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Section: Options

Incisional Double Eyelid "Cutting" Technique

Exact surgical technique will vary surgeon to surgeon depending upon his or her training, experience, and preferences. Likewise, variations in preexisting patient eyelid-facial anatomy will require a customized approach in each individual.

What follows below is a simplified overview of general principles.


Local anesthesia with light sedation is preferred so that the surgeon can verify the shape and position of the eyelid and crease during surgery by asking the patient to open and close his or her eyes.

Upper Eyelid Surgery

Cross-Section of the
Asian Upper Eyelid

Subcutaneous Fat
Orbicularis Muscle
Sub-Brow Fat Pad
Orbital Septum
Orbital Fat
Levator Muscle Complex
Tarsal Plate

(Upper eyelid anatomy is
discussed elsewhere.)

Incisional Technique

Because Asian skin is said to be "more reactive," incisions are best make with a scalpel instead of the laser to minimize scarring.

The skin is incised with a scalpel at a height dictated by measurements of certain existing anatomical landmarks. The incision may be tapered into the epicanthal fold towards the nose (if desired) and/or flared slightly upwards at its outer end (if desired).

Most typically, a small strip of skin above this initial incision is excised using scissors. The amount of skin removed varies depending upon the proposed height of the new crease as well as preexisting anatomical conditions. In some cases, no skin is removed.

The incision is carried deeper into the eyelid through the orbicularis muscle and orbital septum until the orbital fat is exposed.

Small strips of orbicularis muscle and orbital septum are excised. The amount and location of orbital fat removed has a significant influence on the height, shape, and depth of the new crease. In most cases, no fat is removed.

The levator aponeurosis (tendon) is identified just beneath the fat. In contrast to an older form of incisional double eyelid surgery known as "anchor blepharoplasty," the levator aponeurosis is not aggressively exposed or detached from its connection to the tarsal plate, a step that is, in our opinion, unnecessary to formation of a natural-appearing crease and invites a higher incidence of serious complications such as ptosis, lid retraction, or peaking of the eyelid margin.

Wound closure employs a "deep-fixation" technique to create an attachment between the aponeurosis and the dermal layer of skin. Following suture removal, internal scars at these points of fixation act much like "spot welds."

The final crease height and shape are the result of both selective tissue removal and precise internal tissue rearrangement. The operation may be used to create tapered, parallel, lateral flare, and, rarely, semilunar shaped creases or to correct incomplete or multiple creases. The incisional approach is considered the "gold standard" in Asian double eyelid surgery.

While some older incisional methods create deep fixation through the use of permanent internal stitches sewn into the tarsus, we have found this approach to be less stable and more likely to cause crease irregularity and scarring. We have developed our own method of deep fixation that leaves behind no suture fragments.

Incisional method photographed step-by-step

* * *

While a laser may be substituted for the scalpel, its use as a cutting tool in eyelid surgery has diminished greatly in recent years. The collateral heat damage caused by the laser may have negative consequences on the final scar, especially in young Asian skin.

Summary: Pros and Cons of the Incisional Method


The incisional technique allows the surgeon to directly address any anatomical impediments to crease formation by altering and rearranging internal eyelid tissue layers. Such changes replicate as closely as possible the natural conditions that exist in any Asian or non-Asian patient born with a crease.

The new crease is there to stay because the internal anatomy is changed. There is no dependence on retained sutures for effect.

The incisional technique allows for more variation in the final height and shape of the crease (for instance, higher or lower, tapered or parallel, etc.).

If indicated, skin and/or fat may be trimmed. This is especially important in the patient past his or her twenties or in a patient who wishes to alter crease height or shape.

The crease is "dynamic," which means:
When the eye is opened, it appears.
When the eye is closed, it disappears.


The time between the operation and final healing is much longer with the incisional technique. The more you do, the more there is to heal.

Performing the operation skillfully is more challenging for the practitioner who doesn't do much eyelid surgery. Especially under such circumstances, the chance of functional or aesthetic problems is increased.

Next: Non-Incisional Cutting Method

from this section: Options >

Surgical Options
Incisional "Cutting" Method
• Non-Incisional "Suture" Method
Partial "Small" Incision Method

Patient Options
Crease Preferences

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Note: Information, observations, and opinions are offered for general reference only and should not be taken as medical advice or diagnosis.

Incisional Asian Eyelid Surgery