Asian Facial Cosmetic Surgery

26/11/2025 • by Bs CKI Phẫu thuật tạo hình, tái tạo và thẩm mỹ Trương Hoài Anh • cắt mí

Asian Facial Cosmetic Surgery – Jung I. Park, Dean M. Toriumi

Asian Facial Cosmetic Surgery là một tài liệu toàn diện, đóng vai trò là cẩm nang thiết yếu cho các bác sĩ phẫu thuật tạo hình và thẩm mỹ muốn nắm vững các nguyên tắc và kỹ thuật chuyên biệt cho khuôn mặt Châu Á. Được biên tập bởi Jung I. Park và Dean M. Toriumi cùng sự đóng góp của nhiều chuyên gia hàng đầu, cuốn sách cung cấp một cái nhìn sâu sắc, từ giải phẫu đến các thủ thuật phức tạp.

Tóm tắt nội dung và các Chương nổi bật

Giải phẫu khuôn mặt Châu Á chuyên biệt: Cuốn sách bắt đầu bằng việc phân tích những khác biệt giải phẫu quan trọng của người Châu Á so với phương Tây, là nền tảng cho mọi can thiệp thẩm mỹ.
Phẫu thuật Mí mắt Châu Á: Đi sâu vào kỹ thuật Asian Blepharoplasty để tạo nếp mí đôi (double-eyelid crease) và điều chỉnh góc mắt, một lĩnh vực được tác giả William Pai-Dei Chen, một trong những người đóng góp, làm nổi bật.
Tạo hình Mũi (Rhinoplasty): Đề cập đến các phương pháp phẫu thuật nâng mũi và chỉnh sửa mũi Châu Á, bao gồm cả cách tiếp cận từ tiền đình (vestibular approach) và các kỹ thuật liên quan đến trụ mũi và chóp mũi.
Tạo hình Mặt và Môi: Trình bày các kỹ thuật như tạo hình môi (Vermilion lip flap), xử lý sẹo phức tạp (W-plasty), và các thủ thuật chỉnh hình hàm mặt (Orthognathic surgery).

Tài liệu này bao gồm cả các thủ thuật xâm lấn tối thiểu như tiêm Filler và Botox, đồng thời cập nhật các xu hướng và bằng chứng y khoa mới nhất. Đây là nguồn kiến thức không thể thiếu để đạt được kết quả thẩm mỹ tự nhiên và hài hòa nhất cho bệnh nhân Châu Á.

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Asian Facial Cosmetic Surgery Jung L. Park, Editor Deam M. Toniumi, Asociate Editor

vii
Rong Min Baek, MD, PhD
Chairman and Associate Professor
Department of Plastic and Reconstructive Surgery
College of Medicine
Seoul National University
Bundang Hospital
Seongnam, Korea
Patrick Boulos, MD, FRCSC
Fellow, Oculofacial and Orbital Surgery Service
Department of Ophthalmology
Harvard Medical School
Fellow and Associate Staff
Oculofacial and Orbital Surgery Service
Department of Ophthalmology
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts
Henry H-L Chan, MD, FRCP
Honorary Clinical Associate Professor
Division of Dermatology
Department of Medicine
University of Hong Kong
Hong Kong, China
Ronald P. Chao, MD
Former Fellow, Jung I. Park, MD Cosmetic Surgery
Fellowship Program
American Academy of Cosmetic Surgery
Cosmetic Surgeon, Private Practice
Beverly Hills, California
Contributors
William Pai-Dei Chen, MD, FACS
Clinical Professor of Ophthalmology
UCLA School of Medicine
Los Angeles, California
Senior Attending Surgeon
Ophthalmic Plastic Surgery Service
Harbor-UCLA Medical Center
Torrance, California
Associate Clinical Professor of Surgery
UC Irvine College of Medicine
Long Beach, California
In Chang Cho, MD
Clinical Professor
Department of Plastic and Reconstructive Surgery
Yonsei University College of Medicine
Director
Bando Plastic Surgery Clinic
Seoul, Korea
Jin-Young Choi, DDS, MD, PhD
Associate Professor
Department of Oral and Maxillofacial Surgery
Seoul National University Dental Hospital
College of Dentistry
Seoul National University
Seoul, Korea
Masami Deguchi, MD
Director
Shirakabe Institute
Osaka, Japan

CONTRIBUTORS
viii
Chan-Yeong Heo, MD
Assistant Professor
Department of Plastic and Reconstructive Surgery
College of Medicine
Seoul National University
Bundang Hospital
Seongnam, Korea
Gyu Suk Hwang, MD
Clinical Professor
Department of Plastic and Reconstructive Surgery
College of Medicine
Yonsei University
Secretary General
Korean Association for Private Practice Plastic Surgeons
Homme and Femme Plastic Surgery and Aesthetic Clinic
Seoul, Korea
Dong Hak Jung, MD
Clinical Professor
Department of Otorhinolaryngology
Inha University School of Medicine
Incheon, Korea
Director
Shimmian Rhinoplasty Clinic
Seoul, Korea
Byung Gun Kim, MD
Director, BK Plastic Surgery Clinic
Clinical Professor
Department of Plastic and Reconstructive Surgery
College of Medicine
Seoul National University
Seoul, Korea
Jung Chul Kim, MD
Director
Hair Transplantation Center
Kyungpook National University Hospital
Professor
Department of Immunology
School of Medicine
Kyungpook National University
Daegu, Korea
Jong-Hak Lim, MD, PhD
Visiting Instructor
Department of Functional Histology and Neuroscience
Ehime University School of Medicine
Ehime, Japan
Director
Kairos Aesthetic Clinic
Seoul, Korea
John A. McCurdy, Jr., MD, FACS
Assistant Clinical Professor
Department of Surgery
John A. Burns School of Medicine
University of Hawaii
Honolulu, Hawaii
Adolfo Napolez, MD
Fellow
Jung I. Park, MD Cosmetic Surgery Fellowship Program
American Academy of Cosmetic Surgery
Munster, Indiana
Kunihiko Nohira, MD
Clinical Professor
Department of Plastic Surgery
Hokkaido University
Director
Soshundo Plastic Surgery
Hokkaido, Japan
Dae-Hwan Park, MD, PhD, FACS
President
Oculoplastic Surgery
Seoul, Korea
Professor
Department of Plastic Surgery
Daegu Catholic University School of Medicine
Director
Tissue Engineering Center
Chief
Department of Plastic Surgery
Daegu Catholic University Hospital
Daegu, Korea

