트임성형외과 바로가기

트임 성형외과 로고


 

 

Dr. Kwon established Evolution Theory of Asian eyelid

 

  • quick_title
  • location link
  • after note link
  • consultation link
  • reservation link
  • go to page top

Double Eyelid Surgery

home link home > Double Eyelid Surgery


01Understanding Asian double eyelid


History and Dilemma

Double eyelidplasty is the most frequent cosmetic procedure for Asians, and different anatomy including the epicanthus was a conundrum which limit cosmetic result of double eyelidplasty. Among the various anatomical difference, the epicanthus was most significant problem which was not identified clearly at all. Double eyelidplasty without epicanthoplasty tend to be unattractive or unnatural. Aesthetically, the epicanthal fold is worsened when performing double eyelidplasty without epicanthoplasty, because double eyelid formation aggravates vertical tension on epicanthal skin. It has been a long-standing dilemma for plastic surgeons which procedure to choose, i.e. infold type double eyelidplasty with a less satisfactory result or outfold type double eyelidplasty with concomitant epicanthoplasty, taking risk of hypertrophic scar in Asian eyelid.

When the epicanthal fold is severe, the surgical incision of skin flap also become longer, and a scar could be easily visible in conventional method, which based on the concept of local skin flap. Although it has been reasoned that combined epicanthoplasty is helpful in Asian double eyelidplasty, there has not been clear understanding about epicanthal fold, resulting in controversies for solution. There have been so many epicanthoplasty methods developed in its early days, which are mostly based on skin flap concept. Currently using methods are combined technics including skin excision, z-plasty, myotomy or myectomy of preseptal orbicularis muscle, skin redraping, plication of medial canthal ligament and so on.

The development of incomplete methods were unavoidable without understanding about true nature of the epicanthus. As the clinical significance of the epicanthus is mainly related with Asian double eyelidplasty, essential epicanthoplasty should be a key to plastic surgeons for choice of all the type of double eyelid including high outfold type(parallel type). But, there has not yet been a potent epicanthoplasty method which deserves universal solution for Asian double eyelidplasty before development of devolutional epicanthoplasty (Kwon’s method, so called magic epicanthoplasty). Dr. Kwon researched basically the formative causes of the differences of Asian eyelid, and also epicanthal deformity and absence of double eyelid. Dr. Kwon finally solved this conundrum, and suggested Kwon’s Theory about the evolution of eyelid to explain anatomical differences of Asian eyelid and Kwon’s Method for Asian blepharoplasty based on devolutional concept.

Differences of appearance in Asian eyelid


Asian eyelid with incomplete double eyelid or without double eyelid


Surface inspection is is important not only in the evaluation of general conditions such as existence of crease, epicanthus, epiblepharon, blepharoptosis, but in planning the most appropriate surgical plan in Asian double eyelid surgery. The eyelashes are the true boundaries of the palpebral fissure. The eyelashes of a Caucasian is exposed completely and the eyes look clear. Also, the eye looks bigger with the parallel supratarsal crease of eyelid. In contrast, most Asian people have the epicanthi of varying degree with absence or incomplete presence of supratarsal crease. The eye of Asian without supratarsal crease is veiled by various amount of skin drooping and the eyeline where the lashes grow is hidden beneath the soft tissues called epiblepharon. The more the eyelid tissues droops down, the smaller and the puffier the eyes look.

The canthus of Caucasian is exposed completely, whereas the inner part of medial canthus of Asian eye is veiled by the epicanthus. The shapes of the canthal angle are quite various, but generally Asian canthal angles are rounder and shorter than those of the Caucasians. There are various distortions of canthal shape in Asian medial canthus which have been affected in the eyelid evolution. The epicanthus and single eyelid exists as a normal characteristic in Asian ethnicity, and it is peculiar to East Asians. Asian blepharoplasty can be best performed with special reference to the anatomical blueprint and implemented with respect to the devolutional concept of normal eyelid structure with supratarsal crease.

Typical Asian single eyelid and Caucasian double eyelid



Anatomical differences of eyelid between Caucasian and Asian


Anatomical charicteristics of Asian upper eyelid :

Thick, streched skin
Subcutaneous fat
Preseptal/pretarsal fat
Thickened, malpositioned orbicularis muscle
Lax, ballooned septum with lower insertion with levator aponeurosis
Prolapsed, hypertrophied preaponeurotic fat pad with incompentant septum
Weak, incomplete anterior expansions of the levator aponeurosis.
Stretched, weakened levator aponeurosis and Muller muscle
Smaller vertical height of tarsal plate


Although the eyelid is very thin, various tissues (skin, orbicularis muscle,septum,levator muscle, Muller muscle, tarsal plate, fat, conjunctiva) are composed in it. The levator muscle and mullermuscle are those that help open the eyes. In Caucasian, the levator aponeurosis is usually attached to the tarsus and skin of inferior part of eyelid . The strands of the muscle tissues (levator expansion) are attached to the back of the skin of the eyelid, and the skin attached is pulled during eye opening, then a double eyelid is formed.

The fusional part of the orbital septum and levator aponeurosis in Caucasian eyelid is typically in the skin crease (8-12 mm from eyelid margin). Its location lies above the superior tarsal border(2-5mm), which limit the downward prolapse of the orbital fat pads and enable aponeurotic expansions to insert toward the subdermal surface of the pretarsal eyelid skin. Whereas the fusional part lies at the lower point in Asian eyelid and the height of tarsal plate is relatively less than Caucasian’s(more than 8mm in Caucasian). Because of the differences in the eyelid anatomy of Asians, the surgical methods ususally applied to Caucasian cases cannot yield the favorable result in Asian blepharoplasty. Considering the differences of the Asian eyelid and relationship of the epicanthus and double eyelid, structural Asian blepharoplasty based on devolutional concept should be applied to establish a appropriate plan and accomplish best results. The devolutional Asian blepharoplasty can yield much better, natural looking surgical results because it is basically different from conventional blepharoplasty based on Caucasian’s eyelid anatomy

For Asian blepharoplasty, the upper eyelid should be evaluated for :

Epicanthus and epiblepharon with/without orbicularis muscle
malposition
Existence or absence of crease
Excess and thickness of skin
Amount of preaponeurotic fat,usually pseudoherniated and hypertrophied
Blepharoptosis
Pericanthal skin tension
Shape of medial canthus
Brow ptosis and lacrimal gland ptosis
Inclination between medial canthus and lateral canthus
Eyelash direction and prickling around medial canthus
Skin fold on lower eyelid and related wrinkles

Sayoc’s Theory for supratarsal crease (double eyelid)

Previously, Sayoc’s theory has been accepted to explain absence of supratarsal crease in Asian since 1956. Sayoc suggested that in Caucasian, parts of the levator muscle of the upper eyelid are attached to the skin, While in Asians, it is absent or sparse. So, the natural double eyelid is congenitally absent or incomplete in Asian. It had been main medical theory for double eyelid up to early 2000



However, the electron microscopic studies confirmed that levator aponeurotic fibers penetrate the orbicularis muscle in both single and double eyelids of Asian, of course Caucasian. This finding suggested that Sayoc’s theory of the “levator expansion” had been incorrect.


Kwon’s Theory for Asian eyelid



Three parts of the eyelid which are affected in evolutional process. In eyes with a double eyelid, parts of levator muscle are attached to the back of the skin. On the other hand, an eye without a double eyelid has a structure called a epiblepharon which result from orbicularis oculi muscle displacement . Also, the preaponeurotic fat tissue is drooped down like pseudoherniation.

If so, why does the supratarsal crease not exist although aponeurotic fibers do penetrate the orbicularis muscle in Asian single eyelid? Dr. Kwon reconsidered basically without stereotype for previous theory about Asian double eyelid and the epicanthus from 2005, because Sayoc’s theory could not explain absence of Asian double eyelid and presence of epicanthus clearly. Dr. Kwon’s research tried to address the formative causes of epicanthal deformity and loss of double eyelid at the same time in evolutional aspect. Dr. Kwon’s research concluded that the answer for Asian double eyelid is not “not previously existed” but “lost” during evolution. Environmental adaptation is the basic cause for loss of supratarsal crease and formation of the epicanthus. Genetically, all modern humans are included into the subspeciesHomo sapiens sapiens,i.e. the subspecies of Homo sapiens. It has been reasoned that the racial differences of modern humans are just phenotypic variations. The stereotype of Sayoc’s theory may mislead plastic surgeons to misunderstand Asian double eyelid and epicanthus incorrectly. So, the evolutionary approach to Asian epicanthus or absence of supratarsal crease has not been researched and not suggested ever. Dr. Kwon suggested Kwon'stheory for the evolution of Asian eyelid.

