Double eyelid surgery

What it treats

• Single eyelid: an upper lid with no supratarsal fold, the anatomic starting point for the operation PMID 3154592.
• Song RY described three historical methods in 1985: ligation, incision, and skin grafting PMID 3907310.
• Chen WP's 1987 comparison of Asian and white eyelid anatomy led to a technique combining skin, orbicularis, septum and fat excision with fixation of skin to the levator aponeurosis, aimed at a more predictable, longer-lasting crease PMID 3154592.
• Mild to moderate (subclinical) ptosis often coexists with a single eyelid and changes the choice among incision, partial incision, and no incision PMID 26306083.
• Palpebral fissure and crease asymmetry is common before surgery: in 594 Koreans photographed, fissure inclination differed by 2 degrees or more in 22.3% of men and 35.8% of women, and fissure height differed by 1mm or more in about a quarter of both sexes PMID 17293281.

How it is done

Technique families

• Suture (nonincisional), partial-incision, and full-incision are the three principal methods used to form the fold PMID 19336072.
• Kure K described a nonincisional double-armed-suture-and-twist technique in 2001; in 1,108 procedures over 10 years, no loss of the eyelid line occurred at a mean 32-month follow-up PMID 19331897.
• Fan J's two-way continuous buried-suture approach used 7 to 9 stab incisions and one continuous thread; in 51 patients, no double eyelid disappeared and no corneal damage occurred PMID 19421810.
• A full-thickness single continuous 7-0 nylon method is the nonincisional technique described as preferred in a 2021 review, chosen to lower the rate of crease loss PMID 34579835.
• Lam SM's partial-incision method combines an incision through skin and orbicularis, partial fat removal, and a 7-0 nylon suture tacking the levator aponeurosis to the skin edge; in 1,500 cases, loss of the lid crease, suture extrusion, and asymmetry each occurred in about 2% to 3% PMID 19336072.
• Full-incision (incisional) technique is favored for the more prominent preseptal fat of the Asian eyelid and is described stepwise, including counseling on recovery and revision PMID 34579834 PMID 25049125.
• A systematic review of small-incisional techniques covering 13 studies (4,177 patients) using 1 to 4 incisions found a pooled complication rate of 5% and pooled fold-loss rate of 2% for both single- and three-incision groups, with no significant difference between incision numbers PMID 36348097.
• Chen WPD's trapezoidal debulking of the preaponeurotic platform uses no permanent buried sutures; in 362 patients (724 lids), chosen crease height ranged 6.0-8.0mm (median 7.0mm), and 65% chose a parallel crease shape versus 35% a nasally joining shape PMID 31333982.

Crease measurement

• In 32 Chinese women, crease width correlated with crease height, crease thickness, and upper lid movement distance (R2 = 0.667) PMID 27769607.
• In young Asian women one year after blepharoplasty, crease width correlated with incision width, levator function, skin-orbicularis thickness, lid tissue thickness, and age (adjusted R2 = 0.695) PMID 40325224.
• Live measurement of tarsal height in 1,272 patients and the septum-aponeurosis fusion point in 386 patients found both higher than previously reported, informing a technique that preserves pretarsal fibrofatty tissue and links orbicularis to the pretarsal membrane with horizontal mattress sutures PMID 39761004.
• A composite height-depth-shape scoring system was built from 64 revisional cases (126 lids) to standardize planning for difficult secondary surgery PMID 33154864.

Combined with ptosis correction

• A single-knot continuous nonincisional technique correcting the fold and mild-to-moderate ptosis together, in 127 patients (254 lids), raised MRD1 from 1.62mm to 3.97mm (P<.001); mean surgery time for both lids was 14.8 minutes PMID 26499751.
• In 264 patients with congenital blepharoptosis treated over 15 years, the crease on the ptotic side was set 1-2mm below the normal side; only 30% of operated lids were perfectly symmetric afterward, with asymmetry typically appearing by 6 months even when lids looked symmetric right after surgery PMID 17955284.

Results and evidence

• The 13-study, 4,177-patient systematic review of small-incisional techniques found a pooled complication rate of 5% and pooled fold-loss rate of 2% PMID 36348097.
• In 1,000 buried-suture cases split evenly by method, the continuous suture had a lower 4-year reoperation rate than the two-point suture (13.4% versus 26.2%, P<.001); the two-point method carried a hazard ratio of 2.1 for reoperation, and 81.87% of reoperations were for suture loosening PMID 40571750.
• Among 2,934 two-point buried-suture procedures, 188 cases with upper eyelid fat removal had a lower reoperation rate than 188 matched cases without it (17.0% versus 33.5%, P<.001), with fat removal an independent protective factor (adjusted odds ratio 0.390) PMID 41361145.
• In 600 cases stratified by age, reoperation for suture loosening occurred in 22.3% overall, highest under age 20 (41%) and lowest at ages 30-39 (12%, P<.001); the under-20 group carried a hazard ratio of 1.91 PMID 41171312.
• The HIROSHIMA study followed 513 nonincisional cases: continuous fixation outperformed interrupted fixation (hazard ratio 0.29, P<.001) and non-puffy eyelids outperformed puffy eyelids (hazard ratio 2.47, P<.001) for crease retention; surgeon case volume was not a significant predictor (P=.441) PMID 41907130.
• In 788 continuous buried-suture cases, reoperation or suture removal within 12 months was more common at age 45 and older (16.3%) than at ages 18-39 (7.0%; subhazard ratio 2.49); most events reflected dissatisfaction with eyelid shape rather than crease loss or infection PMID 41838082.
• In 200 patients (400 eyes) who had minor-incision double-eyelid surgery with epicanthal correction, mean FACE-Q eye-appearance satisfaction was 81.7 of 100; partial fold loss occurred in 8 of 400 eyes and no hypertrophic scar was recorded PMID 28579035.
• Among 149 patients surveyed after full-incision upper blepharoplasty, overall satisfaction was 89.43% at a mean 23.23-month follow-up; independent negative factors for satisfaction were visible bilateral asymmetry, apparent scarring, and lower education level PMID 38955835.

