Double Fold (Incision)

Overview

Asian upper eyelids often lack the crease or fold observed in Caucasians and other ethnicities. In fact, the upper eyelid fold is absent in 85 % of Asians. However, during the last 20 years or more, most Asian actors and models have begun to appear with double folds. What is causing this? They are either one of the 15% of Asians born with a natural fold, or they are part of the growing group of Asians who choose the double fold eyelid procedure.

This operation has grown so popular that it is the most common cosmetic surgery in Asia and the most popular among Asians in America. Why is this so popular? A well-placed double fold on an Asian eyelid may make the eyes appear more defined, younger, less tired, brighter, larger, and more attractive.

 It is vital to notice that the features of the Asian double fold differ from those of caucasian eyelids, thus attention must be used to respect the original theme and anatomy of the Asian eyelids.

Eyelid Structure

Eyelid, movable tissue composed mostly of skin and muscle that shields and protects the eyeball from mechanical harm and contributes to the moist chamber required for appropriate conjunctival and corneal function. 

The conjunctiva is the mucous membrane that borders the eyelid and covers the visible parts of the eyeball excluding the cornea (the transparent part of the eyeball that covers the iris and the pupil).

Each eyelid has a fibrous plate known as a tarsus that gives it structure and form, as well as muscles that move the eyelids and meibomian (or tarsal) glands that release lubricating fluids. The lids are skin-covered, coated with mucous membrane, and framed by a fringe of hairs, the eyelashes. 

The lids move due to the activity of the orbicularis oculi, a circular lid-closing muscle, and the levator of the upper lid, a lid-raising muscle. The face (seventh cranial) nerve sends closure impulses, while the oculomotor (third cranial) nerve sends opening impulses.

An oily fluid (called sebum) of the meibomian glands keeps the lid margins moist. This secretion is absorbed into the tear film and helps to minimize evaporative tear loss.

What Causes a Double Vs Single Fold? 

When the eyelid skin joins to the inner muscle that lifts the lids (levator palpebrae superioris), a double fold develops. Most Asians, on the other hand, have a layer of fat and muscle that prevents the skin from attaching to the levator muscle, resulting in a heavier (thicker) looking single eyelid. Other ethnicities, such as many Latinos, may also have single lids. Latinos without a double fold eyelid are frequently mistaken for Asians or people of mixed Asian ancestry.

While ethnicity influences our look, not all Asian eyelids are the same. Asian ethnicities have a variety of different eyelid forms and patterns. As previously stated, the majority have little to no crease over their eyes; others have a noticeable double fold; and some have a part-time fold, noting that their fold is sometimes non-existent. The fold's form and location can also vary greatly. The epicanthal fold is the distinguishing feature of Asian eyelids. This is the hood of skin on the medial corner (toward the nose) of the eyelid that distinguishes an Asian upper lid.

The Asian eyelid configuration can cause the eyelashes to turn inwards and irritate or scratch the surface of the eyes, resulting in a variety of unpleasant symptoms such as burning, light sensitivity, and excessive tears, and in extreme cases, patients may even experience irreversible vision damage. doctors can correct the eyelash angle during blepharoplasty surgery to minimize post-operative eye discomfort.

Why You Need Double Fold Surgery?

Some people have visible eyelid wrinkles, which are referred to as double eyelids. Some people are born with no wrinkles on their eyelids. This is known as a single lid or a monolid. There's nothing wrong with either of them from a medical point of view.

Some of the reasons you might seek double eyelid surgery are:

• Your eyelids are interfering with your vision.
• You have one single and one double eyelid, and you’d like them to match.
• Permanent creases can help make your eyes appear larger.
• It will be easier to apply certain styles of makeup.

What to Expect From Double Fold Surgery?

Many surgeons have considerable experience performing this procedure as leaders and specialists in double-fold procedures. During your consultation, the doctor will go through every detail, allowing you to choose the type and position of your fold, as well as your preferred style. Asian double fold surgery is performed as an outpatient treatment, which means you will be able to return home the same day.

In most cases, the treatment is completed in an hour under local anesthetic, and the effects are seen immediately. Your operation will consist of removing any extra skin, fat, and muscle from the heavy upper lid that is preventing it from folding. We then carefully molded the contour of your new lid by carefully creating the fold in the exact required spot. In the new fold, an imperceptible scar is carefully hidden.

 Most patients are able to resume their normal activities within a few days of having Asian blepharoplasty. Bruising and swelling may persist 10-14 days. Within 6 weeks, a beautiful effect is seen, and the full result is visible after 6 months when the rest of the swelling has subsided.