 

The stage of the eyelid evolution according to the main action of orbicularis oculi muscle in Kwon’s theory.

Loss of medial crease, formation of the epicanthus, loss of mid-lateral crease, formation of the epiblepharon occur in sequence.

I. Stage of hypertrophy: The hypertrophy of orbicularis oculi muscle and depressor supercilli muscle develop by repeated frowning. The hypertrophy of orbicularis oculi muscle cause attenuation of the aponeurotic expansion which penetrate through orbicularis muscle. The aponeurotic penetrations
loosen and become sparse.

II. Stage of sheer stress: Complete detachment of aponeurotic expansions with loss of supratarsal crease takes place on point S by sheer stress. The detachment of aponeurotic fibers can occur beneath the orbicularis muscle or on the orbicularis muscle. Orbicularis oculi muscle contraction acts as sheer tensional stress with depressor supercilli muscle. The depressor supercilli muscle plays an ancillary role.

III. Stage of tensional stress: The successive loss of medial crease below point S results from displacement of preseptal orbicularis oculi muscle toward eyelash and the vicious cycle between malpositioned muscle hypertrophy and crease loss. The orbicularis oculi muscle contraction mainly act as tensional stress on remaining aponeurotic fibers and medial crease.

IV. Stage of compressional stress: Excessive contraction of orbicularis oculi muscle acts as compressional stress on overlying skin of upper medial eyelid with resultant vertical skin shortage and tension. The tight tension band develops due to vertical skin shortening of upper medial eyelid.

V. Stage of traction and tensional stress: Contraction of orbicularis oculi muscle acts as tensional stress on remaining supratarsal crease resulting in successive loss of supratarsal crease on the upper eyelid superiorly and/or act as traction force causing skin tent toward point P on the lower eyelid inferiorly. During and after formation of a tight tension band by vertical skin shortage, the orbicularis oculi muscle contraction causes a prominent skin fold on the lower eyelid by pulling-up the muscle point of origin like setting up a tent pole during contraction. The preseptal orbicularis muscle pulled up its origin superolaterally with skin tent on lower eyelid during contraction.

VI. Stage of degeneration: The atrophy of orbicularis oculi muscle and accompanying degenerative fibrosis develop, leaving the epicanthus with incomplete crease or epicanthus without crease.
The hypertrophied orbicularis oculi muscle becomes atrophied and replaced by fibrosis, but there remains vertical skin shortage and tension left on upper eyelid and skin fold and wrinkles on lower eyelid. Also there has been left centripetal fibrosis toward point p under the skin of lower eyelid.



The formation of  epicanthus and loss of supratarsal crease are  remnant manifestations of eyelid evolution which resulted from hypertrophy of upper orbicularis muscle and related aponeurotic attenuation.
Increased blood supply induced by hypertrophied orbicularis muscle and climate factors would cause hypertrophy and pseudoherniation of preaponeurotic fat. Displacement of orbicularis muscle and fat pad would affect the levator muscle and Muller’s muscle. A relatively longer medial canthal ligament and underdeveloped nasal bone would be additional evolutional manifestation​s by hypertrophy of the orbicularis oculi and excessive tension.

(new paradigm in Asian double eyelid surgery)
Structural eyelidplasty in Asian eyelid based on devolutional concept : Combined Epicanthoplasty and Double Eyelidplasty as One Surgery

The presence of epicanthus or absence of supratarsal crease are one of differences of phenotype by relevant environments. What we should do for Asian blepharoplasty is to understand the evolution of eyelid and reverse evoutionary processes for stability of surgical crease with minimally invasive technique.If patient understand evolutionary eyelid change, and relationship between the epicanthus and the supratarsal crease, epicanthoplasty should be considered the core surgery for Asian double eyelidplasty.

Examples)Magic epicanthoplasty combined with a non- incisional double eyelid surgery


Examples)Magic epicanthoplasty combined with a non- incisional double eyelid surgery

Examples)Magic epicanthoplasty combined with a revisional double eyelid surgery

Combined epicanthoplasty and double eyelidplastymustdeserve one complete "structural eyelidplasty" for Asians. Considering the relationship of the epicanthus and double eyelid, these combined surgeries can acomplish a perfect plan and create best results.

There are three general methods, the complete incision method (incision), partly cutting (partial incision), and cutting for only the needle to enter(buried suture, non-incisional method). From any among them, we must connect a part of the levator muscle to the eyelid skin. There are merits and demerits respectively and it should be determined by enough consultation considering the length and size of the eyes, thickness of the skin, power to open eyes, quantity of fat, epicanthal folds and so on. There are many differences in devolutional eyelidplasty from conventional eyelidplasty without devolutional concept. The structural Asian eyelid surgery based on devolutional concept(magic epicanthoplasty combined with double eyelid surgery) dramatically improves the epicanthus and stably connects the eyelid skin with the levator muscle. In devolutiona lAsian eyelidplasty, destructive procedures on surgical crease for stronger adhesion is less necessary. The tensional stress on crease by vertical skin tension is main cause of crease loss after double eyelidplasty in Asians. Contraction of malpositioned orbicularis oculi muscle in vertical direction is also a potential cause of tensional stress on surgical crease. Because we have resolved the possible causes of crease loss with devolutional epicanthoplasty, aggressive adhesion which performed in conventional double eyelidplasty is less necessary.

In more cases, we can apply non-incisional(or partial incisional) method for crease formation in devolutional eyelidplasty except excessively thick skin condition with true epiblepharon. There are more incidence of mild blepharoptosis in Asian eyelids. We think mild blepharoptosis in Asian eyelid is related with the eyelid evolution. After the evolutional process, the loading conditions of levator muscle had been worsened. The fibrous tissues within the epicanthus and the epiblepharon, vertical skin tension on upper eyelid, hypertrophied orbicularis oculi muscle and hypertrophied preaponeurotic fat pad add levator and muller muscle more loadings, and act as causal factors of blepharoptosis. When we evaluate blepharoptosis, we should consider the epicanthus related factors. When we perform blepharoptosis surgery with devolutional epicanthoplasty simultaneously, correction of blepharoptosis become complete and is expected to get better result. Through more than five thousands cases of people who already underwent devoutional eyelidplasty by Dr. Kwon, Kwon’s theory and method has been proved to be a very effective and universal technique for Asian eyelid. The surgical outcomes are very natural and satixfactory.

Examples)Structural Asian Blepharoplasty , combined magic epicanthoplasty and double eyelid surgery



02Considerations in Asian double eyelid surgery



Epicanthus, Epiblepharon,Attachments between Levator muscle and skin

In an eye with double eyelid, the levator muscle holds the skin and the skin is pulled as people open their eyes and forms a double eyelid. While in Asian eye without double eyelid, most have no attachment between the levator muscle and the skin. There are thick fibrous tissue and malpositioned orbicularis muscle which block pulling the skin. The fibrous tissues and malpositioned orbicularis muscle within epicanthus and epiblepharon prevent even transmission of levator muscle power toward the eyelid skin because the aponeurotic fibers have been detached and do not extend to the epicanthal skin area any more.

The preexisting vertical skin tension on medial eyelid acts as tensional stress on newly formed surgical crease. The epicanthal skin tension is considered as a major factor which inhibits the sustainability of surgical crease in Asian double eyelidplasty. Also, the malpositioned orbicularis muscle can be reactivated as a vertically acting inhibitor which causes active tensional stress on mid-lateral surgical crease, especially when we have performed the outfold type double eyelidplasty without epicanthoplasty. Therefore, Asian double eyelid surgery should reform not only this attachment, but also should resloves the epicanthus and epiblepharon. Then, we can finally creates anatomically stable crease and natural-looking beautiful eyes.


Favorable structural factors for a beautiful Asian eye with a clear double eyelid :


Blepharofissure(The width of the eyes) is long and the tails of the eyes are not so pointed upwards.
The distance between the eye and eyebrow is not short.
The skin of the eyelid is not droopy.
The eyelid skin is thin
Proper amount of fat exists but not too much.
There is no severe epicanthus and epiblepharon.
The function of the muscle to open the eyes is normal and the exposure of pupil/iris is enough for bright looking eye.
Both eyes are symmetric
The position of the eyebrow is not hung down and is symmetric.