CONTRIBUTORS
ix
Kazuo Sato, MD
Clinical and Research Associate
Department of Plastic, Reconstructive, and Aesthetic
Surgery
Main Hosptial
Nippon Medical School
Tokyo, Japan
Yoshihisa Shintomi, MD
Clinical Professor
Department of Plastic Surgery
Hokkaido University
Chief Director
Soshundo Plastic Surgery
Hokkaido, Japan
Dean M. Toriumi, MD
Professor and Director,
Division of Facial Plastic & Reconstructive Surgery
Department of Otolaryngology—Head and Neck Surgery
University of Illinois at Chicago Medical Center
Chicago, Illinois
Rie Yamashita, MD
Assistant Professor
Department of Plastic and Reconstructive Surgery
Kitasato University
Department of Plastic and Reconstructive Surgery
Shonan Kamakura General Hospital
Kamakura City, Japan

ASIAN FACIAL COSMETIC SURGERY is intended as an
introduction to Asian cosmetic surgery for the western
plastic surgeon with a limited exposure to the Asian
patient. Because of a steadily increasing influx of Asians
immigrating to the United States, opportunities to deal
with Asians are more common than in the past. Cosmetic
surgery for the Asian patient is an entirely separate ﬁeld of
plastic surgery. Applying surgical principles for whites to
Asians often produces unexpected, and sometimes even
disastrous, results. The western ideal of beauty may not
conform to the concepts of beauty nurtured by Asians.
Despite the enormous cultural influence of the western
media, there is an element of ethnic pride that perseveres
through the search for the ideals of Asian beauty. On the
other hand, there are plenty of surgical procedures that
beneﬁt Asians and that apply the exact same surgical
principles used for white patients. ASIAN FACIAL
COSMETIC SURGERY is limited to facial surgery simply
because the face is what distinguishes Asians so much from
whites. There are only a few books written in English that
deal with Asian cosmetic surgery. Although the books
teach the philosophical aspect of care for the Asian patient,
surgical procedures are described rather casually and
briefly. The illustrations and operative photographs are
summarized rather than detailed. This book is designed for
surgeons who are not familiar with the procedures
described, and an atlas format is a perfect vehicle for this
purpose. Any surgeon can follow the directions from the
beginning to the recovery period in a step-by-step fashion.
The authors took extra efforts to include every detail that
the learning surgeon should know, going back to the ﬁrst
year of residency. Just as there is no ending in learning the
depth of every surgical procedure, the chapters were
reviewed again and again to guard against the omission of
any aspect of the surgery that might beneﬁt even well-
informed surgeons.
Contributing authors from China, Japan, Korea, and The
United States combine their regionally and culturally
speciﬁc knowledge to create a rich pool of science and
experience. This book represents the soul and sweat of the
contributing authors, each of whom has performed and
taught these procedures day after day for decades.
Preface
iii

v
Many thanks go to Suzanne Flint for her day-to-day colla-
boration in completing this book. My deep appreciation
goes to my sons, Min S. Park, MD, and Kyu S. Park, MD,
for their unpaid contribution in reviewing the manuscripts.
No words could express my thanks to my wife, Young
Yong, who provided unwavering support during the two
years I was preoccupied editing this book.
Jung I. Park, MD, PhD, FACS
I would like to thank three people for ending my ten-plus
years of procrastination in writing this book. My fellow,
Ron Chao, MD, gave a prompt and tireless effort during the
most critical period. Dong Hak Jung, MD, provided
valuable advice and expertise to this undertaking. Rebecca
Schmidt Gaertner, my editor of Elsevier, provided the
opportunity and shared the vision of spreading the
knowledge of Asian cosmetic surgery. I would like to thank
all of the contributing authors and associate editor Dean
Toriumi, MD, for their valuable contributions to this book,
despite their busy practice and teaching schedules.
Acknowledgments

1
Blepharoplasty in Asia is almost synonymous with the
double eyelid operation. The double eyelid operation
technique has come full circle since it was ﬁrst described
by the Japanese surgeon Mikamo,1 who reported a suture
technique in 1896 (Figure 1-1). In 1929 Maruo2 was the
ﬁrst to describe the incision technique (Figure 1-2). In 1939
Introduction to Asian
Blepharoplasty
Jung I. Park
Hayashi3 introduced the technique of excising a strip of
orbicularis oculi muscle (Figure 1-3), 15 years before
Sayoc4published his widely quoted paper in 1954 (Figure 1-
4). Mitsui5 ventured further in 1950 by excising the muscle,
connective tissue, and fat in the pretarsal area (Figure 1-5).
In 1960 Fernandez6 reported the most radical approach
I
1
Asian Blepharoplasty
Figure 1-1
The Mikamo method.
Figure 1-2
The Maruo method.

INTRODUCTION TO ASIAN BLEPHAROPLASTY
2
yet: removal of the skin, orbicularis oculi muscle, orbital
septum, and orbital fat. He then ﬁxated dermis to the
levator aponeurosis (Figure 1-6). In 1963 Boo-Chai7
described a pretarsal and orbital soft tissue technique
similar to Mitsui’s method (Figure 1-7). After a series of
progressively aggressive approaches, the 100-year-old
suture technique is again favored by clinicians in East
Asian countries.
Preferences for the Asian eyelid have changed with time,
from a mild traditional-looking double fold to an aggres-
sive wide fold and then back to a scarless, conservative
double eyelid. The choice of suture material has not drawn
as much attention; surgeons have preferred to use
absorbable catgut or removable or permanent sutures. In
the incisional technique, tissues are ﬁxated between the
skin and the tarsus or levator aponeurosis. In 1999 Park8
reported a technique using the orbicularis oculi muscle
(rather than the skin) as the tissue that ﬁxates to the levator
aponeurosis (Figure 1-8). Doxanas et al9 demonstrated the
anatomic differences between Asians and Caucasians to
support the lack of a supratarsal crease in the Asian eyelid.
The lack of levator aponeurosis penetration into the
pretarsal orbicularis oculi muscle, the lower fusion point
between the orbital septum and the levator aponeurosis,
and the lower penetration of the preaponeurotic fat in the
pretarsal area have been suggested as causes for a single
eyelid in the Asian population (Figure 1-9). Operative
procedures are designed to recreate the anatomic features
that produce the double eyelid fold. Although the inci-
sional technique may give a more distinctive and longer-
lasting crease,10-15 more surgeons are willing to follow the
trend to satisfy their patients with a simple and effective
but somewhat compromised procedure. The correction of
the epicanthal fold has been largely ignored because it
causes a visible scar. With a conservative, small double
eyelid formation, the average-sized epicanthal fold does
not diminish the cosmetic improvement of the double
Figure 1-3
The Hayashi method.
Figure 1-4
The Sayoc method.
Figure 1-5
The Mitsui method.

