoplasty. The final result is shown in Figure 4.

Download video file ^{(76.2MB, mp4)}

Ethical approval was obtained from the institutional ethical committee (IIT2024-058-001), which waived the written consent. The study procedures were in accordance with the ethical standards of our institutional ethical committee and those of the Declaration of Helsinki.

RESULTS

The records of the patients who underwent blepharoplasty using this method and completed the follow-up questionnaire from May 2022 to May 2024 were extracted. Each subject was asked to self-evaluate how natural, smooth and symmetrical their double eyelids were using the Postoperative Double Eyelid Shape Follow-up Questionnaire (Table 1). Each parameter was scored from 1 to 3, and a total score of 3 indicates “satisfied,” 4 to 6 indicates “unsatisfied,” and 7 to 9 indicates “requires adjustment.” The follow-up results showed that 2 patients (1.25%) required postoperative adjustment, among which one felt that the double eyelid folds were too low (Fig. 5), and the other complained of a bifurcation at the tail of the double eyelid fold on 1 eye (Fig. 6). The outcome was unsatisfactory but acceptable for 10 (6.25%) patients, and adjustment was not required. The remaining patients (92.5%) were satisfied with the postoperative outcome of this method, and their double eyelid folds were natural, smooth and symmetrical (Fig. 7).

Table 1.

Postoperative Double Eyelid Shape Follow-up Questionnaire^*

Items	Parameters
Self-assessment of naturalness of double eyelid folds	1. The double eyelid folds are of appropriate height and appear natural 2. The double eyelid folds are mildly high/low 3. The double eyelid folds are very high/low
Self-assessment of smoothness of double eyelid folds	1. The curve is smooth 2. The curve is acceptable 3. The curve is not smooth
Self-assessment of bilateral symmetry of double eyelid folds	1. Perfectly symmetrical with no difference between the two eyes 2. Moderately symmetrical with slight differences between the 2 eyes 3. Evidently asymmetrical

^*This follow-up questionnaire was only used for self-assessment by the patients after blepharoplasty and was anonymous.The questionnaire was archived and used for postoperative outcome evaluation and reference only.

Fig. 5.

Pictures of a patient with low double eyelid folds. A, A preoperative photograph. B, A postoperative photograph.

Fig. 6.

Pictures of a patient with bifurcated double eyelid fold. A, A preoperative photograph. B, A postoperative photograph.

Fig. 7.

Pictures of patients who are satisfied with the surgery. A, C, E, G, preoperative photographs. B, D, F, H, postoperative photographs.

DISCUSSION

Double eyelid blepharoplasty was first proposed in 1896 by Mikamo.⁴ After a century of development, this procedure can now be performed using the buried suture, minimally invasive partial incision and full incision methods. Various modified and innovative surgical methods have been developed based on these 3 techniques and are vigorously competing to strive for improvement. Among them, the full incision method is widely accepted by clinicians due to its broad indications and durable and stable effects. However, how to create double eyelid folds that are of appropriate height, smoothness and symmetry by incisional blepharoplasty is a key concern of every plastic surgeon. Therefore, preoperative design is critical, and appropriate preoperative marking can provide strong assurance of a good postoperative outcome.⁵ Despite precise preoperative design, any deviation of the incision from the designed marker lines and suturing of the tarsal plate at a position too low or too high during the surgery can lead to inadequate or excessive height and asymmetry in the double eyelid folds after surgery.⁶ The accuracy of intraoperative operations directly affects surgical outcomes, and this is why Yang et al⁷ pointed out that repeated comparison and measurements are necessary during blepharoplasty to ensure postoperative symmetry. However, this, to some extent, increases the operation time and causes uncertainty in the postoperative outcome. Therefore, having a precise intraoperative marking similar to the preoperative design is important for providing further surgical guidance and reassuring a good postoperative outcome.