In cases that a lot of these conditions are satisfied, the Asian blepharoplasty can express very good results without much difficulty. But actually, most of cases are not like that. If patient don’t meet any or only a few of these conditions, there may be a high chance that less satisfactory results may be shown.The unfavorable conditions are much related with epicanthus and eyelid evolution. In unfavorable cases, devolutional concept of Asian blepharoplasty is more important. We can get better result through structural eyelidplasty based on devolutional concept. Through cases who already underwent devolutional Asian blepharoplasty, this method has been proved to be a very satisfactory and beneficial method for Asian eyelid. We could lessen the rate of sausage phenomenon, loss of surgical crease and hypertrophic scar obviously in unfavorable cases. The surgical outcomes are very natural and much better than conventional double eyelidplasty.

Functional aspect of a double eyelid : field of vision


The eye of Asian without supratarsal crease is veiled by various amount of skin drooping and the eyeline where the lashes grow is hidden beneath the soft tissues called epiblepharon. The more the eyelid tissues droops down, the smaller and the puffier the eyes look. A single eyelid of Asians is likely to cover the iris and pupil partially. When skin drooping is severe, eyelashes can prickle the cornea and it can cause problem of visual acuity . In this case, a double eyelid surgery removing parts of the drooping eyelid , forming a double eyelid and extending exposure of pupil, will brighten the patients’ vision. Therefore, a double eyelid surgery has a positive effect to get a better vision for the basic function of the eyes. After double eyelid surgery, the eyes look more clear and bright.

Examples) An excisional double eyelid surgery has an beneficial effect on providing a better vision (exposure of pupil)


Examples) Forming a clear double eyelid and more exposure of pupil/iris by ptosis correction and revisional double eyelid surgery


Examples) Forming an inner type of double eyelid and increased exposure of pupil by ptosis correction and a double eyelid surgery.

Examples) Forming an parallel type of double eyelid and increased exposure of pupil/iris by ptosis correction and double eyelid surgery




03The relationship between epicanthus and double eyelid in Asian eyelid


The epicanthus is a characteristic of the Asians which forms small, stuffy or unfavorable eyes. The epicanthus makes the distance between the eyes seem wider than the actual distance, and lets eye form sharp or slanted shape. More importantly, a double eyelid surgery without correcting the epicanthus can cause an undesirable crease, and even cause it to become loose or faded.

The epicanthus is the most significant factor for determining the shape of the double eyelid, but it was not well-known. Previously plastic surgeons also thought that epicanthoplasty is just ancillary procedure, it might be natural because plastic surgeons didn't know what the epicanthus exactly is. Additionally, unsightful scar formation and unsatisfied result may appear after defective previous epicanthoplasty methods. Considering previous history of Asian blepharoplasty, epicanthal folds have been an important key, but it had not been corrected properly because of defective methods based on defective understanding about the epicanthus. When women have a consultation about the double eyelid surgery, most of them ask for clearer and wider eyes such as the look of an actress.

Most women say "I want to have beautiful and clear eyes", or "I want to have bigger eyes and bigger crease after surgery" during consultations. However, a double eyelid surgery without epicanthoplasty will likely make the eyes look unsatisfactory because this will result in a wide interepicanthal distance and incomplete double eyelid. If a person who has severe epicanthus, small eyes and a wide interepicanthal distance, take only double eyelid surgery itself, the surgery can result in a unfavorable appearance by the epicanthus covering over the epicanthal region. In case of less severe epicanthus, the double eyelid surgery alone can possibly make relatively desirable and favorable lines, but only an infold type of small double eyelid will appear after all. Performing double eyelid surgery on Asian eyes without properly managing the epicanthus causes inevitably incomplete results(small infold or large awkward crease) or can be a critical reason for getting double eyelids to fade away. In fact, most of the problems after Asian double eyelid surgery are caused by the tension of the remaining epicanthus.

Good candidates of Asian eyelid surgery are determined mostly by the degree of the epicanthus. Dr. Kwon reasoned that the epicanthus is a manifestation of the eyelid evolution by hypertrophy of the orbicularis oculi muscle. The affected areas of eyelid can be divided into three parts in aspect of their evolutional processes. The manifestations of the eyelid evolution consists of 1) The epicanthus with vertical skin shortage and tension on upper medial eyelid, 2) The epiblepharon with loss of crease on the rest upper eyelid. 3) Skin fold on lower eyelid. The epicanthus exists as a remnant fibromuscular volume on the upper medial canthal region with vertical(actually diagonal, relative meaning in relation to horizontal supratarsal crease) skin shortage and tension which causes difficulty in horizontal skin folding. It acts as a major hindrance of a double eyelid formation in Asian blepharoplasty. The fibrous tissues and malpositioned orbicularis muscle prevents the even transmission of levator muscle power toward the medial skin because the aponeurotic fibers have been detached and do not extend to the epicanthal skin area any more. The preexisting vertical skin tension acts as tensional stress on newly formed surgical crease. The epicanthal skin tension is considered as a major factor which inhibits the sustainability of surgical crease in Asian double eyelidplasty.

Also, the malpositioned orbicularis muscle can be reactivated as a vertically acting inhibitor which causes active tensional stress on mid-lateral surgical crease, especially when we have performed the outfold type double eyelidplasty without epicanthoplasty.

Examples)Magic epicanthoplasty combined with a non- incisional double eyelid surgery

It should be explained to patient that combined epicanthoplasty and double eyelidplasty would creates a clearer and well-defined double eyelid crease by resolving epicanthus and exposing the hidden part of the inner eye better. In case a of single eyelid, it would be better to perform combined epicanthoplasty and the double eyelid surgery. When one has a severe epicanthus, double eyelids must be made by combining two of these surgeries.

Although it seems that only magic epicanthoplasty or only double eyeliplasty makes an some effect on eye, combined surgeries make harmonious surgical plans and dramatic results for beautiful Asian eye considering the correlation between epicanthus and double eyelid.
It is unnecessary to hesitate to have an epicanthoplasty because of the development of devolution epicanthoplasty. Recently, taking double eyelid surgery combined with magic epicanthoplasty is becomming a new paradigm of Asian blepharoplasty



04The structural double eyelid surgery in Asian (Kwon’s Method)


The concept of structural eyelidplasty in Asian:
New paradigm in Asian blepharoplasty : Combined Epicanthoplasty and Double Eyelidplasty as One Surgery under Devolutional Concept

Double eyelidplasty is the most frequent cosmetic procedure for Asians, and the epicanthus was a conundrum which limit cosmetic result of double eyelidplasty. Dr. Kwon suggested Kwon's Theory for the evolution of Asian eyelid. Now, Asian blepharoplasty can be best performed with special reference to the anatomical blueprint and implemented with respect to the devolutional concept of normal eyelid structure with supratarsal crease. It could be reasoned that there is no difference in basic anatomical structure of eyelid between Asian and other ethnicities. The presence of epicanthus or absence of supratarsal crease are one of differences of phenotype by relevant environments.

What we should do for Asian blepharoplasty is to understand the evolution of eyelid and reverse evoutional processes for stability of surgical crease with minimally invasive technique.If surgeons understand evolutional relationship between the epicanthus and the supratarsal crease, epicanthoplasty should be considered the core surgery for Asian double eyelidplasty, as there is close relationship between loss of supratarsal crease and development of the epicanthus and epiblepharon. Considering the relationship of the epicanthus and double eyelid, these combined surgeries can acomplish a perfect plan and create best results.

What we do in combined devolution epicanthoplasty and double eyelidplasty in sequence.

1. Design both epicanthoplasty and double eyelid surgery simultaneously

2. Mark the marginal transverse incision along the skin tension line of original canthal margin on lower eyelid

3. Incision for epicanthoplasty and double eyelidplasty

4. Elevation of flap for epicanthoplasty

5. Shaving excessive fibrous tissues under upper epicanthal skin flap, if necessary

6. Reposition of orbicularis oculi muscle

7. Confirming absence of vertical tension and smooth skin folding along the designed crease by simulation of crease folding.

8. Dissection or resection of eyelid soft tissues in double eyelidplasty

9. Removal of orbital fat, if necessary

10. Anchoring suture for crease formation

11. Skin closure

There are many differences in devolutional eyelidplasty from conventional eyelidplasty without devolutional concept. The epicanthus and epiblepharon is same manifestation except their location. Both are composed of preseptal orbicularis muscle and degenerative fibrous tissues which replaced the room of atrophied orbicularis oculi muscles. There are more incidence of mild blepharoptosis in Asian eyelids. We think mild blepharoptosis in Asian eyelid is related with the eyelid evolution. After the evolutional process, the loading conditions of levator muscle had been worsened.