INTRODUCTION TO ASIAN BLEPHAROPLASTY
3
eyelid surgery. As the double eyelid operation becomes
more aggressive, the presence of the epicanthal fold
becomes more visible (Figure 1-10); at times, it gives the
appearance of a round eye (Figure 1-11). More importantly,
public desire for surgical enlargement of the eyes has
caused surgeons to seek better techniques to eliminate the
epicanthal fold. Variations of direct excision, V-Y advance-
ment, W-plasty, and Z-plasty techniques have been
published. Despite the numerous methods available, many
surgeons are reluctant to perform the medial epicantho-
plasty because of the potential for visible scar formation.
The popularity of scarless surgery also diminished the
demand for the procedure. However, it cannot be denied
that a well-executed epicanthoplasty adds signiﬁcant
beauty to the eyelid without visible scarring. Some
surgeons perform lateral canthotomy/canthoplasty in an
attempt to enlarge the eyes.
The older Asian patient presents an entirely different set of
aesthetic challenges for the surgeon. In addition to creating
the double eyelid, the surgeon must be concerned with
redundancy of the eyelid skin. The fullness of the upper
eyelid secondary to brow ptosis adds to the complexity of
upper eyelid surgery on the older Asian patient. These
patients have reluctantly accepted unsightly and prolonged
upper lid edema and pufﬁness after double eyelid surgery
(Figure 1-12). These problems stem from the excision of
large amounts of thin pretarsal skin and the creation of a
fold in which the remaining eyelid skin is much thicker and
closer to the eyebrow. A forehead lift resolves this issue
adequately; the thicker brow skin is pulled up and out of
the way, and the thinner pretarsal skin is used to create
a more delicate double eyelid fold (Figure 1-13). The
forehead lift for the older Asian patient has an additional
purpose: to prevent an unwanted thicker postoperative
double eyelid fold. Patients often have to be persuaded of
the beneﬁts of this procedure and encouraged to accept it.
Orbicularis oculi
and skin excised
Orbital septum
Tarsal plate
Levator aponeurosis
Figure 1-6
The Fernandez method.
Figure 1-7
The Boo-Chai method.

INTRODUCTION TO ASIAN BLEPHAROPLASTY
4
A
B
Figure 1-9
A, Cross-section view of the Asian eyelid, demonstrating that the orbital septum fuses with the lelvator aponeurosis below the superior tarsal border. B, Cross-section view
of the Caucasian eyelid.
A
B
Figure 1-8
The Park method. A, Cross-section view. B, Operative view.

INTRODUCTION TO ASIAN BLEPHAROPLASTY
5
References
1. Mikamo K: A technique in the double-eyelid operation, J
Chugaishinpo, 1896.
2. Mauro M: Plastic construction of a “double eyelid,” Jpn J
Clin Ophthalmol 24:393, 1929.
3. Hayashi K: The modiﬁcation of the Hotz method for plastic
construction of a double eyelid, Jpn Rev Clin Ophthalmol
34:369, 1939.
4. Sayoc BT: Plastic construction of the superior palpebral
fold, Am J Ophthalmol 38:556-559, 1954.
5. Mitsui Y: Plastic construction of a “double eyelid,” Jpn Rev
Clin Ophthalmol 44:19, 1950.
6. Fernandez LR: The double-eyelid operation in the Oriental
in Hawaii, Plast Reconstr Surg 25:257, 1960.
7. Boo-Chai K: Plastic construction of the superior palpebral
fold, Plast Reconstr Surg 31:74-78, 1963.
8. Park JI: Orbicularis-levator ﬁxation in double-eyelid
operation, Arch Facial Plast Surg 1(Apr-June):90-95, 1999.
9. Doxanas MT, Anderson RL: Oriental eyelids: An anatomic
study, Arch Ophthalmol 102:1232-1235, 1984.
10. Moutou Y, Moutou H: Intradermal double eyelid operation
and its follow-up results, Br J Plast Surg 25:285, 1972.
11. Weingarten CZ: Blepharoplasty in the oriental eye, Tram
Acad Ophth Otol 82:442, 1976.
12. Matsunaga RS: Westernization of the Asian eyelid, Arch
Otolaryngol 111:149, 1985.
13. Hiraga Y: Blepharoplasty in Orientals. Problems in plastic
and reconstructive surgery, 1:504, 1991.
14. Chen WPD: Revision and correction of suboptimal results.
In Chen WPD: Asian blepharoplasty, Newton, MA, 1995,
Butterworth-Heinemann, p 84.
15. Lee JS: Simpliﬁed anatomic method of double-eyelid
operation: Septodermal ﬁxation technique, Plast Reconstr
Surg 100:170, 1997.
Figure 1-10
Creation of the double eyelid crease accentuates the presence of the epicanthal fold.
Figure 1-11
The eyes appear round because the epicanthal fold and high double eyelid fold are
present.
Figure 1-12
The postoperative double eyelid fold in this older woman appears thick and
unnatural.
Figure 1-13
The ﬁnger can be used to simulate a brow lift and demonstrate a favorable effect on
the double eyelid fold. Thinning of the left double eyelid fold is evident.

7
In recent years, patients and surgeons have preferred the
buried suture method because it involves a short downtime
and causes no scarring. When the author began using
the single suture method in 1988, the downtime was long
and the swelling lasted approximately 3 weeks. Since
then, great advances have been made in this method. The
procedure simpliﬁed, and swelling and subcutaneous
bleeding have been drastically reduced. Recent buried
suture methods have adopted many improvements that
have signiﬁcantly reduced the incidence of loss of the
double eyelid. Three different methods for the single suture
technique are available.
Single Suture Method (Eye Makeup
Method)
Transcutaneous Ligation
See Figure 2-1.
1. Skin–levator muscle ligation method: The levator and
Müller’s muscle are ligated with the skin at the upper
margin of the tarsus. The sling technique is the most
representative method.
2. Skin-tarsus ligation method: This method is simple and
provides satisfactory ﬁxation. Possible drawbacks
include potential corneal erosion, impingement of the
subconjunctival capillary flow, and deformity of the
tarsus.
Single Suture Technique
Kazuo Sato*
Transconjunctival Ligation
This method is difﬁcult and requires considerable expe-
rience. It is also difﬁcult to remove the sutures.
At present, the author uses the skin–levator muscle
ligation method. The term “eye makeup method” is used
because this method induces so little swelling that patients
feel as though only eye makeup has been applied.
Single Suture Method with Orbital Fat
Removal (Eye Shape-up Method)
Inner and outer orbital fat is removed through a small
opening at the outer margin, which has been prepared for
2
*The author wishes to thank Dr. Hiko Hyakusoku of Nippon Medical
School for his valuable advice and Mr. Akio Kakinuma for his
photography and illustrations in this chapter.
Skin-levator muscle
ligation method
Skin-tarsus
ligation method
Figure 2-1
Comparison of the skin–levator muscle ligation and the skin-tarsus ligation method.

