Double Eyelids

Overview

One distinctive feature of the eye that varies from person to person is the number of creases on the eyelid. Double eyelids are those with a visible out fold crease. This is in contrast to single eyelids, or monolids, which have no crease. Genetics determine whether you have double eyelids or not. Surgery to form double eyelids is available. It may be done for cosmetic reasons or because an eyelid that doesn't have a crease is interfering with your vision.

Asian Eyelid Morphologies

Asian people have a diverse range of eyelid morphologies. The arrangement of internal eyelid structures, the presence of epicanthal folds, and the organization of fat pads all work together to create distinct Asian eye shapes. The presence or absence of a supratarsal crease is one noticeable difference among Asian eyes that has led to the desire for the double eyelid procedure. Asian eyelids have been divided into three major categories, each with two subcategories.

Category 1 - Single Eyelid Crease

Subtype A - There is a single eyelid with no visible lid crease

Subtype B - There is a low eyelid crease, which is mostly hidden and is tapered toward the nose

Category 2 - Double Eyelid Crease

Subtype A - Infold type: The supratarsal crease height is lower than the epicanthal fold

Subtype B - On fold type: The supratarsal crease height meets or is on the epicanthal fold

Category 3 - Double Eyelid Crease (Outfold types)

Subtype A - Outfold Type 1: The height of the eyelid crease is superior to the epicanthal fold

Subtype B - Outfold Type 2: There is a double eyelid crease, but no epicanthal fold is present

What Causes Different Types of Eyelids?

There are a few genetic conditions, such as Down Syndrome, that cause people of any ethnicity to have more prominent epicanthal folds.

It is commonly assumed that people of European descent have double eyelids, whereas people of East Asian descent have monolids — but this is an oversimplification. For example, in one study on eyelid shape, half of the Latino participants had monolids or epicanthal folds. Many people all over the world, regardless of ethnicity, have heavier, or "hooded," eyelids.

What is a Double Eyelid?

A double eyelid is an eyelid that has a fold or wrinkle on the upper lid. Because it's a dominant gene, it's more likely to be expressed or evident, unlike the recessive monolid gene. Double eyelids are generally linked with appearance and beauty, especially in Asian cultures.

Most people with a single lid are frequently seeking the best options to create double lids. Luckily, there are several treatment options to consider depending on the desired goals. These include both surgical and nonsurgical interventions.

Advantages of Getting Double Eyelids

The major reasons why people opt for double eyelids include;

Enhanced vision

Even though this might come to you as a shock, it is the truth. Besides, not all that concerns double eyelids are meant to be attractive. Adding another eyelid on top of the already existing one can also help you see well.

It helps to reduce the appearance of wrinkles on the forehead

Another shocking finding is that having a single eyelid could be the cause of wrinkles on the forehead. Whenever the eyes feel heavier, people attempt to raise their brows in order to see well. The excessive skin on the upper part of the eyes folds as a result. With time, you will begin to see deep wrinkles on top of the forehead. Luckily, you can prevent this by undergoing a procedure to get rid of excess fats in the eyes.

It makes you appear more alert and less weary

It is typically common to see individuals who appear to be drowsy or exhausted despite the fact that they are fully awake or active. Every day, we come across such people. This is because such individuals have additional skin around the eyes, which adds to puffiness on top of the eyes and forms bags beneath them. Getting double creased eyelids can thus help correct this problem, giving you a more alert look.

It makes you look and feel younger

Bags, wrinkles, and other unwanted folds around the eyes are all major contributors to aging. This can, however, be removed with double eyelid surgery. As we get older, some fat surrounding the eyes tends to droop and sag downwards, making one look more aged. With the procedure, you can get a more youthful appearance.

Surgical Preparation

The general preparation in the OR is the same whether performing an incisional or non-incisional blepharoplasty. Pre-operative preparation begins with eyelid marking in the upright position to allow visualization of the eyelid's final gravitational position. This is then evaluated in supine position. The proposed supra-tarsal crease is drawn from the medial to lateral canthus at the patient's desired height. Once the symmetry of the mark in both the upright and supine positions has been properly assessed, a sterile preparation can be performed.