The fibrous tissues within the epicanthus and the epiblepharon, vertical skin tension on upper eyelid, hypertrophied orbicularis oculi muscle and hypertrophied preaponeurotic fat pad add levator and muller muscle more loadings, and act as causal factors of blepharoptosis. We can experience the improvement of mild blepharoptosis after devolutiona lepicanthoplasty often. When we evaluate blepharoptosis, we should consider the epicanthus related factors. When we perform blepharoptosis surgery with devolutional epicanthoplasty simultaneously, correction of blepharoptosis become complete and is expected to get better result. Also in devolutionaleyelidplasty, destructive procedures on surgical crease for stronger adhesion is less necessary.

The tensional stress on crease by vertical skin tension is main cause of crease loss after double eyelidplasty in Asians. Contraction of malpositioned orbicularis oculi muscle in vertical direction is also a potential cause of tensional stress on surgical crease. Because we have resolved the possible causes of crease loss with devolutional epicanthoplasty, aggressive adhesion which performed in conventional method is less necessary. In more cases, we can apply non-incisional method for crease formation except excessively thick skin condition with true epiblepharon. When we should remove excessive and malpositioned soft tissues in cases of droopy eyelids with epiblepharon, conservative resection for resolving the displaced soft tissues of the anterior lamella and partial removal of preaponeurotic fat in the posterior lamella is enough without unnecessary tissue injury. The overactive resection and resultant unnecessary tissue injury only cause prolonged swelling and depression scar.

Unlike conventional methods, Structural Asian eyelidplasty (Kwon’s method) have merits such as :

Less invasive procedure and less tissue injury resulting in less swelling
More natural surgical result
Better result of combined ptosis correction.
Minimal incision scar
Less risk of crease loss
Prevention of swelling retention by lymphatic blockage which is caused by vertical tension
Enabling high parallel crease
Ease in converting infold type crease to outfold
Ease in refining unnatural out-fold crease which was formed by double eyelidplasty only


If we review the eyelid evolution and consider the epicanthus in relation to double eyelid, Asian double eyelidplasty would need to be refined more in combination with epicanthoplasty under devolutional concept. Dr. Kwon emphasize that epicanthoplasty needs to be considered as a core surgery for Asian double eyelidplasty, especially when forming the parallel-type of double eyelid. Epicanthoplasty is not an ancillary surgery in Asian double eyelidplasty,but combined epicanthoplasty and double eyelidplasty based on devolutional concept deserve one complete "structural eyelidplasty" for Asians.

Through more than five thousands cases of people who already underwent devoutional eyelidplasty by Dr. Kwon, Kwon’s theory and methodhas been proved to be a very effective and universal technique for Asian eyelid. The surgical outcomes are really natural and satisfactory.

Examples) Example of an eye with a natural double eyelid and a slight epicanthus. The caruncle(red part) is exposed almost completely and the natural inout fold is expressed. The eyeline is exposed fully up to the canthal angle(corner) and the eyelashes decorate eyes so beautifully.


Examples) Magic epicanthoplasty with revisional double eyelid surgery was performed


Examples) Combination of magic epicanthoplasty and incisional double eyelid surgery


Examples) Combination of magic epicanthoplasty and double eyelid surgery


Examples) This is a case of the double eyelid surgery without the improvement of the epicanthus.


The right eye (actually on left from the point of view of the reader) looks unnatural because the outfold is designed above the epicanthal fold. The crease become attauated. It is likely to fade away gradually. The left eye shows an infold type under the epicanthal fold. When there is severe epicanthus with strong tension, a double eyelid tend to be designed like the left eye where the crease is lower and closer to the lashes.

Examples) Combination of magic epicanthoplasty and incisional double eyelidplasty in the case of severe epicanthus. Inout folds or parallel folds are created, and the eyes have changed into clear and vivid appearance by correcting epicanthi which makes the eyes have a fierce look.


Examples)Combination of magic epicanthoplasty and double eyelid surgery in the case of severe epicanthus in male patient.


Examples) Sausage type of double eyelids were made after not taking epicanthoplasty . Magic epicanthoplasty and revisional double eyelid surgery refined the images of eye in manner of natural and distinctive looks.


Examples) This case shows the negative effect of epicanthus on the outfold(parallel) double eyelid . There is no continuation of line up to the medial corner of the eye. Magic epicanthoplasty and medial correction of double eyelid refined the images of eye in manner of natural and distinctive appearance


Examples) Partial correction of double eyelid creases with magic epicanthoplasty in incomplete natural double eyelids with epicanthus. These types of double eyelid creases are usually formed at much lower position. When the magic epicanthoplasty is performed, it is frequently necessary to correct medial double eyelid creases at the same time in the epicanthal area to obtain clear double eyelids.


Examples)The effect of magic epicanthoplasty to the double eyelid crease. Only the magic epicanthoplasty is performed without correcting the line. Some people just prefer infold crease.


Examples) Buried suture method (non-incisional double eyelid surgery) with magic epicanthoplasty was performed to correct the creases. It shows slight outfold (parallel) lines after surgery.


Examples) These are the cases which show vertical tension of epicanthus in the eyes with outfold double eyelid. Clearer creases were made by the combination of magic epicanthoplasty and medial correction of double eyelid.



05Types of the double eyelid – Infold, Inout-fold, Outfold

Inner-fold double eyelid

An inner fold is a shape of the natural double eyelid of Asian, which is very low, formed close to the eyelash. It is almost invisible.

Infold double eyelid


Infold double eyelid


An infold is a shape of the natural double eyelid of Asian, which is most general for northeast Asians in relation to the anatomical structure around the eyes. The medial eyelid crease is hidden by various amount of coverage by the epicanthus and looks thin and only noticeable in the mid-lateral eyelid. If the epicanthus is severe, the epicanthoplasty may be needed to improve severe infold crease.

Examples) Performing only double eyelid surgery on these kinds of eyes renders them have infold type eyelids


Examples) Slight improving of infold crease ,slight amount of inner corner exposure by magic epicanthoplasty in severe infold type eyelids.


Examples) converting of infold crease to inout-fold by magic epicanthoplasty and partial correction of medial crease with non-incisional anchoring


Examples) Structural double eyelid surgery combined magic epicanthoplasty and double eyelid surgery for parallel type of double eyelid.




Inout-fold double eyelid


Inout-fold double eyelid (tapered type)


An inout-fold is the middle form between an infold and an outfold. The crease starts from the tip of the corner of the eye and extend gradually to the end of the eye. The crease converges and tapers to the eyelid margin nasally. The inout crease show usually small or medium height. It shows a clear and natural look for the Asian eyes and is a crease that is preferable by most Asian woman. This crease does not look unnatural and looks splendid and attractive. In most Asian cases, it can be formed when magic epicanthoplasty is done together with double eyelid surgery. In case of minimal epicanthus, medium height inout crease can be formed by only double eyelid surgery.

Examples) Combination of Magic epicanthoplasty and non-incisional double eyelid surgery to make an inout-fold crease.


Examples) Magic epicanthoplasty with partial correction of medial crease can convert an infold to an inout-fold crease.




Outfold double eyelid


Outfold double eyelid (parallel type)


An outfold is an eyelid crease that starts apart from the heads of eyes(medial canthus) without touching the inner corner. Westerns mainly have just like this structure(actually semilunar type), and they have an eyeball socket structure that set deep inside in contrast to their forehead and nose. Preoperative consultation should evaluate individual anatomical conditions and consider the individual expectations of each patient as well. To avoid an unnatural, unsatisfactory, unattractive result, the surgery aim should be decided and planned within the medical limitation of what the surgical result look like a non-surgical state.If patient are of mixed Occidental and Asian decent, the case is very good candidate for dolly( high parallel type) double eyelid.


Favorable structural condition for a beautiful Asian eye with a parallel double eyelid :

Blepharofissure(The width of the eyes) is long and the tails of the eyes are not so pointed upwards.

The distance between the eye and eyebrow is long.

The eyelid skin is thin

The function of the muscle to open the eyes is good.

verticallly longer tarsal plate

The relative protruding eyeball type



In Asians, outfold type can be by made double eyelid surgery combined with proper epicanthoplasty. But high outfold can look unnatural even after proper combined surgery in unfavorable conditions, because of the structural differences of Asian eyes. When only the double eyelid surgery is performed, swelling will be severe and may last for a long time(sausage phenomenon). This will lead to unnatural eyelid look. So the limitation of outfold height shoud be determined according to the given anatomical conditions for natural looking eye.


Example) Semilunar double eyelid of a Westerner. The crease is relatively wide and deep under orbital bone. The semilunar supratarsal crease of Westerner is somewhat different from parallel double eyelid of Asian. The orbital bone structures and soft tissues are different in shape. So, even though Asian have outfold double eyelids, crease location and contour are somewhat different from a Caucasian’s semilunar crease.


