[Duhan Plastic Surgery Double Eyelid Surgery] - [Types of Double Eyelid Surgery]

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Guide to double eyelid surgery for beautiful eyes

Indications for double eyelid surgery

① When the eyes look small

② When there are wrinkles on the eyelids

③ When the eyelids look droopy

④ When only one side has a double eyelid

Examples of eye shapes that may need double eyelid surgery

Basic principles and concept of double eyelid surgery

People often mistakenly think that double eyelid surgery is simply an operation to create a double eyelid line.

That is not the only purpose.

The purpose of double eyelid surgery is to make the eyes look larger and brighter, giving a smarter and more beautiful impression.

Surgery performed only to create a double eyelid line can sometimes create an unfavorable impression.

The ultimate goal of double eyelid surgery is to create a natural and beautiful eye shape.

Types of double eyelid surgery methods

♥ Full incision method: The full incision method is applied when the skin is sagging.
♥ Partial incision method: The partial incision method is applied to younger patients whose skin is not sagging, regardless of skin thickness.
♥ Buried suture method: The buried suture method is applied to younger patients with thin skin and no sagging skin, and with little fat.

1. Full incision method

The full incision method is mainly applied when the skin has sagged due to age.

It can remove sagging skin, and when there is thick fat or muscle, it also allows removal of fat and muscle.

○ Advantages of the full incision method

① This method is used when the skin has sagged and there is a lot of excess skin.

② The double eyelid line is clear, and a refined line can be designed.

③ Unnecessary orbicularis oculi muscle and fat can be removed.

④ The double eyelid is less likely to loosen.

⑤ If ptosis is present, ptosis correction can also be performed.

○ Disadvantages of the full incision method

① A long scar remains.

② Swelling and bruising last longer than with the buried suture method or partial incision method.

③ If the line is unsatisfactory, revision is difficult.

2. Partial incision method

The partial incision method complements the shortcomings of the buried suture method.

It is a method of creating a double eyelid by making only three incisions of about 2 mm each along the planned double eyelid line.

It is less likely to loosen than the incision method, and leaves almost no scar like the buried suture method, combining the advantages of both the incision and buried suture methods.

This is the technique mainly used at Duhan Plastic Surgery’s double eyelid clinic.

○ Advantages of the partial incision method

① The surgery takes about 30 minutes, and you can return to daily life immediately; washing your face and applying makeup are possible starting the next day.

② There is almost no swelling or bruising.

③ Orbital fat can also be removed, and stitches do not need to be removed.

④ A natural double eyelid line can be achieved quickly, and it does not look like surgery.

⑤ It is less likely to loosen than the incision method.

⑥ There is almost no scar.

3. Buried suture method

This method makes a tiny incision in the skin and buries the thread.

It is mainly applied to young people with thin skin.

However, there is a high chance that the line may change or come undone, and fat cannot be removed, so it is not a very desirable method.

○ Advantages of the buried suture method

①1. The surgery takes 30 minutes, and you can return to daily life immediately; washing your face and applying makeup are possible starting the next day.

②2. A natural double eyelid line can be achieved quickly, and there is almost no visible sign of surgery.

③3. There is almost no scar.

○ Disadvantages of the buried suture method

① If the skin is thick, it loosens easily.

② Over time, the line tends to become loose or deformed.

③ Fat cannot be removed.

④ If internal bleeding occurs, there is no outlet for drainage, so swelling and bruising are often severe.

⑤ Because the thread is fixed above the tarsal plate, it is difficult to control the thickness of the line.

⑥ In cases such as the single-knot continuous-knot method, a large amount of thread is buried, so swelling may not subside easily.

The appropriate surgery method for you is determined

based on the shape and condition of the eyes, as well as the surrounding circumstances.

For young people whose skin has not sagged much, the partial incision method is used in most cases;

for older patients, if the degree of skin sagging is severe, the incision method is recommended.