SINGLE SUTURE TECHNIQUE
8
the passage of suture material with subsequent buried
suture. This method does not cause scarring or require
suture removal.
Lateral Ligation Method
This is a buried suture method for middle-aged to older
adult patients. The author has used the incision method for
middle-aged or older patients with excess skin but has also
used the buried suture method to minimize scarring and
reduce downtime.
Patient Selection
Single Suture Technique
The single suture technique is the method of choice for
nearly all initial surgeries.
Single Suture Technique with Orbital Fat
Removal
The single suture technique with orbital fat removal is
suitable for patients who are in their late 20s and have fuller
upper eyelids. This method can also be used for younger
patients. The author does not remove fat in individuals
who tend to raise their eyebrows when opening the eyes.
These individuals tend to develop a sunken look when
orbital fat is removed.
Lateral Ligation Method
The lateral ligation method is suitable for middle-aged or
older patients who ask for the buried suture method and
who have lateral skin sagging.
Consultation
The advantages and disadvantages of the single suture
technique, partial incision technique, full incision technique,
and a combination of these procedures with orbital fat
removal should be thoroughly discussed with the patient.
The advantages of the single suture method are a short
downtime (less than 1 week) and the ability to reverse or
readjust the double eyelid. The clinician suppresses the
effect of the frontalis muscle by pressing the eyebrows with
the patient’s eyes closed, and then asks the patient to open
the eyes; this conﬁrms the movement of the levator muscle
and the symmetry of the palpebral ﬁssure (Figure 2-2). The
patient should be warned of the possibility of asymmetry
despite exact preoperative measuring because the differ-
ence in brow elevation may cause postoperative asym-
metry. The double eyelid may look wider in an eye with
greater eyebrow excursion. Postoperative changes in the
Figure 2-2
Open/close test: The differences in the palpebral ﬁssure between the eyes are tested
by opening the eyes while pressing the eyebrows, which suppresses the effect of the
frontal muscle.
A
B
C

ANESTHESIA
9
size of the palpebral ﬁssure, eyelid edema, pitting, and the
thickness of the double eyelid fold should be discussed.
Preoperative blepharoptosis should be mentioned so that
the patient knows that the “sleepy eye” appearance is not a
result of the surgery.
Because use of contact lenses is related to the disappear-
ance of the double eyelid after surgery, the patient should
be advised to use eyeglasses during the postoperative
period.
If an asymmetric palpebral ﬁssure or epicanthal fold is
present, the patient should be informed about post-
operative differences in these areas.
Preoperative Care
Contact dermatitis is common among patients who use glue
or eye tape to create a double eyelid appearance. In these
patients, 1 week of steroid ointment treatment is recom-
mended to eliminate any inflammation before surgery.
Marking
Single Suture Technique and Single Suture
Technique with Orbital Fat Removal
See Figures 2-3 and 2-4 for illustrations of these
techniques. Place the patient in the supine position with
the eyes open. Expose the medial canthus by retracting the
epicanthal fold. Align the ophthalmic measure with the
medial canthus; the pupil should be aligned at the central
(0) point. Use an ophthalmic measure to draw the central
vertical line on the upper eyelid through the center of the
pupil (Figure 2-5). Next, ask the patient to gently close the
eyes, and draw vertical lines 4 mm medial and 2 mm lateral
from the center (0) with an oil-based, extra-ﬁne felt-tip pen
(0.05 mm) (Figure 2-6). Mark a point on the upper eyelid
based on the planned location of the double eyelid crease
(Figure 2-7). With the patient’s eyes closed, apply the bent
tip (90-degree angle at about 1 to 1.5 cm from the tip) of
a #4-0 (0.65 mm) Bowman lacrimal probe to the marked
point. While the tip of the probe is maintained in this
position, ask the patient to open the eyes and then look
downward. The pressure of the lacrimal probe forms a
wrinkle; mark the line at which the wrinkle crosses the
vertical lines (Figure 2-8). After marking the patient,
measure the distances of the inner and outer points from
the ciliary margin and compare them between the two
eyes. Gently pull up the upper eyelid skin for measurement
(Figure 2-9). Place the tip of the probe on the medial/
lateral skin marks of both sides at the same time, and ask
the patient to open the eyes to conﬁrm symmetry (Figure
2-10). Then ask the patient to look in a mirror and conﬁrm
the lines (Figure 2-11). The lines may be moved upward or
downward depending on the patient’s preference.
Lateral Ligation Method
See Figure 2-12 for an illustration of this technique. Draw a
vertical line 8 mm lateral from the center line (0) with an
extra-ﬁne felt-tip pen. With the patient’s eyes open, mark
the inferior margin of the sagging upper eyelid. Next, ask
the patient to close the eyes, and compress the marked
point with the tip of the Bowman lacrimal probe. This
action forms a radiating horizontal wrinkle line. Mark the
point that crosses the center and lateral vertical line. Then
mark a new outer point approximately 3 mm higher than
the initial mark crossed by the wrinkle line. Draw a line
between the new outer point and the center (0). Repeat this
process for the other eye. It is particularly difﬁcult and time
consuming to ﬁnd the ideal line in older patients with
excessive skin redundancy and wrinkles. After determining
the location of the double eyelid lines, seat the patient in an
upright position. Next, check the lines and ask the patient
to conﬁrm them with a hand mirror. The lines may be
moved upward or downward if necessary.
Anesthesia
Administer anesthetic eye drops (0.4% oxybuprocaine
hydrochloride) (Figure 2-13). Use a 32-gauge, 1/2-inch
needle to inject a mixture of 1% lidocaine hydrochloride
with 1:100,000 epinephrine solution buffered with sodium
bicarbonate in a 3:7 ratio. Then inject a total of 0.2 ml
solution through a disposable 1-ml syringe. Evert the upper
tarsal plate, and place a corneal shield under the upper
border of the flipped tarsal plate. Inject a small amount of
anesthetic into the conjunctiva between the upper margin
of the tarsus and the corneal shield; this achieves distension
(Figure 2-14). Diffuse the anesthetic solution by squeezing
the conjunctiva with the tip of the corneal protection plate
pointing up and pushing down on the tarsus (Figure 2-15).
Take care not to push the eyeball with the corneal shield,

SINGLE SUTURE TECHNIQUE
10
which would cause an oculocardiac reflex.4 To distend
the eyelid skin, inject local anesthetic solution into the
superﬁcial subcutaneous tissue plane. Then pinch the skin
to spread the anesthetic solution (Figures 2-16 and 2-17).
Less than 0.1 ml of anesthetic is sufﬁcient for both sub-
cutaneous and conjunctival injection in one eye. It is
desirable to limit the total amount of anesthesia for both
eyes to less than 0.2 ml to prevent postoperative blepharo-
ptosis and excessive distension of the skin and conjunctiva.
Instruments
Marking Instruments
1. Ophthalmic measure, eye makeup measure
2. Bowman lacrimal double-ended probe: #04 to #05
(diameter: 0.65 to 0.70 mm)
3. Oil-based, extra-ﬁne felt-tip pen (0.05 mm)
4. Caliper
See Figure 2-18 for examples of marking instruments.
Skin
Orbicularis
Levator
Tarsal plate
Conjunctiva
MEDIAL
Single stitch
LATERAL
6
4
2
Figure 2-3
Formerly, the author used the 2-point stitch procedure. This figure illustrates the author’s current single-stitch procedure.