Generally, the aesthetic results of Asian double eyelidplasty without epicanthoplasty tend to be incomplete (less natural or unattractive), especially when designing for high parallel type. When performing outfold type eyelidplasty without epicanthoplasty, prolonged swelling retention(so-called sausage phenomenon) tend to occurs due to blockage of lymphatic flow by vertical tension of epicanthus and fading away of double eyelids are frequently noted. Unless the epicanthoplasty resolves epicanthal tension and remove potential inhibition factors of crease loss, the surgical crease will not look natural or not be able to last stably.

Examples) High and unnatural double eyelid line without the improvement of epicanthus


Examples) Combination of magic epicanthoplasty and revisional double eyelid surgery in case with sausage phenomenon and iatrogenic ptosis


As the clinical significance of the epicanthus is mainly related with Asian double eyelidplasty, essential epicanthoplasty should be a key to plastic surgeons for choice of all the type of double eyelid including high outfoldtype(parallel type). But, previously there has not been a potent epicanthoplasty method which deserves universal solution for Asian double eyelidplasty.

Examples) An outfold crease in an Asian eye with epicanthus looks unnatural and incomplete. Magic epicanthoplasty was performed to correct them.


Examples)Double eyelid surgery, ptosis correction with epicanthoplasty. Notice minimal epicanthus before epicanthoplasty.


Before devolution epicanthoplasty (=Kwon’s method. Magic epicanthoplasty), It has been a long-standing dilemma for plastic surgeons which procedure to choose, i.e. infold type double eyelidplasty with a less satisfactory result or outfold type double eyelidplasty with concomitant epicanthoplasty, taking risk of hypertrophic scar in Asian eyelid. When the epicanthal fold is severe, the surgical epicanthoplasty incision of skin flap also become longer, and a scar could be easily visible in conventional method, which based on the concept of local skin flap and lacked a consideration of upper orbicularis muscle and vertical epicanthal tension. So, plastic surgeons thought that tapered type is best within limitation of natural-looking eyes in Asian blepharoplasty.

The devolutional Asian blepharoplasty resolved previous limitation and extended possible asthetic aim and enable to form parallel double eyelid which looks naural without surgical mark.

Examples)Structural double eyelid surgery combined with the magic epicanthoplasty and double eyelid surgery for parallel type of double eyelid.


Now, we can accomplish parallel type double eyelid which look natural and last stably by structural Asian eyelidplasty based on devolutional concept. In favorable condition of Asian eyelid, we can make dolly eyelid such as celebrity’s natural eye.

Examples)Magic epicanthoplasty combined with a non- incisional double eyelid surgery


The devolution epicanthoplasty plus double eyelidplasty, these two combined surgery is becomong the firm basic concept(Structural eyelidplasty concept in Asian eyelid : Combined Epicanthoplasty and Double Eyelidplasty as One Surgery) for the Asian blepharoplasty to accomplish most attractive, natural-looking eyes.

Examples)Combined magic epicanthoplasty and double eyelid surgery.



Examples)double eyelid surgery without epicanthoplasty in case of minimal epicanthus. Notice the degree of an outfold line that can be permitted to Asians in case of minimal epicanthal tension.


06How do you know which type and which height to take? An infold, inout-fold,outfold?


There would not be a ideal crease type and height which is best for all cases. As is the case for all aesthetic facial surgery, the surgical aim should be determined under individual anatomical conditions and patient’s request. We should consider anatomical differences of Asian eyelid to accomplish naural-looking surgical results. The fusional part of the orbital septum and levator aponeurosis in Caucasian eyelid is typically in the skin crease(8-12 mm from eyelid margin). Its location lies above the superior tarsal border, which limit the downward prolapse of the orbital fat pads and enable aponeurotic expansions to insert toward the subdermal surface of the pretarsal eyelid skin. Whereas the fusional part lies at the lower point(6-8 mm from eyelid margin) in Asian eyelid and its location lies usually at the superior tarsal border. The height of tarsal plate is relatively less than Caucasian’s( more than 8 mm in Caucasian). It is anatomically desirable to form surgical crease at the level of superior tarsal border in Asian blepharoplasty. If the longitudinal length of tarsal plate long, it is beneficial when forming bigger parallel surgical crease.

If the eyelid crease in the inner corner of the eyes is not clearly visible due to the epicanthus , it is an infold. The infold crease is usually very low. Although low Asian crease is generally infold, it looks natural. In cases of Asian descent who have a crease congenitally, the crease is usually low infold or inout crease. If the epicanthus is mild, the congenital crease is usually medium height inout crease. For natural image of surgical result, the relationship of the epicanthus and double eyelid should be taken into account.

If it is located on the epicanthus apart from medial canthus , it is an outfold. The height of outfold is usually more than medium. To form an high outfold like those of the Westerners, patient should undergo the epicanthoplasty and resolve epicanthus . For ease Asian decent, people don’t have depressed eyeball socket characteristics and high nose, so the high outfoldmay turn out unnatural in structural aspects. But an inout-fold or medium outfold can turn out to be relatively natural with structural eyelidplasty (combined epicanthoplasty and double eyelid plasty)and is usually recommended.

Previously many patients concerned about whether to take the epicanthoplasty or not. Now it is definite that the epicanthus determines the type of double eyelid crease and natural images after Asian blepharoplasty . So, devolution epicanthoplasty must be accompanied for higher parallel crease and a natural-looking, stable inout crease in Asians.The higher outfoldcrease patient prefer, the epicanthoplasty is more instrumental in Asian blepharoplasty.

It is not true that only large double eyelids make big and beautiful eyes. Because skin thickness, fat, muscle, surround bony structure of eye are different in each person, proper height is also different in each case. The most important key for natural looking beautiful eyes depends on the designed height of the double eyelid which is appropriate for each anatomical condition. An inadequate height can make eyes look unnatural and disturb functioning of the eyes (opening and closing the eyes) and will swell for a long time, and even look as if people have drowsy looking eyes.Patient should understand that there is medical limitation in crease height and crease type to preserve natural image of the eyelid after Asian blepharoplasty.

Examples)This is a case of an infold crease without improving the epicanthus. Magic epicanthoplasty with partial correction of medial crease is done to create an inout-fold crease


Examples)This is a picture of an infold without improving the epicanthus. Magic epicanthoplasty and revisional double eyelid surgery is done to form an inout-fold crease.


Examples)An infold without improving the epicanthus. Magic epicanthoplasty with revisional double eyelid surgery is performed to create symmetric outfold crease.


07The reason why the medial double eyelid is likely to get attenuated or fade inceptively


Generally, all surgical double eyelids can become attenuated or fade away as time passes. The fading risk is less when the epicanthal tension is weak and there’s small amount of fat in the eyelid, and when the eyelid skin is thin. The tensional stress on medial crease by vertical skin tension is the main cause of crease loss after double eyelidplasty in Asians.

(Left) After conventional double eyelidplasty, 1 year post-operatively. A clue of past evolutional process, notice aggravation of vertical tension on the epicanthus and attenuated medial crease. This eyelid is similar with the stage of compressional stress before loss of mid-lateral supratrsal crease in the eyelid evolution. (Right) A natural Asian eyelid with an epicanthus and incomplete presence of attenuated supratarsal crease. Notice loss of medial crease, epicanthal bulging, appearance of lesser crease along the malpositioned preseptal muscle, and skin fold of lower eyelid. This eyelid shows the vestiges of eyelid evolution obviously.

Examples)This is a case of an infold crease without resolving the epicanthus. Magic epicanthoplasty with partial correction of medial crease is done to create an inout-fold crease


Contraction of malpositioned orbicularis oculi muscle in a vertical direction is a potential cause of tensional stress on mid and lateral surgical crease. When the crease is designed high, the tension and fading risk increase proportionally. To maintain the stable double eyelids, it is recommended to make the inout-fold or the outfold with resolving the epicanthus by proper epicanthoplasty.

08The epicanthus as a cause of fading double eyelids in Asian eyelid.


Although the fading of double eyelid is undesirable, it may occur after some period of time. The most important thing is to analyze the causes and correct them by applying suitable methods. There are three main causes for fading. First, it is caused by weak fixation. Second, it is caused by blepharoptosis(weak eye-opening power). Third, the epicanthus plays an important role for the fading of the crease. Unless a double eyelid surgery meets certain requirements, the double eyelid crease will not be able to last for long time. If a person with severe epicanthus undergoes a double eyelid surgery only, the crease of the eye would rather get loose or fade out. When severe epicanthus makes the double eyelids look unnaturally thick(sausage phenomenon) after double eyelid surgery only, it is not easy to correct after all. So the structural Asian eyelidplasty (combined epicanthoplasty and double eyelidplasty) based on devolutional concept should be performed in primary surgery.

