People with “single eyelid” do not have the presence of a superior palpebral fold and the upper eyelid drapes like a single, unruffled curtain from the supraorbital ridge to the eyelashes.  The suggested anatomical reasons for “single eyelid” could be the lack of levator aponeurosis (the muscle responsible eye opening) penetration into the pre-tarsal orbicularis oculi muscle (the muscle for eye closure) and skin.   Poor internal definition which allows more fat protrusion has also been suggested as a cause for single eyelid in the Asian population.


The “double eyelid” appearance can be created without surgical intervention.  For many years, patients have used external appliances such as adhesive tape, soft silicone bars and glue.   These methods do not provide a permanent solution and after a while, many patients will resort to a more permanent solution using surgical intervention.


Double eyelid surgery has become one of the most popular cosmetic surgical procedure performed amongst East Asians and is synonymous with blepharoplasty.


The intention of the “double eyelid” operation is to create the attachment between skin and the deeper tissue, creating a fold above the eyelashes.  The attachment separating the pre-tarsal and pre-septal area leads to the formation of a palpebral sulcus.


There are two techniques in double eyelid surgery: – Suturing and Incisional.  Japanese surgeon Mikamo first described the suturing method in 1896 and in 1929, Maruo described the incision technique.


The suturing technique involves making a few small stab incisions at the level of the tarsal crease and sutures are inserted through the incisions so that all the different layers are stitched together to create a fold.  It has gained a certain degree of popularity, with the main advantages being less scarring and a reduction in the duration of swelling and oedema. However, literature reviews suggest a higher rate of recurrence and failure.


Incisional techniques involve making an incision at the level of the tarsal crease , allowing the appropriate tissue layers to be stitched together more precisely than the suturing technique.  It also allows for excess skin to be excised, which is important in older patients where excess skin needs to be removed to improve tarsal show. The scar is hidden behind the skin fold and as the scar is at the level where there is a natural line with double eyelid, a well-healed scar would hardly be noticeable.  The main disadvantage would be prolonged swelling but the failure rate is lower than the suturing technique.


The creation of the double eyelid is usually in continuation with the line formed by the epicanthic fold (excess skin on the medial aspect of the eye described as “Mongoloid” feature).    Some patients prefer the double eyelid crease situated higher outside the epicanthic fold line and this is a matter of personal choice and feasibility.  Your surgeon can help you with the decision.


Epicanthoplasty can be carried out at the same time as the double eyelid surgery, if patients want to see an improvement in the medial canthic region. Despite many different techniques, the major issue of medial epicanthoplasty is the potential visible scar formation. The epicanthic fold is an Asian characteristic and it ranges from a mild to a prominent fold.  In some patients with a mild epicanthic fold, nasal augmentation using hyaluronic acid filler can be of help to improve its appearance without having surgical intervention to the area.  However, not all can be treated by this method but your surgeon can provide you with the most appropriate option.

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