Types of Eyelid Folds

• In-out-fold double eyelid:

The crease in this type of fold begins at the corner of the eye and progressively extends the length of the eye, converging and tapering nasally to the eyelid margin. The crease is generally low to medium in height, ensuring that it seems natural - making this sort of fold quite popular because it is a subtle change that does not detract from the patient's ethnicity.

• Out-fold double eyelid:

The out-fold variation includes the formation of a crease that begins further away from the lash border and does not extend towards the inner corner. The crease is normally parallel to the contour of the eye and remains equidistant from it throughout. This is a considerably more 'western' look, yet it remains highly popular with patients.

Pre-operative Care

• Stop taking nutritional supplements, such as vitamins C and E, fish oil, and herbs, two weeks before the procedure.
• Even though double eyelid surgery is merely a local procedure, if you have any medical issues such as hypertension, diabetes, asthma or cardiopathy, please consult with your doctor to ensure your safety.
• Get enough rest. There is no need to fast before the procedure.
• Bring your sunglasses so you may use them after the procedure to protect your eyes from dust.
• Even if your eyes are not puffy, you should not drive yourself shortly after surgery for your own safety.
• Make time for rest and recuperation. If feasible, you should relax for at least a few days following surgery to limit visual activity and give yourself more time to apply a compress to help the incision heal quicker.

Double Fold Surgical Options

Current methods of double eyelid surgery:

• Double eyelid creation with laser.
• Double eyelid surgery by suture technique blepharoplasty.
• Double eyelid surgery by small-incision technique blepharoplasty.
• Double eyelid surgery with full-incision technique blepharoplasty.
• Double eyelid surgery and excess eyelid removal.
• Double eyelid surgery and medial epicanthoplasty or fat transfer, ptosis, sunken eye correction etc.

1. Double Eyelid Creation with Laser:

The Plexr laser employs plasma to remove the drooping eyelid. This procedure is appropriate for someone who already has double eyelids but prefers a non-surgical option since they are somewhat drooping and flagging. For monolided individuals who want to have double eyelids, surgery can produce a better and more attractive double eyelid than laser.

2. Double Eyelid Surgery By Suture Technique:
It is accomplished by piercing the upper eyelid for three holes and suturing the crease, which is a popular procedure for double eyelid surgery.

Advantages:

• There is no visible scar. Because of the microscopic holes, after the incision is entirely healed, it becomes unnoticeable.
• Less swollen. However, for a skilled surgeon, it may not differ from the minimal incision procedure.

Disadvantages:

• The crease is not long lasting. (This is especially true in those with thick and fatty top eyelids.)
• The size of the crease is limited. (This is especially true in those with thick upper eyelids.)
• After a while, the crease begins to move and shrink.
• Fat can be removed from the upper eyelids of those who have fatty upper eyelids (compared with the incision technique).

3. Double Eyelid Surgery By Small-Incision Technique: 

It is performed by an incision of 3-5 mm at the upper eyelid. (Depending on each surgeon’s technique).

Advantages:

• Scar is minor and easily healed.
• Short procedure duration, little edema, and quick recovery (compared with the full-incision technique)
• Suitable for a young individual with a little amount of extra eyelid or a thin eyelid.
• Can generate double eyelids and eliminate fat much more effectively than suture techniques.

Disadvantages:

• After swelling subsides, the eyelids of a person with severe blepharoptosis may droop, the wrinkles will shrink, or there will be mild lateral hooding.
• The creases will appear rather plump for a person with extremely thin eyelids since it is done by suturing the crease up without removing the skin and tissues of extra eyelid.

4. Double Eyelid Surgery By Full-Incision Technique:

It is similar to the minimal-incision procedure, but the incision is larger such that the crease may be sutured all the way across an eye without having to excise the excess eyelid.

Advantages:

• Better than the minimal-incision approach at reducing the potential of lateral hooding (except a severe blepharoptosis).
• Fat can be eliminated, especially if the person has fatty eyelids.

Disadvantages:

• More swollen and longer wound compared with the minimal-incision technique
  
• Same as mentioned in the disadvantages of minimal-incision technique

5. Double Eyelid Surgery Combined With Excess Eyelid Removal:

Advantages:

• Can remove excess eyelid including the fat and eye muscle in patient with thick eyelids to effectively correct blepharoptosis.
• This technique can determine the shape of crease according to your wish.
• Though the crease is clearly seen, it is still natural-looking as the crease does not need to be big thanks to the removal of drooping eyelid which covered the crease. This is different from the minimal-incision technique which did not remove the excess eyelid. So, the crease needs to be sutured higher. As for the patient with severe blepharoptosis, suturing the crease very high will result in sleepy eyes, big crease with unnatural-looking double eyelid.      