There are many differences in devolutional eyelidplasty from conventional eyelidplasty without devolutional concept. In devolutional eyelidplasty, destructive procedures on the surgical crease for stronger adhesion becomes less necessary. The epicanthus exists as a remnant fibromuscular volume on the upper medial canthal region with vertical(actually diagonal, relative meaning in relation to horizontal supratarsal crease) skin shortage and tension which causes difficulty in horizontal skin folding. It acts as a major hindrance of a double eyelid formation in Asian blepharoplasty. The fibrous tissues and malpositioned orbicularis muscle prevents the even transmission of levator muscle power toward the medial skin because the aponeurotic fibers have been detached and do not extend to the epicanthal skin area any more.

The preexisting vertical skin tension acts as tensional stress on newly formed surgical crease. The epicanthal skin tension is considered as a major factor which inhibits the sustainability of surgical crease in Asian double eyelidplasty. Also, the malpositioned orbicularis muscle can be reactivated as a vertically acting inhibitor which causes active tensional stress on mid-lateral surgical crease, especially when we have performed the outfold type double eyelidplasty without epicanthoplasty.

 

The tensional stress on crease by vertical skin tension is the main cause of crease loss after double eyelidplasty in Asians. Contraction of malpositioned orbicularis oculi muscle in a vertical direction is also a potential lcause of tensional stress on surgical crease. Because we have resolved the possible causes of crease loss with devolutional epicanthoplasty, aggressive adhesion which performed in conventional method is less necessary. In more cases, we can apply non-incisional method for crease formation except excessively thick skin condition with true epiblepharon.

When we should remove excessive and malpositionedsoft tissues in cases of droopy eyelids with epiblepharon, conservative resection for resolving the displaced soft tissues of the anterior lamella and partial removal of preaponeurotic fat in the posterior lamellais enough without unnecessary tissue injury. The overactive resection and resultant unnecessary tissue injury only cause prolonged swelling and depression scar.

We think that we need to review conventional procedures of Asian blepharoplasty and theoretical background for adjusting to devolutional Asian blepharoplasty appropriately. If we agree with the eyelid evolution and understand about the epicanthus in relation to double eyelid better, Asian double eyelidplasty would need to be refined more in combination with epicanthoplasty under the devolutional concept.

The epicanthus and epiblepharon is same manifestation except their location. Both are composed of preseptal orbicularis muscle and degenerative fibrous tissues which replaced the room of atrophied orbicularis oculi muscles. There are more incidences of mild blepharoptosis in Asian eyelids.

We think mild blepharoptosis in Asian eyelid is related with the specifics of eyelid evolution. After the evolutional process, the loading conditions of levator muscle had worsened. The fibrous tissues within the epicanthus and the epiblepharon, vertical skin tension on upper eyelid, hypertrophied orbicularis oculi muscle and hypertrophied preaponeurotic fat pad increase loading onto the levator and Muller muscle, and act as causal factors of blepharoptosis. Patients can often experience the improvement of mild blepharoptosis after devolutional epicanthoplasty. When we evaluate blepharoptosis, we should consider the epicanthus-related factors. When we perform blepharoptosis surgery with devolutional epicanthoplasty simultaneously, correction of blepharoptosis becomescomplete and is expected to get better results.

 

Examples) Getting loose or fading of crease after inappropriate solitary double eyelid surgeries


Examples) Cases where combined double eyelid surgery and epicanthoplasty are necessary


Examples) The creases after solitary non-incisionaldouble eyelidsurgery results in infold type. The right crease faded out. After magic epicanthoplasty and double eyelid surgery (buried suture method), it shows symmetrical inout- fold double eyelid.


Examples)Combination of magic epicanthoplasty and revisional double eyelid surgery. If an medium height of inout-fold crease is tried to be created without improving the epicanthus, the medial double eyelid crease will fade away easily. The creases (pre revisional photo) seem unattractive. A crease created by the combined epicanthoplasty and double eyelid surgery provides a clear and natural appearance. When epicanthi are severe, the structural double eyelid surgery should be performed to create stable and attractive inout or outfold crease.


Examples) These cases show the negative effect of epicanthus in the cases in which solitary outfold double eyelid surgery is performed. There is sausage-like fullness and no continuation of crease up to the medial corner of the eye(above). Magic epicanthoplasty and revisional double eyelid surgery refined the eyelid in manner of natural and distinctive appearance.


Examples) This case shows the negative effect epicanthus in the eyelid after solitary outfold(parallel) double eyelid surgery. There is no continuation of crease to the medial corner of the eye(above). Magic epicanthoplasty refined the images of eye in manner of natural appearance. If an outfold(parallel) crease is created without improving the epicanthus, the double eyelid crease will look awkward and incomplete. The creasees (pre revisional photo) seem very unnatural. A crease created by the combined epicanthoplasty and double eyelid surgery provides a clear and natural appearance on proper anatomical conditions. When epicanthi are severe, the structural double eyelid surgery including proper surgical technique for resolving epicanthus should be performed to create beautiful and admirable eyes.


Examples) These cases show the negative effect of epicanthus. There is asymmetric natutal double eyelid crease on the medial corner of the eye. Magic epicanthoplasty and double eyelid surgery refined the images of eye in manner of symmetric outfold(parallel crease) appearance.


09Pre-surgery consultation


Consultation for an Asian blepharoplasty (double eyelid surgery) during the preoperative visit is probably as important as the surgery itself, since it is during the preoperative visit that the important decisions about the design of the eyelid crease are made such as where to set the height and shape of the eyelid crease. The ultimate aim of an Asian blepharoplasty is to create a skin crease to enhance the appearance of the eye, yet at the same time, preserve the features of Asian ethnicity for the individual patient. It is therefore very important that when seeing a patient for the first time for their eyelid surgery, that time and meticulous attention is spent to ensure that both patient and surgeon are clear about the desired eyelid configuration.

At consultation, a patient should thoroughly explain what he/she wants to gain from the surgery. And the doctor must fully understand the expectations by the patient and explain the possible and impossible things that could be done to give the best results. If your eyebrows look like they are hanging down too much, the doctor may consider lifting it up(brow lift surgery) along with your eyelid surgery. Surgical methods are determined among an incision, partial incision method, or the buried suture method.

10Scars after double eyelid surgery


An eyelid has a weak and thin skin and a double eyelid surgery without significant problems can be taken even to a keloid constitution. Usually a keloid scar is different from an hypertrophic scar. A hypertrophic scar is similar with a keloid in that irregular scar is seen when an eyelid are healed. It is different from keloid in that a hypertrophic scar can happen to anyone not relating constitution. Also the hypertrophic scar will spontaneously fade away within 6months. On the other hand, the keloid extends more and more. And after incision, it can be more severe. Generally, a hypertrophic scar may last longer for people who have dark and thick skin, but it is not something to worry much about because they usually last up to only around 3-6 months.

In devolutional Asian eyelidplasty, destructive procedures on surgical crease for stronger adhesion is less necessary. The tensional stress on crease by vertical skin tension is main cause of crease loss after double eyelidplasty in Asians. Contraction of malpositioned orbicularis oculi muscle in vertical direction is also a potential cause of tensional stress on surgical crease. Because we have resolved the possible causes of crease loss with devolutional epicanthoplasty, aggressive adhesion which performed in conventional method is less necessary. In more cases, we can apply non-incisional method for crease formation except excessively thick skin condition with true epiblepharon.

When we should remove excessive and malpositioned soft tissues in cases of droopy eyelids with epiblepharon, conservative resection for resolving the displaced soft tissues of the anterior lamella and partial removal of preaponeurotic fat in the posterior lamella is enough without unnecessary tissue injury. The overactive resection and resultant unnecessary tissue injury only cause prolonged swelling and depression scar. Therefore there would be less chance of hypertrophic or depression scar in structural Asian blepharoplasty based on devoutional concept.

Examples)Magic epicanthoplasty and a revisional double eyelid surgery. The scar has been removed.




11Method for a double eyelid surgery : non-incision, natural adhesive


The buried suture method, natural adhesive method (non-incisional double eyelid surgery)

For the buried suture method, we must consider the amount of ptosis, size of eyes, thickness of tissues of the eyelids, the degree of the hanging down of the eyelids, your skin, and your muscles. The buried suture method needs to make small halls with the needle in several units for binding skin and levator muscle through these holes. If you feel that you cannot see much of a difference after the surgery, or if your new image is hard to accept, it can be returned to your original natural state by the removal of the suturing thread. This surgery is operated by very a very small incision (usually 1-2mm.). Usually after the surgery, a scar cannot be seen, even without make-up on.