Following that, a corneal shield and local anesthetic are applied to the upper eyelids. The procedure can be carried out with or without intravenous sedation. Because few clinical or animal studies have been conducted to evaluate the efficacy of various suture types in facial surgeries, the choice of suture material for the procedure is largely based on surgeon preference.

Double Eyelids Surgery

A type of eyelid surgery that plastic surgeons can recommend to address a variety of issues is known as blepharoplasty. These problems can include the following;

Skin that is loose or drooping, causing wrinkles or disrupting the natural curve of the top eyelid and at times obstructing vision.
Puffiness around the eyelids due to fatty deposits
Bags beneath the eyes
Lower eyelids that droop and display white beneath the iris
Lower eyelid extra skin and fine creases
Reconstruction of the aesthetic appearance

Asian blepharoplasty is a term used to describe plastic surgery that is used to generate double eyelids. This operation is usually performed as an outpatient procedure to form a fold, or an upper eyelid wrinkle, in patients who don't have one.

Epicanthoplasty is a procedure that is sometimes combined with blepharoplasty. Epicanthoplasty involves the removal of some of the excess skin at the inner corner of the eye, known as the epicanthal fold. The natural formation of an outfold crease is hampered by a heavy epicanthal fold. As a result of removing some of the epicanthal fold, a crease can form naturally without tension or scarring.

Mikamo performed the first reported "double eyelid operation" in 1896. Although this cosmetic procedure is frequently referred to as an attempt to achieve a more "westernized" appearance, the first description of double eyelid blepharoplasty predates the western influence on Asian culture. As a result, Mikamo's development of double eyelid surgery is thought to have been motivated by a desire to achieve a more aesthetic, round-eyed, and expressive appearance.

Candidates for Double Eyelids Surgery

Double eyelid surgery can be performed for both cosmetic and functional reasons. On the cosmetic side, someone may choose eyelid surgery because they prefer the look of double eyelids over monolids.

Alternatively, they may choose surgery because their eyelid skin has drooped as a result of the natural loss of collagen and elastin in the skin that occurs with age. In some cases, the eyelid droops so low that it obstructs vision. Eyelid surgery may thus be used to correct the drooping eyelid(s) and prevent vision problems.

Generally, double eyelid surgery is not suitable for every person. In addition, there are several factors you need to consider before deciding to undergo the procedure. These factors include;

Being in good health and not having major medical problems
Not having any illnesses or disorders that could slow or prevent healing.
You are not a smoker
Having reasonable objectives for the outcome
There should be no major eye problems.

People considering blepharoplasty need to be aware that exaggerating the height of the wrinkle added to the lid can appear artificial. Therefore, discuss your eye form, facial structure, and surgical goals with your plastic surgeon beforehand.

What are Cons of Getting a Blepharoplasty?

Blepharoplasties are generally considered safe outpatient procedures because the majority of the physical side effects are transient. Consider the following disadvantages of this procedure:

Itching, swelling, bruising, and double vision may occur immediately after surgery, and these side effects may persist.
If the surgery was purely cosmetic, you may feel self-conscious about your new appearance.
Blepharoplasty is the most requested surgery in Asia, according to the American Academy of Ophthalmology. If your family, friends, or culture put pressure on you to have cosmetic surgery, you may come to regret your decision.

Blepharoplasty cannot be reversed, and double eyelid surgery is frequently quite expensive. This means that if you decide to have your eyelids surgically altered for cosmetic reasons, you must be absolutely certain that this is what you want. You should wait until you are old enough to make your own decisions.

Blepharoplasty can be very helpful in alleviating eyelid problems that cause vision problems — but it's important to remember that both double and monolid eyelids are normal, healthy eyelids. If you want to have cosmetic surgery for yourself, consult with your doctor and possibly a trusted friend or mental health counselor to ensure you're doing it for the right reasons.