Director Shin Duhan

Comparison of common double eyelid surgery methods

	Incision method	Buried suture method	Partial incision method (quick double eyelid)
Indications	Performed when the upper eyelid skin is significantly sagging	Applied when the skin is not sagging, is thin, and there is not much fat in the eyes	Applied to eyelids without sagging skin
Advantages	* Sagging skin can be removed.* The line is less likely to loosen.* Unnecessary fat can be removed.* Ptosis correction is possible.	* Scars are less likely to form.* Swelling subsides quickly.	* Almost no scar remains.* Swelling is minimal and subsides quickly.* The line is less likely to loosen.* Orbital fat can also be removed.
Disadvantages	* A scar from the incision remains. * Swelling lasts a long time.	* Cannot be applied when the skin is sagging.* There is a high chance that the line will loosen or become thinner.* Orbital fat cannot be removed.	* Cannot be applied when the skin is sagging.

What is quick double eyelid surgery (partial incision method)

Quick double eyelid surgery is an operation that uses minimal incision and minimal swelling, allowing immediate return to daily life after surgery.

Duhan Plastic Surgery’s quick double eyelid procedure is performed using a minimal-incision partial incision method, and because skin suturing is not necessary, daily activities are possible,

and it is characterized by almost no swelling immediately after surgery and a natural appearance.

It also has the advantage of being less likely to loosen.

The 4 principles of quick double eyelid surgery (partial incision method)

Swelling must be minimizedQuick double eyelid surgery is one of the methods that causes the least swelling of any approach.
The line must not loosenBy removing the orbicularis oculi muscle and orbital fat, the line is unlikely to loosen.
Scarring must be minimalWith a minimal 2 mm incision, scar formation is almost nonexistent.
The line must be naturalBy pre-creating the line while seated, the most natural line is chosen for the surgery.

The surgical process of quick double eyelid surgery (partial incision method)

① Design the desired double eyelid line.

Usually, the design is made along the existing scar line.

Sometimes, it is designed according to the height and shape the patient wants, or the surgeon evaluates and designs the most suitable line.

Also, depending on whether an out-fold or an in-fold will be created, the direction of the design line changes.

② Mark three incision points with design ink.

The locations are lightly marked on the inner, middle, and outer parts.

③ Under sedation anesthesia, after sleeping for about 5 minutes, local anesthetic is injected into the three marked areas.

The local anesthetic is administered in the smallest possible amount to prevent swelling as much as possible.

④ Make very small incisions of about 2 mm at the three marked areas.

If the incision is made larger, more scars remain, so the surgery is performed with the smallest possible incision so that almost no scar remains.

⑤ Through the incision sites, first pull the orbicularis oculi muscle and remove it with scissors.

The orbicularis oculi muscle is the muscle layer covering the eyelid and is tissue that interferes with double eyelid formation, so it must be removed to keep the double eyelid line from loosening.

Along with removal of the orbicularis oculi muscle, preaponeurotic fat beneath the muscle layer is also removed.

⑥ If there is a lot of orbital fat, pull the orbital fat out through the outer incision.

Fat removal is mainly performed from the outer side.

⑦ Hold the fat with a hemostatic forceps and cut the base of the protruding fat with a scalpel.

Excessive fat removal can cause a hollowed eyelid, so it is better to remove only the amount that protrudes as much as possible.

⑧ After removing the fat, cauterize with an electrocautery device to stop bleeding.

If hemostasis is not properly achieved, orbital bleeding can occur and bruising and swelling can become severe, so proper bleeding control is important.

⑨ Through the three incision sites, use a very fine dissolvable thread to connect the levator aponeurosis and the skin, creating the double eyelid line.

⑩ After burying the thread and applying eye ointment, the surgery is finished.

Washing your face and applying makeup are possible starting the next day.

Use the cool pack provided by the hospital for cold compresses for 3 days.

If you apply cold compresses for more than 3 days, the swelling will not go down further, so it is best to do it for exactly 3 days.

Postoperative care after quick double eyelid surgery (partial incision method)

① Apply cold compresses with the cool pack provided by the hospital.

Do it for 2 hours a day for 3 days only.

The cold compress time can be continuous for 2 hours, or it can be divided into 20 to 30 minute sessions.

Usually, it is convenient to do it before going to sleep.