INSTRUMENTS
11
Figure 2-4
Inner and outer fat extraction through the lateral incision.
Figure 2-5
Placement of an ophthalmic measure on the medial canthus while the Mongolian
fold is pulled with the ﬁngers.
Figure 2-6
Mark the medial and lateral points.
Figure 2-7
Mark the margin of the upper eyelid.
Figure 2-8
Mark the line that crosses the ﬁrst mark and the wrinkle from the tip of the Bowman
lacrimal probe.
Figure 2-9
Measure the inner and outer points with calipers to conﬁrm that there is no
difference between the left and right eye.
Fat removed

SINGLE SUTURE TECHNIQUE
12
Operative Instruments
1. Suture thread (80 μm [0.08 mm] regular) with double-
armed disposable needle (needle diameter 0.45 mm,
length 19 mm, 3/8 circle): The needle is made with a
special silicone coating, which passes smoothly and is
ideal for reducing tissue damage.
2. Needle holder with tungsten carbide inserts (12.5 cm)
3. Lid plate (corneal protection plate) (9 cm)
4. Bard–Parker knife handle
5. Stainless surgical blade (#11)
6. Bowman lacrimal, double-ended probe (#5 to #6,
diameter: 1.50 to 1.60 mm)
7. Scissors, curved, ﬁne point (9.5 cm)
8. Disposable syringe (1 ml)
9. Disposable injection needle (32-gauge by 1/2 inch)
10. Geneva Pattern, Micro Instruments, ﬁne points for
hairsprings (#0, 12 cm)
11. Antiseptic solution (chlorhexidine gluconate 0.02%),
with 3 sterile cotton balls
12. Sterile pad (cotton gauze): several pieces
13. Small sterile cotton ball for stain remover
14. Saline
15. Other: Curved mosquito hemostat
See Figure 2-19 for examples of operative instruments.
Procedure
Single Suture Technique
See Figure 2-20 for an illustration of this technique.
1. Make 1- to 2-mm incisions at the medial and lateral skin
marks with a #11 Bard Parker blade with the sharp edge
facing upward (Figure 2-21). Be careful not to cut the
orbicularis oculi muscle. Pinch the skin tissue at the
Figure 2-10
Place the tips of the Bowman lacrimal probes to the inner and outer points (placing left and right at the same time), and open the eyes to view the double eyelid lines.
Figure 2-11
Have the patient sit up, and check with a hand mirror.
A
B
C
D

PROCEDURE
13
lateral incision with #0 Geneva pattern forceps, and use
scissors to cut off the bulging subcutaneous tissue
(Figure 2-22). This helps prevent postoperative suture
abscesses and suture spitting.
2. Evert the eyelid, insert a corneal shield, pass a double-
armed needle vertically into the corneal shield through
the conjunctiva above the upper margin of the tarsus,
and then pull the levator muscle inferiorly to stretch the
muscle tightly on the corneal protect plate. The tarsus is
flipped backward while the levator muscle is stretched.
Push the needle through the skin at the outer incision
site (Figures 2-23 and 2-24). This avoids catching other
tissues on the needle.
3. Evert the eyelid again, insert the other double-armed
needle close to the previous needle entry site, and pass
the needle 4 mm through the subconjunctival plane
8
8
3
Figure 2-12
Diagram showing the design methods. The pink point is the natural width index. The “opening eye”indicates a point at the upper eyelid margin; the “closed eye”indicates the
same point on the eyelid skin as on the “opening eye”view.
Figure 2-13
Administer anesthetic eye drops (0.4% oxybupirocaine hydrochloride).
Figure 2-14
Use a small amount of anesthetic at the conjunctiva with a corneal protection plate.

SINGLE SUTURE TECHNIQUE
14
Figure 2-15
Push the tarsus inward after the injection. An anesthetic spreads medially and
laterally.
Figure 2-17
Pinch the skin to spread the anesthetic.
Figure 2-18
Marking instruments.
Figure 2-16
Distend the tarsus with a small amount of anesthetic by making a shallow
subcutaneous injection at the marked line.
Skin
Orbicularis
Levator
Tarsal plate
Conjunctiva
MEDIAL
LATERAL
Figure 2-19
Operative instruments.
Figure 2-20
Single-stitch threading procedure: steps 1 through 5.

PROCEDURE
15
(Figure 2-25). The needle exits the conjunctiva at the
medial side. In the same manner as before, turn over
the eyelid while the levator muscle is stretched, and
pass the needle through the medial skin incision site
(Figure 2-26).
4. Bring the needle back to the medial skin incision site.
Pass the needle through the subcutaneous tissue toward
the lateral incision, and then pull the needle out through
the lateral incision (Figure 2-27).
5. Pass a lacrimal probe #6 (1.60 mm) under the suture,
and tie the knots over the probe (Figure 2-28). This
makes four knots. The second ligature is especially
important because it determines the tightness. The
ﬁrst suture should be loose. When the suture is pulled
downward after tying the knot, it should form a small
Figure 2-21
Make a 1- to 2-mm skin incision at the marked medial and lateral points with a #11
Bard Parker blade. The sharp edge of the blade should face upward.
Figure 2-22
Pinch the skin of the lateral incision site, and cut the protruding tissue.
Figure 2-23
The tarsus is flipped backward while the levator muscle is stretched.
Figure 2-24
Push the needle through the skin at the outer incision site.
Figure 2-25
Insert the other end of the double-armed needle close to the previous needle entry
site. Traverse the subconjunctival tissue plane for a distance of 4 mm medially, and
then exit the conjunctiva again.

SINGLE SUTURE TECHNIQUE
16
triangle, with the skin at the base and the knot at the
apex (Figure 2-29). The formation of an isosceles shape
suggests that the ligature is too loose. When the ligature
is too tight, the suture does not come out of the incision
site when it is pulled.
6. Push the knots and bury them deep into the skin
incision with #0 Geneva pattern forceps.
7. Proceed in the same manner on the other eye.
When the surgeon is right-handed and operating from the
top of the head, it is easier to pass the needle from the
lateral aspect for the right eye and from the medial aspect
for the left eye (Figures 2-30 to 2-33).
Figure 2-26
A,Turn over the eyelid while the levator muscle is stretched, and B, pass the needle through the medial incision of the skin.
A
B
Figure 2-27
The needle reenters the medial incision and passes through the subcutaneous tissue
toward the lateral incision. It exits through the lateral incision.
Figure 2-28
Pass a lacrimal probe #6 (1.60 mm) under the suture, and tie the knots over the
probe.
Figure 2-29
When the suture is pulled up after tying the knot, it should form a small triangle
with the skin at the base and the knot at the apex.