Common problems that are often encountered in incisional blepharoplasty include (1) control of the height of the double eyelid fold (ie, naturalness) during intraoperative suture, as suturing the pretarsal tissue at a position too high or too low can result in wide or narrow double eyelids, which affects the naturalness of the double eyelid folds and renders the postoperative outcome inconsistent with the preoperative simulation; (2) control of the smoothness of the double eyelid folds during intraoperative suture, as unsmooth suture of the pretarsal tissue may lead to an unaesthetic curvature and thus unsatisfactory double eyelid folds after the surgery; (3) control of symmetry during intraoperative suture, which is particularly important when the presence of swelling and/or hematoma on 1 eye can seriously affect the judgment of bilateral symmetry, and improper adjustment may cause asymmetrical double eyelid folds after the surgery; and (4) during intraoperative suture, the patient is required to open and close their eyes repeatedly for the surgeon to judge the shape of the double eyelid folds. The presence of swelling and/or hematoma, inconsistent globe prominence, and/or difference in levator palpebrae superioris muscle strength between the 2 eyes, and even the injection of unequal volume of anesthetics can thus influence judgment. In addition, another challenge of the procedure is the fact that some patients who desire for blepharoplasty are extremely afraid of pain and surgery and may faint at the sight of needles and blood. General anesthesia has not been feasible in this procedure thus far, because patients are required to open and close their eyes for the surgeon to make a judgment. To address these problems, this study proposes a method of drawing a second marker line on the pretarsal tissue during the surgery and then suturing the lower margin skin, pretarsal tissue, upper margin skin, orbital septum, and orbicularis oculi muscle along the marker line. This allows the intraoperative suture to be made precisely at the predesigned site, thus reducing the need for patients to repeatedly open and close their eyes, decreasing the amount of resuturing during the surgery, and improving the one-time success rate of suturing during blepharoplasty. As a result, this provides patients with natural, smooth, and symmetrical double eyelid folds. In addition, blepharoplasty using this method can be performed under general anesthesia without the intraoperative cooperation of the patient, which not only allows patients to have a comfortable surgical experience but also reduces bleeding in the surgical area when the patient is relaxed, which facilitates the surgical procedure. Moreover, only a small amount of norepinephrine-containing anesthetic is required for injection in the surgical area, which can reduce the impact of the anesthetic on the surgery. Furthermore, for patients with different eye sizes due to inconsistent globe prominence and differences in levator palpebrae superioris muscle strengths, an asymmetric design of double eyelid folds is required to achieve postoperative symmetry. If asymmetric levator advancement is required during an incisional blepharoplasty to correct inconsistent eye size, the eye with greater levator adjustment will have a higher double eyelid fold than the contralateral eye. For patients with differences in globe prominence, the double eyelid fold on the eye with greater prominence will need to be lower than that on the contralateral eye. Both cases can pose challenges to incisional blepharoplasty. However, these challenges can be overcome by meticulous preoperative examination, design and measurements, as well as precise secondary intraoperative marking.

The patients who received blepharoplasty using this method were followed up for 6–12 months and were asked to complete the postoperative double eyelid shape questionnaire. The results showed that 92.5% of the patients were satisfied with the postoperative outcomes, with no complications such as unnatural, unsmooth, or asymmetrical double eyelids after the surgery. Among the 2 patients that were unsatisfied and required adjustments after surgery, one had a bifurcation in the tail of the double eyelid fold on 1 eye (Fig. 6). This highlights an issue associated with drawing a second marker line during the surgery, which can be addressed by thinning the orbicularis oculi muscle in the transition area such that a proper buffer area can be formed between the areas surrounding the orbicularis oculis muscle in the surgical area and the areas outside the surgical area. For patients with low double eyelid folds, preoperative communication, design, and simulation are critical (Fig. 5). As long as the preoperative designed double eyelid folds are of appropriate height and the intraoperative secondary marker line is drawn strictly in accordance with the design, the postoperative double eyelid height will be satisfactory.

There are several advantages to making a secondary marking during incisional blepharoplasty. First, it provides a reference for intraoperative suture, which can reduce the possibility of having unaesthetic double eyelid folds after surgery and thereby ensures the precision of the double eyelid shape and satisfaction with the surgical outcome. Second, it reduces repeated suture adjustments during surgery, shortens operation time, and minimizes patient discomfort. Last, it allows the surgical procedure to be performed under general anesthesia, which solves the problem of patients wanting to have blepharoplasty but being unable to tolerate the surgery.

CONCLUSIONS

We report a method for precisely designing the double eyelid shape in incisional blepharoplasty. This method is precise, effective, simple to perform, and easy to learn. The long-term follow-up results showed a high postoperative satisfaction rate, and most patients did not have complications of unnatural, unsmooth, or asymmetrical double eyelids. Therefore, this method is worthy of wide application in incisional blepharoplasty.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

Patients provided written consent for the use of their images.