Natural Adhesion vs. Incisional: What Criteria Should You Use to Choose?

Double eyelid surgery is not simply a procedure that creates a crease,

but a treatment that requires a comprehensive evaluation of each person’s eyelid structure, skin thickness, amount of fat, and eye-opening strength,

followed by selecting the surgical method that best fits those factors.

Below are the criteria actually used at Baba Plastic Surgery when choosing between natural adhesion (non-incisional) and incisional methods.

① Criteria for Natural Adhesion (Non-incisional)

✔ Basic conditions for eyes that can undergo natural adhesion

When you simulate a double eyelid crease by hand (“simulation”)

and the line does not loosen and remains in place for within 5 seconds,

a stable crease can also be formed with the natural adhesion method.

On the other hand, if it comes undone immediately within 5 seconds,

the structure lacks sufficient holding power, so an incisional method is recommended.

✔ Natural adhesion surgical method

About 10 to 14 tiny holes are made to match the individual eye structure,

and a thread is passed through them to create adhesion, after which the double eyelid is formed by single-knot fixation.

✔ Difference in surgical methods

Multi-knot method

A method that secures each of several holes with thread individually

Disadvantage: higher risk of thread exposure

Single-knot method (used at Baba Plastic Surgery)

Thread is passed through multiple holes, but fixed with one knot on the outer side of the eye

Minimizes the risk of thread exposure

Improves crease holding power and stability

② Cases in Which Incisional Surgery Is Necessary Even for a First Eyelid Surgery

These are structural features for which incisional surgery should be considered before natural adhesion.

If the skin is very thick

If there is excessive fat above the eyes

→ This also includes cases where, during consultation, the crease does not fold properly when designing a simulated double eyelid line by hand

If the eye-opening strength is weak due to severe ptosis

If there is significant asymmetry between the left and right eyes

If the skin has stretched due to the use of double eyelid tape or glue

→ In such cases, Baba Plastic Surgery uses the “Agnima program” (a precision imaging analysis system)

to analyze the structure accurately.

③ Does Natural Adhesion Loosen More Easily?

✔ Dr. Jang Seung-bin’s opinion

“Although there is a hypothesis that incisional methods rarely come undone while natural adhesion does,

based on actual surgical experience, I have never felt that natural adhesion has weak fixation.

However, if natural adhesion is forced onto cases that require an incisional method,

the thread may loosen due to structural limitations.”

✔ Dr. Kim Sang-il’s opinion

“With incisional surgery, if the crease is maintained for about the first 6 months to 1 year, the chance of it loosening afterward is low.

With natural adhesion, the chance of early loosening is lower than with incisional surgery,

and if it does loosen, in most cases it does so slowly after 4 to 5 years.”

In other words, the issue is less about the surgical method itself and more about whether it is appropriate for the case.

④ Eye Correction Surgery (Ptosis Correction) — Incisional vs. Non-incisional

Eye correction surgery strengthens the muscles that open the eyes (levator function).

✔ Non-incisional eye correction (mild ptosis)

If the eyes can basically open close to normal

The purpose is to make the black part of the eye look larger and clearer

✔ Incisional eye correction (moderate to severe ptosis)

If eye-opening strength is weak and the eyes cannot open normally

Incision is more stable because the muscle can be directly 확인 and corrected accurately

✔ Common symptoms that indicate the need for eye correction

A habit of opening the eyes with the forehead

Fatigue or heaviness when opening the eyes

A sleepy-looking impression

Difficulty opening the eyes wide

⑤ Double Eyelid Line and Eye Features — In-out vs. Semi-out

There is a clear distinction in which line best suits the anatomical structure of the eye.

✔ Eyes that suit an in-out line well

→ When the epicanthal fold angle is high

If such eyes are designed with a semi-out line,

the likelihood of sausage-like eyes, multiple creases, and dissatisfaction with the line increases.

✔ Eyes that suit a semi-out line well

→ When the epicanthal fold angle is low

For this type, designing an in-out line is structurally difficult.

⑥ Deep-set Eyes and Double Eyelids — Tips for Success

Compared with protruding eyes, deep-set eyes have the following characteristics:

The distance between the eyebrows and the eyes is narrow

Thicker skin

If the line is set too high in this situation,

it can create a sausage-like or unnatural appearance.

→ If necessary, performing a brow lift together to secure space before setting the line

can produce very satisfying results.

※ Note: Protruding eyes generally have higher satisfaction after double eyelid surgery than deep-set eyes.

⑦ Canthoplasty Combined with Double Eyelid Surgery

Due to the characteristics of the epicanthal fold in East Asian eyes,

combining double eyelid surgery with medial canthoplasty and upper canthoplasty

can make the eyes appear much more open and three-dimensional.

In particular, when the inner corner coverage is strong,

performing canthoplasty together improves harmony with the crease.

⑧ How to Design a More Open Back Line in Double Eyelids

Many people say the back line looks short or feels cramped.

To improve this:

Set the fixation strength of the back line precisely

Design the line so it extends naturally in a straight rather than rounded shape

However, if it extends too far outward,

the line can appear lifted and unbalanced,

so the medical team’s precise design ability is essential.

Conclusion

The most important thing in double eyelid surgery is not

“Which method is better?” but

“Which method is most suitable for my eye structure?”

At Baba Plastic Surgery, every factor—skin, fat, muscle, epicanthal fold, and levator function—is analyzed in detail

to maximize the advantages and minimize the disadvantages of each surgical method,

with the goal of customized eye surgery.

If you are wondering which line will look the most natural and last the longest,

or which surgical method is safest,

it is safest to consult with medical professionals who can provide an accurate analysis.

Every eye structure is different.

Finding your own ideal line,

that is Baba Plastic Surgery’s role.