② For postoperative visits, come to the hospital once the day after surgery to disinfect the surgical site and observe the progress.

③ Makeup and face washing are possible starting the next day.

④ Postoperative swelling varies from person to person, but in most cases it subsides almost completely in about 7 days, while the full settling period takes 1 to 3 months.

Before and after quick double eyelid surgery (partial incision method)

Comparison between quick double eyelid surgery (partial incision method) and the buried suture method

​	Quick double eyelid surgery (partial incision method)	Buried suture method
Use of thread	Dissolvable thread	Non-dissolvable thread
Degree of incision	About 2 mm, 3 incisions	About 2 mm, 3 incisions
Postoperative swelling	Slight	Slight
Degree of loosening	Almost does not loosen	Frequently loosens or becomes thin
Line clarity	Maintains the clarity of the incision method	Often loosens or becomes unclear
Fat removal	Possible	Impossible
Removal of stitches	Not necessary; can be removed if desired	Impossible or very difficult
Scar formation	Almost none	Almost none

What is swelling

It occurs when exudate generated by surgery accumulates within the tissue.

The reason quick double eyelid surgery causes almost no swelling is that

through the micro incisions, the swelling-causing tissues, the orbicularis oculi muscle and fat tissue, are removed,

and because exudate produced by surgery is immediately drained through the micro incision sites,

there is little room for swelling to develop.

For example, a bruise without a cut swells, while a cut wound hardly swells; it works on the same principle.

A bruise without a wound swells because exudate is produced inside but cannot drain and accumulates.

A cut wound does not swell because the exudate drains immediately.

Director Shin Duhan

Removal of the epicanthic fold (epicanthoplasty)

When the distance between both eyes appears wide, the skin at the inner canthus often covers the eyeball excessively. The skin covering the eyeball on the inner side of the eye is called the epicanthic fold.

This surgery removes the skin at the inner canthus to make the distance between the eyes normal and open up the inner corner of eyes that look constricted.

How to diagnose epicanthic fold removal (epicanthoplasty)

If the distance between the eyes is 40 mm or more, or if the skin at the inner corner of the eye covers the white part of the eye and gives a constricted feeling, an epicanthic fold is diagnosed.

Eyes with an epicanthic fold usually have an inner corner that is not sharp and appears rounded or slopes down sharply.

Duhan Plastic Surgery’s double eyelid clinic,

Why scars do not occur in epicanthoplasty

If the skin is incised, a scar is inevitable.

The same is true for the epicanthic fold, since surgery is also performed with an incision, so scars are unavoidable.

If the scar is exposed on the surface, it can look unattractive no matter how precisely it is sutured.

However, if the scar line is hidden at the very edge of the eye corner so that it is covered, the scar becomes almost unnoticeable.

Because the scar is not exposed on the surface, it does not show.

Director Shin Duhan

Indications for epicanthic fold removal (epicanthoplasty)

① When the eyes appear far apart

As a rule, surgery is performed when the inner corners of the eyes are more than 40 mm apart.

A normal distance between the eyes is about 36 to 37 mm, but if the distance is normal and there is an epicanthic fold, it is better not to perform surgery.

If done incorrectly, the distance between the eyes may become too short, making the eyes look too close together.

② When you want to create an out-fold double eyelid

If there is an epicanthic fold, an in-fold double eyelid is created, so epicanthic fold removal is needed to create an out-fold double eyelid.

Principles of epicanthic fold removal (epicanthoplasty)

There should be no scar.The incision line should be hidden inside the boundary line of the eyelid so that scar formation is almost absent.
The shape should be natural.The inner shape of the eye should be designed horizontally so that the epicanthoplasty looks natural.
It should not recur.The inner corner should be fixed and sutured to the ligament so that it does not return to its original position.

Comparison between exposed epicanthoplasty scars and epicanthoplasty at Duhan Plastic Surgery’s double eyelid clinic

The principle of epicanthic fold removal (epicanthoplasty) is that it should leave minimal scarring, have a low recurrence rate, and be a method that can be performed together with double eyelid surgery.