Risks and complications

• A review of complications divides them into disordered (medical) and esthetic categories and links overactive frontalis or corrugator muscle activity to a fold that reads as too high, too low, or absent PMID 35502011.
• In a 7-year analysis of 138 formal complaints, asymmetry was the leading complaint after both primary and revision double eyelid surgery, and "asymmetric crease height" accounted for most of that category; revision surgery drew more complaints of asymmetric crease shape than primary surgery did (P<.05) PMID 39998431.
• Among 116 patients (210 eyelids) referred for treatment of buried-suture complications, 12 (10.3%) needed suture removal alone and 104 (89.7%) needed secondary double-eyelid surgery, treated by small skin incision (46 patients), full skin incision (63), or a conjunctival approach (7) PMID 27622107.
• In 12 patients with suture-related ocular injury after buried-suture surgery, corneal epithelial injury occurred in 9, corneal ulcer in 2, and one patient had a globe-penetrating injury requiring vitrectomy for endophthalmitis PMID 34226132.
• In 14 patients with corneal complications from exposed sutures, 3 were first misdiagnosed with dry eye, 9 with viral keratitis, and 2 with allergic conjunctivitis before suture exposure was identified; 8 had corneal epithelial injury and 6 had corneal ulcers, and all resolved after suture removal PMID 37653179.
• Recurrent corneal erosion has been reported after buried-suture surgery using barbed thread PMID 39829612.

Recovery

• After partial-incision surgery, the crease sits elevated from postoperative edema and settles 1-2mm to a more natural position over 3 to 12 months PMID 19336072.
• Mean surgery time for combined double eyelid and ptosis correction by a nonincisional technique was 14.8 minutes for both lids PMID 26499751.
• Reoperation for suture loosening clusters early: in 788 continuous buried-suture cases, cumulative incidence rose sharply between 30 and 90 days after surgery in patients 45 and older, while it rose more gradually over time in younger patients PMID 41838082.

With ptosis correction and epicanthoplasty

• Double eyelid surgery is commonly combined with ptosis repair in the same setting, since patients with ptosis generally want both corrected at once PMID 17955284.
• It is also commonly combined with epicanthoplasty, the operation that removes the medial epicanthal fold; a separate procedure doc, Epicanthoplasty, covers that operation and its outcomes.
• Revision of a prior "European-style double eyelid" complex deformity (high fold, upper eyelid depression, multiple folds, scarring) was carried out in 65 patients (106 eyes) with preaponeurotic fat flap transfer (47 eyes, 87.2% rated excellent), free fat graft (35 eyes, 85.7% excellent), or free dermis-fat graft (24 eyes, 66.7% excellent); only 3 eyes (2.8%) were rated unsatisfactory PMID 30456638.

Current questions

• Continuous buried sutures outperform two-point and interrupted sutures for crease retention across several 2015-2026 cohorts (8.6% versus 19.3% at 3 months minimum follow-up PMID 26413962; 13.4% versus 26.2% at 4 years PMID 40571750), but none of these cohorts reduces reoperation to zero.
• Reoperation risk after buried-suture surgery varies widely by age and cohort, from 7.0% in patients 18-39 in one series to 41% in patients under 20 in another, so a single quoted "loss rate" for the technique is not informative without the age group and suture pattern behind it PMID 41171312 PMID 41838082.
• Upper eyelid fat removal as an adjunct to buried-suture surgery lowered reoperation risk in one large matched cohort from a single clinic network; whether this generalizes elsewhere is untested PMID 41361145.
• The HIROSHIMA study found fixation method and eyelid puffiness mattered more to crease retention than surgeon case volume, a finding that runs against the assumption that more experienced surgeons always produce more durable results PMID 41907130.
• Whether suture-free debulking (no permanent buried material) matches the durability of buried-suture methods has no direct head-to-head comparison in the current literature PMID 31333982.
• Patients under 20 and patients 45 and older both carry higher reoperation risk than patients in their 30s, for different presumed reasons (tissue and healing pattern in the young, skin laxity and adhesion differences with age) PMID 41171312 PMID 41838082.

Terms

• Supratarsal fold (double eyelid): the crease formed above the upper lash line when the levator aponeurosis attaches to the overlying skin PMID 3154592.
• Buried suture (nonincisional) technique: forms a fold using sutures passed through the lid without a skin incision PMID 19331897.
• Partial-incision technique: a short incision combined with partial fat removal and a fixation suture PMID 19336072.
• Full-incision (incisional) technique: a complete incision along the crease line with excision of skin, muscle and fat as needed PMID 34579834.
• Crease loss (fold loss): fading or disappearance of the surgically created crease, the leading reason for reoperation after buried-suture surgery PMID 40571750.
• MRD1: distance from the corneal light reflex to the upper lid margin, used to measure ptosis correction PMID 26499751.
• Levator aponeurosis: the tendon that lifts the upper lid and is fixed to skin to form the crease PMID 3154592.
• Preaponeurotic fat pad: the central upper-lid fat compartment addressed during debulking PMID 31333982.
• Subclinical ptosis: mild lid droop that can coexist with a single eyelid and affects technique choice PMID 26306083.
• Pretarsal fibrofatty tissue: soft tissue overlying the tarsal plate, preserved in some crease-height-adjustable techniques PMID 39761004.

Papers