Types of Double Eyelids Procedures

Your plastic surgeon will assist you in determining which surgical procedure is appropriate for you. This will, however, depend on your objectives, face form, other conditions, and healing durations.

Asian Double eyelids involve a variety of procedures, including;

Incision approach

This involves creating an incision in the upper eyelid and removing the tissue. This approach is virtually painless and allows for greater personalization of the ultimate effect, as well as the removal of wrinkles on the eyes. Because the skin of the top eyelids is the thinnest in the body, a scarcely detectable scar, if any, may occur as a result of the surgery.

Despite the scar being present, it can only be visible when the eyes are closed completely. Plastic surgeons who undertake this operation may employ very small sutures that dissolve in six or seven days and don’t need to be removed.

Buried suture technique

The plastic surgeon can create minute holes and use three buried sutures to form an eyelid crease. This approach is ideal for people who desire a quick recovery without any scars. However, the double eyelids may fade over time, and the lids might go back to their normal condition.

Beads technique

The beads procedure involves placing six sutures through the lid and stabilizing using beads so that they do not cut via the skin. After scarring develops a double eyelid, the sutures are then removed a few days later.

This is the least invasive option, although it does result in a lot of inflammation, which is necessary to form the double eyelid scar. Even though this procedure does not require any cutting or incision, it does need the most time to recuperate because of postoperative swelling.

Double Eyelids Procedure Recovery

Depending on the approach employed, recovery after eyelid surgery will vary from one person to another. Incisional blepharoplasty leaves behind a scar. However, non-incisional blepharoplasty patients may endure more and persistent irritation and swelling following the treatment.

Generally, the length of time it takes for you to heal after double eyelid surgery is highly dependent on the type of surgery you have done. Sutures will be inserted using incisional procedures, and they may need removal after a few days.

Initial recovery takes roughly two weeks, while complete recovery may take months. You can anticipate to recover after surgery in around two weeks using partial incision and non-incisional procedures.

Double Eyelids Aftercare

Your plastic surgeon will provide you detailed guidelines on how to take care of your eyelids following surgery. You will also learn how to manage the associated pain as well as discomfort. These aftercare measures include;

Using a cold compress to relieve pain as well as swelling during the first two days. Your eyes, however, remain swollen for weeks or even months after treatment.
After surgery, do not lift anything heavy or strain for at least three weeks. In most cases, you can recommence to mild activities in three days.
Throughout the day, keep your head raised and do not sleep flat. An additional pillow during bedtime will suffice.
Stay out of the sun.
Avoid using any cosmetics. You can resume using makeup in about 10 to 14 days following the procedure.
Refrain from using any over-the-counter ointments and creams
Apply a thin layer of petroleum jelly twice per day to any external stitches.
Do not wear your contact lenses for two to three weeks if you use them.

Complications of Double Eyelids Surgery

Asymmetric and Excessively High Folds

The most common complication is uneven eyelid height or shape, which can occur in up to 35% of cases. Asymmetric eyelid folds can be caused by differences in preoperative marking, discrepancies in the amount of skin excised, unequal tension on the skin during supratarsal fixation, and unequal amounts of fat excision.

Postoperatively, approximately 7% of patients have excessively high folds. If the folds extend above the superior border of the tarsal plate, they are considered too far superior. As previously stated, the ideal position for the eyelid crease is 6 to 8mm above the lid margin. Adhesions between the orbicularis and the skin above the level of surgical fixation can cause this unnatural appearance. High folds can also be caused by excessive resection of preaponeurotic fat pads.

Blepharoptosis

Iatrogenic damage to the levator palpebrae superioris muscle and its aponeurosis can cause drooping eyelids after Asian blepharoplasty. Unintentional separation of the levator from the tarsal plate, as well as scarring from excessively high aponeurosis fixation to muscle, disrupts proper levator function.