At Duhan Plastic Surgery’s double eyelid clinic, Furukwa and Y-V methods are used.

The advantages of the surgery are that scars are less visible, the result looks natural, and when performed together with double eyelid surgery, the epicanthic fold can be removed naturally as an extension of the double eyelid line.

Various epicanthic fold surgery methods and scar shapes

At Duhan Plastic Surgery’s double eyelid clinic, the Furukwa method shown in the lower right is mainly used.

Its advantages are that scars are almost invisible, the shape is natural, and when combined with double eyelid surgery, the epicanthic fold can be removed naturally as an extension of the double eyelid line.

Surgical process of epicanthic fold removal (epicanthoplasty)

1. Pull the skin toward the nose to make it taut.

2. With the skin pulled taut, design the area with special ink.

The shape of the design varies depending on the surgical method, so it is not always the same.

At our clinic, the Y-V method is mainly used to make the scar less noticeable.

3. Under sedation anesthesia, local anesthesia is applied to the designed area.

4. Make a precise incision along the design line with a scalpel.

5. Lift the skin away from the muscle.

6. Reposition the skin tissue so that the epicanthic fold is pulled toward the nose.

At this point, an appropriate amount of excess skin tissue is removed.

7. Suture the skin with fine thread.

No bandage is needed immediately after surgery, and stitches are removed after 5 to 6 days.

Examples of epicanthic fold removal (epicanthoplasty)

Postoperative care for epicanthic fold removal (epicanthoplasty)

① For the postoperative visit, come the day after surgery to disinfect the surgical site and observe the progress.

② Stitches are removed on the 5th day after surgery.

③ Postoperative swelling is almost nonexistent, and the full settling period is about 1 to 3 months. During this period, the surgical area should not be rubbed vigorously.

④ For about 3 months, a slight scar may be visible at the inner edge of the eye, but this is a normal process and it becomes almost unnoticeable after 3 months.

⑤ Be careful not to rub the surgical site when washing your face.

If the surgical area is rubbed hard, the scar may become messy or widen, so caution is needed.

Cases in which epicanthic fold removal (epicanthoplasty) should not be performed

▶ When the distance between the eyes is less than 40 mm

Usually, a normal distance is about 36 to 37 mm.

If it is less than 40 mm, removal should not be performed.

If epicanthoplasty is performed on eyes with a normal distance, the eyes may look too close together, so caution is needed.

▶ When the distance between the eyes is wide but the inner corner of the eyes is already sharp in shape

Epicanthic fold removal should not be performed.

The goal of epicanthic fold removal is to open up the inner corner of the eye when the shape is rounded and make it look more open.

If the eyes are already sharply open, surgery may make the eye shape look even harsher, so caution is needed.

​Cautions for epicanthic fold removal surgery, epicanthoplasty

▶ It should only be performed when it suits your own eye shape.

During consultation, you should discuss with the specialist and carefully consider whether epicanthic fold removal is truly necessary before deciding on surgery.

▶ No matter which method is used, it is difficult to perform epicanthic fold removal surgery without leaving any scar at all.

It is better to use a method that leaves fewer scars, and it is preferable to perform surgery in a way that hides the scar inside.

Because the scar is not visible on the surface, there is almost no sign that surgery was performed.

Epicanthoplasty revision surgery

This refers to surgery that restores the original eye shape after the inner corners were opened unnecessarily, not because it was indicated, but because the appearance was made worse and needs to be returned to its original state.

Why epicanthoplasty revision surgery is needed

If epicanthoplasty was done out of necessity, you should think carefully about whether it really needs to be revised.

It happens when epicanthoplasty is recommended without considering the eye shape after surgery.

If epicanthoplasty is performed when it is not indicated, various problems can occur.

Problems caused by unnecessary epicanthoplasty

① The distance between the eyes becomes shorter than normal, making the eyes look too close together.

② If epicanthoplasty is performed when the inner corner is already sharp, the eyes become sharper and look more severe.

③ The inner conjunctiva is exposed too much, making the appearance unpleasant.

④ With epicanthoplasty, the inner line becomes thicker, and if an in-fold line was desired, it may become an undesired out-fold line.