Examples)Magic epicanthoplasty combined with a non-incisional double eyelid surgery.



Examples)Magic epicanthoplasty combined with a non-incisional double eyelid surgery. The actual double eyelid crease is designed at lower level intentionally according to patient’s demand.


Examples) Only a non-incisional double eyelid surgery was performed.


Examples)Magic epicanthoplasty combined with a non-incisional double eyelid surgery in a male patient.


Techniques of the buried suture method


In this method, there are various types. The first type is that we make a single loop. Another type is that we make a short loop in three to five parts. And the final type is to make many loops according to doctor’s demand. The main reason to avoid this method is that the double eyelid might fade away after a long time. However, Teuim plastic surgery minimizes that problem by experienced suture technique and devolutional epicanthoplasty. In devolutional eyelidplasty, destructive procedures on surgical crease for stronger adhesion is less necessary. The tensional stress on crease by vertical skin tension is main cause of crease loss after double eyelidplasty in Asians. Contraction of malpositioned orbicularis oculi muscle in vertical direction is also a potential cause of tensional stress on surgical crease. Because we have resolved the possible causes of crease loss with devolutional epicanthoplasty, aggressive adhesion which performed in conventional method is less necessary. Through devoutional Asian blepharoplasty, we can apply non-incisional method for crease formation in more cases, except excessively thick skin condition with true epiblepharon

Who are suitable for the buried suture method?


In Kwon’s classification of Asian eyelid, type I, II, III are good candidates. The buried suture method is basically suitable for thin skinned eyelids.Surely, the buried suture method can be applied to any type of eyelid, but the best results can be expected in thin eyelids. Also, for people who easily make crease with Eyecharms, tape, or eye glue, this method is useful. In general it is desirable method for people who have good skin conditions.


Favorable conditions for non-incisional method

1. Eyes with not much fat and with thin eyelids.
2. People with a double eyelid on only one side of the eye.
3. Eyelids that are not symmetric and are imbalanced.
4. Men who want to get small crease .
5. People who have eyes that are easy to make double eyelids with tapes or glue.
6. Eyes that sometimes form double eyelids but sometimes not.
7. Eyes that have an indistinct double eyelid crease.

Advantages of the buried suture method

Buried suture method shows rapid recovery with less swelling. It is natural and a scar is hardly seen. The eyes will look natural in only about 2-3 weeks. It creates a very natural double eyelid line. A scar won’t remain. The duration of the operation is about 20-30 minutes. The recovery period is also very short. But, the final result of incisional method is more likely to be permanent due to the creation of stronger attachments between the skin and underlying deeper eyelid structures. Despite the open incisional technique being a superior operation, the closed suture techniques remain the most popular surgery due to their simplicity and no scar.

Concerns about the double eyelid fading away

It’s a fact that people have experienced their creases fading away in the past from the buried suture method. The main reason for this is that there was a chance the eyelid surgery was undertaken improperly. If the crease gets loose, it causes discomfort for both the patient and the doctor. It is wrong to think that the buried suture method would get loose and fade away even though a proper surgery is performed from a skillful surgeon. The tensional stress on crease by vertical skin tension is main cause of crease loss after double eyelidplasty in Asians. Contraction of malpositioned orbicularis oculi muscle in vertical direction is also a potential cause of tensional stress on surgical crease. Because we can resolve the possible causes of crease loss with devolutional epicanthoplasty, aggressive adhesion which performed in conventional incision method is less necessary. If we apply combined epicanthoplasty and non-incisional double eyelidplasty in proper cases, there’s no need to worry about crease loss.

Examples)Magic epicanthoplasty combined with non-incisional double eyelid surgery in eyes that have faded lines.


Buried suture method for eyelid skin that hangs down.

When skin hangs down a lot, it is better to take an incisional double eyelid surgery including excision of excessive skin. For eyes that hang down, although the lines are made high, looks like small creases due to drooped skin.

Is there a special clinic for the buried suture method?

It can be said that for 30% of Korean woman, an excision or incision is needed for beautiful eyes. Most these cases need combined surgery considering the epicanthus and the condition of the eyelids. But when skin the conditions are good, then the buried suture method or the partial incision method can be effective. When buried suture method is operated for eyes that really need an excision, the double eyelids are most likely to fade away in spite of combined epicanthoplasty. In most thick skin conditions, Asian eyelids tend to have severe epicanthal folds, so the epicanthoplasty is necessary for good results. So it is true that most hospitals apply incisional or non-incisional method properly. If a hospital operates only with the buried suture method, it cannot be accepted both surgically and aesthetically. This cannot create desirable results and it would be an act against the cosmetic principle either

12Method for a double eyelid surgery : Partial incision


What is a partial incision?

In Kwon’s classification of Asian eyelid, type II, III, IV are candidates. This is suitable for a person who has slightly puffy eyes and who wants to obtain a natural medium double eyelid. It can be operated by a minimal incision and it can make a more certain adhesion than the buried suture method. In a months, the swelling will decrease.



Advantages and disadvantages of the partial incision method

Advantages
Patient will experience a rapid recovery. Also the fat of the eye will be minimized.
1. It is unnecessary to worry about a scar after surgery with minimized incision.
2. Fat is removed.
3. Recovery time is short.

Disadvantages
1. It cannot be applied to eyes that show true epiblepharon
2. The swelling eases faster than that of the full incision or excision method, but more than that of the buried suture method.


13Method for a double eyelid surgery : Full incision


Incision/Excision

What is an incisional method? It is a method cutting along the line intended. This usually includes the excision of skin. It resoves and manages many factors such as excessive eyelid skin, muscle, eye socket fat and so on. When there is too much fat on the eye socket, the operation can remove it. By making adhesions with the levator muscles and the skin, the crease form. Usually in a case an incisional method is needed, natural-looking creases can be made by operating with the epicanthoplasty because many people have severe epicanthus. So, a combined operation of the two surgeries will make clear eyes and clear creases. The final result of incisional method is more likely to be permanent due to the creation of stronger attachments between the skin and underlying deeper eyelid structures. Despite the incisional technique being a superior operation, nonincisional method is preferred by patient due to no scar. In Kwon’s classification of Asian eyelid, type V are absolute candidate.

The types of eyes that need the incision method

Actually it can be said that more than 30% of Korean women have to take an incisional method to gain beautiful eyes. Most of them are required a combination surgery of magic epicanthoplasty with an incisional double eyelid surgery. And few of them can make suitable results by the buried suture method or partial incision method. We must consider the hanging down of the skin, condition of the eyelid, ptosis, epicanthus and expectations from the patients.

Structural eyelidplastytin Asian eyelid : Combined Epicanthoplasty and Double Eyelidplasty as One Surgery : new paradigm in Asian double eyelid surgery

Most cases needed for an incision show severe epicanthus and epiblepharon. Considering that the correlation between Mongolian folds and a double eyelid, it is a natural phenomenon. In this case, simple operation for a double eyelid is improper for best result and a more complex approach is needed. The magic epicanthoplasty enables harmonious complex surgery.

Teuim plastic surgery performs both surgeries at the same time and creates the best eyes for patients. We highly assure that this complex operation would be the basis for the plastic surgery of Asian eyes in the future worldwide. In devolutional eyelidplasty, destructive procedures on surgical crease for stronger adhesion is less necessary. The tensional stress on crease by vertical skin tension is main cause of crease loss after double eyelidplasty in Asians. Contraction of malpositioned orbicularis oculi muscle in vertical direction is also a potential cause of tensional stress on surgical crease. Because we have resolved the possible causes of crease loss with devolutional epicanthoplasty, aggressive adhesion which performed in conventional method is less necessary.

When we should remove excessive and malpositioned soft tissues in cases of droopy eyelids with epiblepharon, conservative resection for resolving the displaced soft tissues of the anterior lamella and partial removal of preaponeurotic fat in the posterior lamella is enough without unnecessary tissue injury. The overactive resection and resultant unnecessary tissue injury only cause prolonged swelling and depression scar.

Concerns about remaining scars from an incision.

A scar from an incision is very timid after 3months .Also,the surgical lines are hidden when the eyes open, so there is no need to worry about it.

If you are scared to take the incision.

Incisions are a necessary method for eyes that have some difficult conditions. Although it requires more time for being natural, the recovery period is occasionally faster than the aggressive buried suture method in such bad conditions. A scar will not remain obviously, so it is not needed to worry about it.