Disadvantages:

• More swelling and take longer time to heal than other techniques.
• The scar will be as long as the eye. (Same as the full-incision technique).
•  Longer operation time.
   

6. Double Eyelid Surgery Combined With Medial Epicanthoplasty:

Because not everyone who wants to undergo double eyelid surgery requires medial epicanthoplasty, the doctor will examine the necessity and suitability of each patient.

7. Double Eyelid Surgery Combined With Fat Transfer:

A patient with sunken eyes cannot get standard double eyelid surgery since there will be no crease and the sunken eye will remain.

Concerning double eyelid surgery for a sunken eye patient, the doctor must carefully examine the approach for individual sunken eye correction because each patient has distinct sunken eye symptoms. As a result, the doctor will choose a different approach.

Surgical Techniques

Incisional procedure:

These are the basic steps to double eyelid surgery using the incisional method:

1. The proposed double eyelid line will be measured and drawn with a pen with care.
2. Along with local anesthetic, IV sedation or general anesthesia will be delivered.
3. Along the double eyelid line, several tiny incisions will be made.
4. The skin that has been marked will be removed.
5. Between the incisions, the orbicularis oculi muscle and adipose tissue will be removed.
6. Skin glue or stitches will be used to seal incisions, which will need to be removed four or five days following surgery.
7. If you have thick skin, require more skin and fat removed, or want a lasting outcome, the incisional approach may be an excellent alternative.
8.  This procedure cannot be reversed. Some possible hazards include:

• Anesthesia. 
• Allergy. 
• Infection. 
• Transient or permanent eyesight changes. 
• Noticeable scarring.

Non-incisional procedure:

A double eyelid can be made without making an incision. This is known as the buried suture method or non-incisional double fold. It can also be done under general anesthesia, IV sedation, and local anesthetic.

The eyelid, like the incision, will be precisely measured and marked. The skin is then punctured along the line with a succession of microscopic punctures.

Sutures are threaded through the punctures and tightened until the proper crease is formed. The sutures will remain hidden beneath the skin. You will not be required to return to get them removed.

The non-incisional treatment leaves minimal scarring and may be reversed. If you don't require excess skin and fat removed, the non-incisional procedure may be a viable alternative. Some possible hazards include:

• Asymmetry or loosening of the double fold.
• Irritation from the sutures.
• Infection.
• Visible puncture marks when your eyes are closed.
• Inclusion cyst from a buried stitch.

How Much Does Double Fold Surgery Cost?

According to the American Society of Plastic Surgeons, the average cost of cosmetic eyelid surgery in 2018 was $3,163. That is the average cost of the operation alone. This estimate excludes anesthesia, operating room costs, and other related charges, so the final cost will almost certainly be greater.

Costs can vary based on factors, such as:

• The type of procedure.
• Your geographic location.
• What pre-surgery tests are needed.
• The surgeon and surgical facility.
• Prescription medications.
• Any complications.

If you're getting the procedure because your eyelids are interfering with your lashes or eyesight, your insurance may cover it.

Obtaining pre-authorization for the treatment is a smart idea. Most insurance, however, do not cover any kind of cosmetic surgery.

Is Double Fold Surgery Safe?

Complications and unwanted results from an eye lift are rare, but sometimes they do happen. They can include:

1. Bleeding.
2. Infection.
3. Dry eyes.
4. Abnormal colouring of the eyelids.
5. Eyelid skin that folds in or out abnormally.
6. Not being able to fully close your eyes.
7. A pulled-down lower lid lash line.
8. A possible loss of vision.

Conclusion

Double eyelid surgery, also known as Asian blepharoplasty, used to create or improve an upper eyelid fold in those who were born without it or with weak or uneven folds. The absence of an eyelid fold is common in Asian individuals due to an anatomic variation in the eyelid anatomy as compared to those who have a natural crease.

There are numerous procedures available for creating a natural and appealing eyelid fold, but the first step is to determine what results are sought and what will appear natural to suit the face features.

Unlike conventional upper eyelid blepharoplasty, where the goal is essential to minimize skin and refresh the tired eyelid appearance, double eyelid surgery involves removing only a small amount of skin and using the excess to create a fold that will enhance the eyes and give the appearance of a larger, more defined eye shape.