⑤ Even when double eyelid revision surgery is performed to reduce the inner line, if epicanthoplasty is done together, the line may not shrink or may become even larger.

How epicanthoplasty revision surgery is performed

It is restored using the V-Y advancement flap method or the Z-plasty method, with a design opposite to epicanthoplasty.

The method used varies depending on the shape of the individual’s eye and the amount of available tissue.

Revision surgery leaves more scars than epicanthoplasty, so this must be taken into account.

Example of epicanthoplasty revision

It is important to prevent a situation that would require epicanthoplasty revision surgery in the first place.

Undergoing revision surgery to undo the result after making the appearance worse with epicanthoplasty is a waste of both time and money.

You should carefully judge and decide whether the surgery is truly necessary for you.

Duhan Plastic Surgery double eyelid revision clinic’s epicanthoplasty revision method

If epicanthoplasty has been done severely and revision is desired,

if the current double eyelid looks natural and there is enough excess skin at the front,

it may be possible to perform it in one procedure, but if there is not enough skin,

and the double eyelid is awkward and large,

step-by-step reconstructive plastic surgery may be needed.

In general, if the thickness (width) of the double eyelid is much greater than about 6 mm,

or if the fixation point of the double eyelid is very high,

it is expected to take a long time before it becomes natural.

Reconstruction can be done to match the shape of your own eyes.

It takes about 1 to 3 months for the swelling to go down and for the result to settle.

Even if epicanthal reconstruction surgery is performed, it cannot make the eyes exactly the same as before, and because the skin around the eyes must be gathered toward the eye area during reconstruction,

care must be taken to prevent the scar from spreading downward and inward at the inner corner of the eye.

The scar does not occur because the inside of the skin is sutured.

Director Shin Duhan

Pain-minimizing pain-free sedation anesthesia and surgical procedure

Concept of pain-free sedation anesthesia

When surgery is performed under local anesthesia, the anesthetic is injected locally with a syringe.

During the injection, anesthesia has not yet taken effect, so pain is felt.

In particular, when anesthesia is administered around the nose or mouth, the pain tends to be relatively stronger than in other areas.

To eliminate the pain of these anesthesia injections, local anesthesia performed while in a sleep state is called pain-free sedation anesthesia.

Mechanism of pain during local anesthesia and application of sedation anesthesia

When surgeries such as double eyelid surgery or nose surgery are performed under local anesthesia, pain occurs when the anesthetic is injected locally.

① First mechanism - Pain occurs when the needle penetrates the skin.

② Second mechanism - When the anesthetic is injected, it spreads between the tissues and causes tissue cells to expand, resulting in pain.

→ Therefore, if sedation anesthesia keeps you asleep during local anesthesia, you will not feel the pain of the injection.

Sedation anesthesia method

Pain-free anesthesia is usually also called sedation anesthesia, and before local anesthesia, an IV line is placed in the arm.

Then, without the patient realizing it, they enter a sleep state, and local anesthetic is injected into the surgical site.

There is no pain at all while the local anesthetic is being administered.

When the anesthesia is complete, the patient wakes from the sleep state, so they do not remember the anesthesia and it finishes without them realizing it.

The surgery is then performed while the patient is awake.

This is the difference from general anesthesia, in which anesthetic gas is continuously delivered through the airway during surgery and the patient is put into a gas-induced state.

The difference is whether consciousness is present during surgery.

Sometimes the sleep state is maintained throughout the surgery, but this is still clearly different from general anesthesia.