PROCEDURE
17
A
B
A
B
Figures 2-30
A
B
Figure 2-32
A double eyelid that is narrower in width than the natural skin fold will improve the depression on the upper eyelid, similar to a curtain.
Figures 2-31
Figure 2-33
Single suture technique, preoperative view (A) and immediate postoperative view (B).
A
B

SINGLE SUTURE TECHNIQUE
18
Single Suture Technique with Orbital Fat
Removal
1. On the side of the conjunctiva, inject slightly more
anesthetic than the amount used in the buried suture
method.
2. After making the incisions and removing the subcutan-
eous tissue, ask the patient to close the eye. This forces
the orbital fat to move inferiorly for easier removal.
3. Pinch the orbicularis muscle superior to the incision site
with #0 Geneva pattern forceps. Squeeze the subcutan-
eous tissue out of the incision sites, and use the scissors
to excise the bulging tissue. Continue the tissue removal
deeper and at a slanted angle toward the eyebrow rather
than straight downward. When the dissection reaches
the preaponeurotic fat compartment, the fat begins to
bulge out through the incision site. A large amount of fat
can be extracted via massage and compression of the
upper eyelids (Figure 2-34).
4. Inject the anesthetic into the fat compartment to
increase the inner pressure and force out the fat (Figure
2-35). Release more fat by incising the membrane that
covers the fat (Figures 2-36 to 2-38).
5. Use a Mosquito hemostat to clamp the base of the
bulging fat, cut it with scissors, and coagulate it with
electric cautery (Figures 2-39 and 2-40). Take care
to avoid touching the skin with the Mosquito
hemostat.
Figure 2-34
A large amount of fat can be extracted via massage and compression of the upper
eyelids.
Figure 2-35
Injection of the anesthetic solution into the fat compartment increases the inner
pressure and forces out the fat.
Figure 2-36
When the membrane that covers the fat is incised, more fat is released.
Figures 2-37
Fat from medial compartment.

POSTOPERATIVE CARE
19
6. After the fat is removed, use a cold saline pad to cool the
incision sites. Use the same technique on the other eye.
Then proceed with the buried single suture technique
(Figure 2-41).
Figures 2-38
Fat from lateral compartment.
Figure 2-39
The base of the bulging fat is clamped with a Mosquito hemostat, cut with scissors,
and coagulated with electric cautery.
Figure 2-40
Orbital fat is removed from both eyes.
Figure 2-41
Buried single suture technique: preoperative (A) and postoperative (B) views.
A
B

SINGLE SUTURE TECHNIQUE
20
Lateral Ligation Method
The procedure is the same as the buried suture method
and orbital fat removal techniques (Figure 2-42).
Postoperative Care
After surgery, elevate the and use ice packs to cool the
eyelids for about 30 minutes. Advise the patient to keep the
wound cooled for 2 days. The patient is allowed to bathe
the next day. Antibiotics, analgesics, and antiinflammatory
enzyme preparations are administered for 3 days. The
patient should wash the face twice per day and then apply
an ophthalmic eye ointment that contains antibiotics to
the wound. Advise the patient to avoid using cosmetic
products on the upper eyelid for at least 3 days.
Recovery
The eyes will look slightly swollen the morning after
surgery and may remain so for 4 days. As the suture
loses its tension during the next 3 weeks, the eyes begin to
look more natural. Many patients experience a gluelike dis-
charge from their eyes in the morning after the surgery. 6
Immediately after the operation, an unnatural pulling
sensation occurs when the eyes are opened. 6 This
sensation usually subsides in 1 week. Bruising tends to
occur more frequently in patients with hypertension or
who are menstruating. Bruising is also more common in
patients who hold their breath during the operation;
therefore advise the patient to breathe through the mouths
and relax the eyes throughout the procedure.
Postoperative swelling gradually diminishes over a period
of about 1 month.
Complications
1. Asymmetry: The patient may have a preexisting asym-
metry between the eyes. It is important to mention this
difference before the surgery.
2. Loss of double eyelid lines: This appears to occur more
frequently on the side with excessive eyebrow excursion.
A possible cause may be continuous pulling. Strong
external forces can break the suture thread within 3
months of the surgery; this is more common among
patients who wear contact lenses.
3. Corneal irritation: Some patients may complain that
“Something’s touching my eye and it hurts” or “I feel
something in the eye.” This irritation occurs when the
suture thread loosens and touches the cornea. The
suture must be removed immediately.
4. Cysts or exposure of the suture thread: This is rare and is
caused by insufﬁcient burial of the knot during surgery.
When the needle is passed through the skin incision, it
may pass through the margin of the incision, catching a
piece of epidermis in the skin. It may also occur when
the ligature is too loose. The cause may be premature
use of cosmetics on the upper eyelid or cosmetic
material or dirt at the incision sites. Removal of the
suture solves the problem. If the double eyelid lines
disappear, the suture needs to be reapplied.
References
1. Mauro T: Essentials of ophthalmology, ed 7 (rev.), Tokyo,
2000, Ishiyaku, pp 98, 282.
2. Miyake I, Tange I, Hiraga Y: MRI ﬁnding of the upper eyelid
and the relationship with single and double eyelid formation,
Aesth Plast Surg 18:183-187, 1994.
3. Miyake I, Hiraga Y: Knack and point of cosmetic surgery.
The dissection of an eyelid necessary for cosmetic surgery,
Jap J Plast Reconstr Surg 38:65-71, 1995.
A
Figure 2-42
Lateral ligation method: preoperative (A) and postoperative (B) views.
B

COMPLICATIONS
21
4. Ashner B: Veber einen bischen noch nicht beschrieben
Reflex von Auge auf kreislauf und Atmung. Verschwinden
des Radialispulses bei Druck auf das Auge, Wien Klin
Wochenschr 21:1529, 1908.
5. Matarraso A: The oculocardiac reflex in blepharoplasty
surgery, Plast Reconstr Surg 83:243-248, 1989.
6. Lebowitz PW, Newberg LA, Gillette MT: Clinical anesthesia
procedures of the Massachusetts General Hospital, Tokyo,
1983, Medical Sciences International, pp 69, 168 (Translated
by I Yutaka et al).
7. Ichida M: Atlas of skill aesthetic plastic surgery. I. Eyelid,
Tokyo, 2003, Bunkodo, pp 32-33.