Examples)preoperative, postoperative 2months, postoperative 1year open eye, postoperative 1 year closed eye



Eye enlargement surgery( aesthetic ptosis correction, eye-opening refinement surgery)


This is a surgery that enlarges your eyes vertically. Using the technique of ptosis surgery, we strengthen the muscles that open the eyes and make eyes look clearer by exposing more of the iris. A weak ptosis is often seen in Asians. These eyes cover the iris and give a tired feeling even after a double eyelid surgery. In cases where the iris is covered with the eyelid, this surgery should be taken in addition to double eyelid surgery.


Examples)Double eyelid surgerywith an eye enlargement surgery


Examples)Revisional double eyelid surgery with an eye enlargement surgery.



14Teuim complex enlargement surgery.


If your eyes are small, or if you are a person who wants to extend and enlarge your eyes, a complex surgery with the epicanthoplasty, lateral canthoplasty, eye enlargement and double eyelid surgery can help your eyes dramatically.


Examples)Magic epicanthoplasty combined with an excisional double eyelid surgery and lateral canthoplasty


Examples)Magic epicanthoplasty combined with an excisional double eyelid surgery


15Suggestions for various eyelid


Eyes that look swollen and puffy.

Puffy eyelids are common for Asian women. These eyes are formed when the fat in an eyeball socket is abundant or the orbicularis oculi muscle is thick(true epiblepharon), or when the orbital skeleton is protruded around the eyes. In these kinds of eyes, it is needed to make the eyelid thinner. Operational plans have to be made by determining what the reasons are for the eyes to look swollen. Then, the reason for puffy eyelid must be fixed. The fat may be removed, the skin and muscle may be cut out, and additional operations must be taken if necessary. In cases where the patient has a severe epicanthus, the magic epicanthoplasty must be done at the same time.

Examples)Puffy eyes make the eyes look swollen


Examples)An incisional method for the double eyelid surgery


Eyes that originally have thin eyelid skin

When eyes have a thin eyelid and a weak Mongolian fold, a natural eyelid can be made by only a simple operation such as the buried suture method. There will be no scar remained because the eyelid is not really cut, and a natural double eyelid can be made. In this case, patients are usually satisfied with their existing eyes and hesitate to take an operation, but the result is so good and their satisfaction is usually higher.

Examples)The result of the buried suture method(non-incisional double eyelid surgery) from a patient with very thin eyelid skin


Examples)Magic epicanthoplasty combined with a non- incisional double eyelid surgery


Eyes which show multiple wrinkles

The eyes look very tired if many lines exist on the eyelid. This line is very different from the ordinary, typical eyelid crease, and most of them form as wrinkles and the traces of wrinkle are remained even when closing the eyes. By forming one crease to the proper height, the remaining wrinkles disappear spontaneously.

Examples) A case when many eyelid wrinkle lines are overlapped on eyes


Examples)The multiple eyelid lines are converted to a single clear crease after the buried suture method


Examples) non-incisional double eyelid surgery and fat graft over sunken eyelid are performed


Examples) Magic epicanthoplasty, excisional double eyelid surgery and fat graft over sunken eyelid are performed.


Eyes with damaged skin by using adhesives like Eyecharm(tape forming double eyelid) or glue

Some women use glue or Eyecharm tapes to make temporary double eyelids, but using this can cause the skin to hang down and create weak elasticity of the eyelid skin. A healthy eyelid must have tension without wrinkles even when the eyes are closed. If glue or tape is used repetitively on the eyelid, the skin will hang down and thickening of the skin may also occur. Because of this, the eyelid skin of teenagers looks often as those of the 30s. The habit of gluing on eyelids to make temporary double eyelids is not an habit to fix easily. Accurate evaluation and selection of the proper surgical method(excisional, incisional, or buried suture method) must be done depending on the degree of drooping of the skin.

Examples) Magic epicanthoplasty combined with non-incisional double eyelid surgery


Eyes that form double eyelids only from time to time

This is a case that occurs to people who have thin eyelids and a mild epicanthus .double eyelid is formed when the eyes get tired. To fix this problem, the taking the buried suture method with /without epicanthoplasty is the best way.

Examples) Eyes that form a double eyelid from time to time.


Examples) Eyes changed into a clear double eyelid by magic epicanthoplasty and the non-incisional double eyelid surgery


Eyes that give a sleepy or glaring image because of the coverage of the pupil and iris.

Many Asians’ skin of the eye hangs down and slightly covers the pupil due to true ptosis or epiblepharon. In epiblepharon case, an incisional double eyelid surgery and the magic epicanthoplasty can give clear and distinctive eyes by exposing the pupil properly. There are more incidence of mild blepharoptosis in Asian single eyelid which show epicanthus and epiblepharon. We think mild blepharoptosis in Asian eyelid is related with the eyelid evolution. Sometimes it can be confused with ptosis, but it is different with true ptosis, and correcting the ptosis is not always necessary and only the double eyelid operation can be enough.

Examples) The amount of exposure of the pupil is normalized by the magic epicanthoplasty and a double eyelid surgery with ptosis correction. They had true ptosis preoperatively.


Examples) The amount of exposure of the pupil is increased by the magic epicanthoplasty and a double eyelid surgery without ptosis correction. They have mild blepharoptosis.


Eyes that have a wide space between the two corners of the eyes

The ideal distance between the two eyes is different depending on the size of the face, but it is usually about 33-35mm. The actual distance of typical Korean women is about 35-38mm. And when it is over 38mm, it gives an awkward impression. For these kinds of eyes, the epicanthoplasty is definitely needed. It will achieve better face image. The results are more effective when plastic surgery of the nose is done together

Examples) Magic epicanthoplasty, double eyelid surgery and augmentation rhinoplasty are all performed together in male patient.


Examples )Magic epicanthoplasty, double eyelid surgery and augmentation rhinoplasty are all performed together to bring the maximal result in female patient.


Examples) Magic epicanthoplasty combined with double eyelid surgery including ptosis correction.


Double eyelids that are not symmetric each other.

There are some people who have different size of double eyelids on each eye. Too much difference may give a mismatching image so it’s better to fix it. Although it is possible to operate one eye, it is recommended to take operation on both eyes for desirable results.

Examples) Magic epicanthoplasty and double eyelid surgery


People who have a double eyelid on only one side of the eye

People who have an eyelid on only one side may think it is one of their unique characteristics, but may also feel insufficient about the imbalance of their eyes. So the eyelid surgery is taken to create balanced, even eyes. If the better symmetric crease is made, the eyes will look more beautiful.


Eyes that are pointed upwards or downwards

Eyes with its tails pointed up do not give a good impression generally. In this case, the lateral canthoplasty can help the problem.

If the tails of the eyes point downwards like as shown in the picture below, they can seem to have a depressed or aged appearance. In old-age case, it would be better to take the surgery that lifts the eyebrows so that it can correct the parts that are hanging down.

Examples) Magic epicanthoplasty combined with double eyelid surgery


Examples) Sub-brow lift surgery.


Eyes that look sunken due to insufficient fat .

These kinds of eyes can express a not so good impression because it gives a tired and drowsy look. This is mainly caused by less fat in the eyelids with deep eyeball sockets. These can be corrected to a more attractive look by the autologous microfat graft, injecting fat to aponeurotic fat pad.

Examples) Upper eyelid sunken can be corrected by the autologous microfat graft


Eyes that are easily prickled by inward eyelashes (by epicanthus or Epiblepharon)

There are casess when the eyeballs get poked by own eyelashes. If this occurs frequently, the eyes will get damaged a lot. By the epicanthoplasty and double eyelidplasty , the direction of your eyelashes can be corrected to point outwards.

Examples) Upper eyelid sunken can be corrected by the autologous microfat graft


Eyes that makes a person look sleepy

When a person opens his/her eyes, only 1-2mm of the iris should be covered by the upper lid nrmally. When more is covered, the person will look sleepy. This is called “ptosis” medically. The cause of this is the weak power of the muscle which raises the eyelid. In this case, merely the double eyelid surgery cannot make good results and a ptosis correction is surely needed to make better eyes additionally.

Examples) Magic epicanthoplasty and a double eyelid surgery with ptosis correction.


Eyes with protruding eyeballs



Eyeball protrusion such as these are caused by the exophthalmos. The excision of skin method or the removal of fat is usually unnecessary. Partial incision or the buried suture method can be easily applied to make natural looking double eyelids with/without epicanthoplasty.


logo

6F, Changlim building, 416, gangnamdaero,Gangam-gu, Seoul, Korea TEL : 02-511-5345 FAX : 02-511-5373
COPYRIGHT 2008 BY TEUIMPS ALL RIGHT RESERVED