Types of sedative anesthetics

Propofol (propopol), also called “pofol,” is the most commonly used sedative anesthetic. It is a relatively safe agent with few side effects. It is used as an induction agent for general anesthesia in plastic surgery clinics and general hospitals, and is also mainly used for sedated endoscopy in internal medicine. Its disadvantages are that the sleep-maintenance time is short and there may be movement during sleep. Its advantages are that there is almost no dizziness when recovering from sedation anesthesia and recovery is fast, so it is the most commonly used agent in many hospitals.
Pentothal sodium (pentotal sodium) is a sedative anesthetic used less often than propofol. Compared with propofol, its disadvantage is that the sedation time is slightly shorter, but its advantage is that the sleep state is deeper, so there is less movement during sleep. Therefore, it is used when administering anesthesia to delicate areas such as double eyelid surgery, eyelids, or under-eye fat grafting.
Midazolam has a long induction time and long sleep-maintenance time, so it can be used when surgery takes a long time, but its disadvantages are that patients move a lot during anesthesia and recovery from anesthesia is slow. It is generally not a commonly used agent.
Ketamine is an inexpensive anesthetic mainly used in animal experiments. Because it can cause side effects such as nightmares during sleep, many people complain of psychological aftereffects after recovering from sedation anesthesia. Therefore, it cannot be said to be a suitable sedative anesthetic.

Scope of application of sedative anesthetics

It is applied to all surgeries performed with standard local anesthesia injections, such as double eyelid surgery, nose surgery, fat grafting, and varicose vein surgery.

Side effects of sedative anesthetics

Side effects of sedation anesthesia may cause coughing, sneezing, and temporary breathing discomfort, but serious side effects and aftereffects do not occur.

Occasionally, breathing problems may occur, but because oxygen saturation and pulse are monitored with a pulse oximetry monitor during sedation anesthesia, the risk of sedation anesthesia can be considered very low.

Scope of application of topical skin anesthetic cream (EMLA)

Topical anesthetic (EMLA) only anesthetizes the surface layer of the skin, so it is not effective when operating on deep areas.

It can be used for procedures such as wrinkle injections (Restylane, Juvederm), sclerotherapy for blood vessels, laser resurfacing, and split-thickness skin grafting, but because the anesthesia depth is too shallow, its use is limited.

□ Topical skin anesthetic cream (EMLA)

A cream used to lightly anesthetize only the skin surface.

It is generally used for surface anesthesia before filler injections when correcting fine wrinkles, but because the anesthesia is not complete and the anesthesia time is long, it is not commonly used.

It is used only in limited cases for filler procedures or laser procedures.

□ Ingredients and effects of topical skin anesthetic cream (EMLA)

It is a mixture of the common local anesthetics lidocaine and prilocaine; when these two substances are mixed, they form an oily liquid.

Then, when this is emulsified, tiny oil droplets containing a much higher concentration of local anesthetic (80%) than the hydrochloride solution (20%) are formed.

The concentration of the local anesthetic in the emulsion is 5%, but the concentration inside the oil droplets in contact with the skin is 80%.

This combination of local anesthetics is called a eutectic mixture of local anesthetics (EMLA), and if this anesthetic is applied to the skin and left for about 40 minutes, the skin surface becomes anesthetized.

□ Method of anesthesia using topical skin anesthetic cream (EMLA)

① Apply EMLA cream to the area where the procedure is desired in an appropriate thickness.

② Seal it with thin plastic so that the anesthetic cream applied to the skin surface does not dry out.

The anesthetic slowly seeps under the skin and takes effect.

③ After 30 to 40 minutes, anesthesia takes effect.

Wipe off the anesthetic from the skin surface and proceed with the procedure.

Features of Duhan Plastic Surgery’s eye plastic surgery clinic

① We have accumulated more than 20 years of rich clinical experience and know-how in double eyelid revision surgery.

② We have a systematic system for double eyelid revision surgery.

③ Through preoperative consultation, various examinations and tests are performed to predict the postoperative result.

④ Surgery is performed only when the possibility of improvement is sufficient through examinations and tests.

If it is determined that the desired result cannot be achieved for the patient, the principle is not to attempt surgery.

⑤ Through examinations, we identify the problems of the previous surgery, provide sufficient and clear explanations, and suggest the best surgical method for the best result.

⑥ We explain the surgical process and progress clearly so that you fully understand them, and we also do not omit explanations about possible side effects after surgery.

⑦ We provide thorough postoperative care after surgery.

We closely monitor the postoperative course to check whether recovery is proceeding properly.

⑧ We do our best and continue researching to make this the last hospital you need to visit, so that no further surgery is necessary.

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