23
The nonincisional technique for the double eyelid opera-
tion uses buried subcuticular sutures or temporary skin
sutures. The main attraction for this technique is that the
double eyelid can be created without an incision on the
eyelid skin or with only a tiny, 2- to 3-mm cut. The ultimate
goal of this operation is to create a connection between the
skin and the tarsal plate or levator aponeurosis. This in
turn creates a crease by pulling on the levator aponeurosis
when the patient opens the eyes.
The primary indication for the nonincisional technique is
the patient who does not wish to have a scar on the eyelids,
is younger, and does not have excessive fat and upper eyelid
skin redundancy. If a patient with excessive fat indicates a
strong desire to avoid a regular incision, then fat removal
and the suture ﬁxation technique can be accomplished
through a tiny incision. The nonincisional method has
several advantages over the incisional technique: the
double eyelid fold appears more natural, the technique is
relatively simple and easy, it can be readily reversed if
the patient does not like the result, there is no scar, and the
minimal amount of edema means that the patient can
quickly return to normal life because edema is minimal.
However, this technique has several disadvantages. The
indication is somewhat limited, and relapse is more likely
to occur than with the incisional technique. Epidermal
cysts, nodules, or suture granulomas may develop. The
double-fold height may be asymmetrical because of the
difference in closing tension at the time of ﬁnal ligature.
Various nonincisional double eyelid operations are
described in the following sections.
Cutaneous Suture Technique
Removable silk or catgut sutures are passed through the
skin and tarsal plate or levator aponeurosis, and the knot is
Multiple Suture Technique
Byung Gun Kim
then tied over the eyelid skin. The double eyelid formation
is expected because of the development of cicatrization
between these tissues. Although the procedure is simple
and intraoperative adjustments are easy to make, it leaves
a scar on the eyelid skin. Double eyelid formation is un-
predictable because cicatrical adhesions develop inconsist-
ently after suture removal. These methods are rarely used
now unless for historical importance.
Mikamo Method
Mikamo described his technique in 1896.1,2 The suture
needle passes through the upper eyelid skin 6 to 8 mm
above the ciliary margin and the upper border of the tarsal
plate. The needle then returns to the skin surface near the
initial entry site, and the suture is ligated. Three such
suture ligatures are made. Removing the sutures 2 to 6 days
after the surgery controls the depth of the double eyelid
crease (Figure 3-1).
3
Figure 3-1
The Mikamo method.

MULTIPLE SUTURE TECHNIQUE
24
Hata Method
In 1933 Hata3 described a method of using silk or catgut
sutures to ﬁxate the skin to the tarsal plate in at least 3
locations. The suture needle passes through the upper
eyelid skin 8 to 10 mm above the ciliary margin and then
through the tarsal plate. The needle reenters the tarsal
plate from the conjunctival side 3 to 4 mm laterally from
the exit point. The needle then exits the skin and is tied
through a glass bead to prevent cicatrization from the
suture mark (Figure 3-2). A problem with this technique is
the development of keratitis, which may occur if exposed
suture material rubs against the tarsal conjunctiva.
Buried Suture Technique
The knot is buried in the subcutaneous or subconjunctival
tissue of the upper eyelid. Although the procedure is
somewhat complicated, suture removal is unnecessary and
the scar is absent or less visible. Suture materials include
catgut, silk, or nylon. Currently, nylon sutures are the most
popular.
Maruo Method
Each double-armed needle with 5-0 or 6-0 thread is intro-
duced through one end of the proposed double eyelid
crease line (point a). Each needle passes through the pre-
tarsal tissue in a wavy S-shaped fashion while alternatively
catching the dermis or tarsal plate in opposing sine curves
through points b, c, and d until the needle reaches point e
(Figure 3-3).
The two strings are then tied, and the knot is buried in
the subcutaneous tissue at point e. Concerns include an
occasional infection when using catgut, weak adhesion,
and a foreign body sensation. It is difﬁcult to create a
smooth double eyelid line because of the complexity of the
suture passages.
Figure 3-2
The Hata method.
Dermal
Tarsal
a
b
c
d
e
Figure 3-3
The Maruo method.

BURIED SUTURE TECHNIQUE
25
Harado and Komato Method
Three small skin incisions are made along the proposed
double eyelid crease line. The upper eyelid is then everted.
The end of the double-armed needle with a 6-0 or 7-0
suture thread passes through the conjunctiva above the
upper margin of the tarsal plate and exits through the same
skin incision separately. These two strings are then tied
around the pretarsal tissue, and the knot is buried (Figure
3-4). Although the two needles pass through separate
routes, the distance between the two strings is narrow
because the same small incision is also used as an exit. As
a result, the suture loop tends to sink into the deeper tissue
and undo the double eyelid fold.5
Umezawa Method
A total of three small 3-mm skin incisions are made along
the proposed double eyelid crease line. A 5-0 or 6-0 nylon
suture passes through one end of the incision and then
through the tarsal plate. The needle passes through the
subconjunctival plane of the everted tarsal plate 3 to 4 mm
horizontally along the incision line. The needle then enters
the tarsal plate and exits the other end of the skin incision.
The suture is tied, and the knot is buried (Figure 3-5).6
Suture buried
A
B
A
B
Figure 3-5
The Umezawa method.
Figure 3-4
The Harado and Komato methods.

MULTIPLE SUTURE TECHNIQUE
26
Mutou Method
Two small incisions are made on the skin along the
proposed double eyelid crease line. The upper eyelid is
everted. One end of the double-armed needle passes
through the subconjunctival tissue plane approximately
3 mm above the upper border of the tarsus and for a
distance of approximately 5 mm along the skin incision
line. Each end of the needle then enters the conjunctiva 1
to 2 mm away from the subconjunctival needle entry and
exits the site bilaterally. The two needles pass through the
pretarsal tissue until they penetrate the skin surface. One
end of the needle penetrates through the intact skin, and
the other end exits through the far end of the incision site.
The needle that exited through the intact skin then reenters
the exit point and travels through the dermal layer to reach
the skin incision site. The two strings are then tied, and the
knot is buried in the subcutaneous tissue. The skin is
closed in the usual manner (Figure 3-6).7
Exit points
Incisions
Tarsal plate
Second pass
First pass – subconjunctival
A
B
C
3 mm
Figure 3-6
The Mutou method.

BURIED SUTURE TECHNIQUE
27
Boo-Chai Method
Three small incisions are made along the proposed double
eyelid crease line. A 5-0 or 6-0 nylon suture passes through
one end of the incision line and exits through the everted
conjunctiva above the upper tarsal border. The needle
reenters the exit point on the conjunctiva and passes the
subconjunctival tissue plane horizontally, following the
direction of the skin incision for a distance of 3 to 4 mm
before it exits the conjunctiva again. The needle then
reenters the second exit point on the conjunctiva and
passes through the pretarsal tissue to exit through intact
skin outside the incision and opposite to the initial skin
entry site. The needle reenters this skin exit point and
travels through the dermal plane to reach the incision site.
The two strings at the incision line are then tied, and the
knot is buried (Figure 3-7).8
A
B
D
C
Figure 3-7
The Boo-Chai method.