Bleeding

Bleeding is a potential risk with any procedure, and it can range from prolonged ecchymosis to massive hematoma. Across all ethnicities, bleeding rates are comparable to those for blepharoplasty.

Weakening of Sutures

Some patients may experience recurrence of skin laxity and loss of the surgically created upper eyelid crease over time. This, however, occurs in less than 3% of cases and is more common with the suture ligation technique and when absorbable suture is used. This is due to the anchoring suture weakening and the failure of adhesion between the levator and muscle or dermis. This complication can be avoided by debulking orbital fat or using purposeful suturing to strengthen the levator-dermal junction and the tarso-dermal junction during supratarsal crease formation.

Upturned Cilia

The presence of an epicanthal fold encourages downturned eyelashes, which explains why Asians have a higher incidence of trichiasis. The formation of a double eyelid can alleviate and aid in cilia eversion. However, if proper preoperative planning and postoperative care are not followed, the upper lid eyelashes can evert and expose the palpebral conjunctiva.

Ocular Surface Disease

As stated in the preoperative evaluation section, the formation of a double eyelid may cause or worsen mild dry eye symptoms. Ptosis, which can occur in people who do not have an eyelid crease, may be protective against the development of dry eye. As a result, it is critical to assess the patient for the development of these complications during the preoperative period.

Ectropion

Injury to the zygomatic or recurrent buccal branches of the facial nerve during surgery may impair orbicularis oculi muscle function. This can cause complications such as ectropion as well as a change in the position of the lower lid margin. Ectropion will also occur if the tension of the eyelid levator is greater than what normal skin allows. This is due to the levator's inferior incision or inferior skin flap being misplaced.

Nonsurgical Approaches for Double Eyelids

Not everyone is prepared to contemplate surgical procedures for achieving double eyelids. In such cases, there are a number of options that can temporarily change your single eyelids into double eyelids. They include;

Eyelid tape

This involves applying a small amount of tape to the upper eyelid. After that, you will use the stick-shaped tool that has tape to push the eyelid upwards to produce a fold. Continue pressing for close to one minute to ensure that a portion of your eyelid firmly adheres to the tape. These tape pieces are in the shape of a crescent.

Makeup remover can be used to remove the tape. After that, you can apply your makeup as usual.

Eyelid glue

This entails using a brush with the bottle to apply eyelid glue to the top part of the eyelid. After the glue is set to dry for 30 seconds, you can use a stick-like object to push the lid and form a fold. It's also a good idea to continue pushing it for another 60 seconds. A makeup-removing content can be used to clean off the glue.

When to See Your Doctor?

There is a chance that complications will arise during your recovery, just as there is with any other surgical procedure. Keep a close eye on your health and don't be afraid to contact your doctor if you have any concerns.

Following your procedure, your provider will most likely prescribe you pain medication. If you are still experiencing pain after taking your medication, please notify your provider. Your eyes may feel a little dry in the days following your procedure, but if the dryness is excessive, contact your provider.

Should any of the following occur during your recovery, seek immediate medical care:

Your stitches come loose or your incision comes open
You are bleeding from the incision
You have any changes in your vision
Your scar is raised or seems excessive
Your scar is still red after four weeks
It hurts or feels uncomfortable to blink or close your eyes
Your feel any pain in your eye

You should also seek immediate medical care if you have signs of infection, such as:

Swelling, pain, warmth, or redness on your eyelid or nearby
Red streaks leading from the incision
Pus draining from the incision
Fever

Conclusion

Double eyelids are a genetically designed trait. Whereas having double eyelids is a dominant feature, having recessive single eyelids is quite common. In Asian societies, where double eyelids are popular, double eyelid surgery is widespread. This also includes double eyelids in Korea.

The surgical procedure is mainly aesthetic, and it can result in unequal eyelids or even a loss of vision. To know if double eyelid surgery is best for you, do prior research on the various techniques.