MULTIPLE SUTURE TECHNIQUE
28
Baek Method
Two tiny incisions are made along the proposed double
eyelid crease line. One end of the 6-0 Prolene double-
armed needle passes horizontally through the everted
conjunctiva 1 mm above the tarsal margin in the subcon-
junctival plane, following the direction of the incision line
for the distance of the two incisions on the eyelid. Each
end of the needle enters each end of the needle entry and
exit point of the subconjunctival thread passage and exits
through each small incision site on the skin. The needle
through the medial incision reenters the incision and
travels through the dermal plane to reach the outer
incision. The orbicularis oculi muscle is dissected to allow
complete burial of the knot. The threads are then tied, and
the knot is buried (Figure 3-8).9
Skin incisions
Conjunctival pass
Conjunctival pass
A
B
D
C
Figure 3-8
The Baek method.

BURIED SUTURE TECHNIQUE
29
BK Method (Single Knot Continuous Buried
Method)
Two dots are marked on each of the medial, middle, and
lateral thirds of the upper eyelid double crease line. Each
dot is designated as a, b, c, d, e, or f from the medial aspect.
A 7-0 nylon suture needle passes through point e and exits
the conjunctiva 1 mm above the upper tarsal margin. The
needle reenters the adjacent conjunctiva to reach the dermal
area of f, thereby creating a small loop. The needle advances
medially in the subcutaneous plane until it penetrates d.
The needle reenters d downward through the everted
conjunctiva and loops around the conjunctiva before
emerging through c on the skin. The needle reenters c in
the transverse subcutaneous plane until it reaches a.
Instead of exiting at a, the needle dives through the
pretarsal tissue to exit the everted conjunctiva. The needle
loops around the conjunctiva and passes through the
pretarsal tissue to exit through b. The needle reenters b
and travels through the subcutaneous plane to exit through
e. The dermis and muscle are dissected at e to allow the
knot to be buried. The two strings are tied and buried at e
(Figure 3-9).10, 11
Needle enters point E
(small incision)
First pass exits
1 mm above
tarsal plate
Knot buried
at point e
A
Epidermis
Dermis
Subcutaneous tissue
Levator aponeurosis
Conjunctiva
C
B
a
a b
c d
e
f
b
c
d
e
f
D
Figure 3-9
A,The BK method. B, Cross-section view of the BK method. C and D, Pre- and postoperative views of the BK method.

MULTIPLE SUTURE TECHNIQUE
30
Oh Method
Three dots (a, b, c) are marked on the proposed double
eyelid crease line. The second set of 3 dots (d, e, f) are
marked 6 mm medially to the dots a, b, c. Incisions (2
to 3 mm) are made through dots a, b, c. The dermis,
orbicularis oculi muscle, and pretarsal fat are removed with
a bipolar cautery device. The preaponeurotic fat may be
removed from the fatty and full upper eyelid. A 7-0 nylon
suture needle passes through a. Take a bite of the tarsal
plate before the needle exits through the everted con-
junctiva. The needle passes through the subconjunctival
plane medially, reenters the conjunctiva, and exits through
d. The needle then reenters d and passes through the
subcutaneous plane to reach a. The strings are tied at a,
and the knot is buried. This process is repeated for all three
compartments (Figure 3-10).12
3-mm incisions
Incision at
point a
Tarsal plate
Conjunctiva
Subconjunctival pass
A
B
C
D
a
b
c
a
b
c
f
e
d
E
Figure 3-10
The Oh method.

BURIED SUTURE TECHNIQUE
31
Jung Method
In this method the knot is buried in the subconjunctival
tissue plane. A dot is marked on the proposed double
eyelid line at the vertical extension of the midpapillary line.
An additional two dots are marked 7 to 8 mm laterally and
medially to the central dot. The eyelid is everted, and a 1-
to 2-mm incision is made through the conjunctiva above
the upper tarsal margin and corresponding with the central
dot of the skin. One end of a 7-0 nylon double-armed
suture needle is passed through this conjunctival incision
and advanced to the dermis under the central dot. The
needle is turned and passed along the proposed incision
line in the dermal plane until it reaches the medial dot.
Without penetrating the skin, the needle enters and then
exits through the conjunctiva. The needle then reenters
the conjunctiva and travels through the subconjunctival
tissue until it reaches the central conjunctival incision. The
second needle takes an identical passage through the
lateral pretarsal tissue as a mirror image of the ﬁrst needle.
The two strings are tied at the central conjunctival incision,
and the knot is buried (Figure 3-11).13
Midpupillary line
7– 8 mm
A
1–2 mm incision
B
Central dot
Medial dot
C
FIRST PASS
Lateral dot
Other end of suture
SECOND PASS
D
Levator
Conjunctiva
Figure 3-11
The Jung method.

MULTIPLE SUTURE TECHNIQUE
32
Various techniques for the double eyelid operation using
the nonincisional method have been introduced in the
past, and many more are expected in the future. However,
surgeons should develop procedures that allow them to
become proﬁcient and obtain good results while avoiding
complications.
Postoperative Care
Ophthalmic antibiotic ointment is applied to the wound
for 2 to 3 days postsurgery. Oral antibiotics are admin-
istered for 3 days. The eyelids are covered with gauze, and
an ice pack is applied to lessen the pain and edema.
References
1. Mikamo M: Plastic operation of the eyelid, J
Chugaiijishimpo 17:1197, 1896.
2. Shirakabe Y, Kinugasa T, Kawata M, et al: The double-eyelid
operation in Japan: Its evolution as related to cultural
changes, Ann Plast Surg 15:224, 1985.
3. Hata B: The bead method in the double eyelid operation,
Jpn Rev Clin Opthalmol 28:491, 1933.
4. Maruo M: Plastic reconstruction of a “double eyelid,”
Jpn J Clin Opthalmol 24:393, 1929.
5. Harada, Komoto: In Mutou Y: Atlas of aesthetic surgery,
Tokyo, 1977, Nansang, p 64 (in Japanese).
6. Mutou Y: Atlas of aesthetic surgery, Tokyo, 1977, NanSang,
p 69 (in Japanese).
7. Mutou Y, Mutou H: Intradermal double eyelid operation
and its follow-up results, Br J Plast Surg 25:285, 1972.
8. Boo-chai K: In Barron JN, Saad MN: Operative plastic
and reconstructive surgery, Edinburgh, 1980,
Churchill-Livingstone, pp 764-768.
9. Baek SM, Kim SS, Tokunaga S, et al: Oriental
blepharoplasty: Single-stitch, nonincision technique,
Plast Reconstr Surg 83:236, 1989.
10. Kim BG: Single knot continuously buried nonincisional
double eyelid operation, 39th Congress of Korean Society of
Plastic and Reconstructive Surgery, Seoul, South Korea,
1995.
11. Kim BG: Single knot continuously buried nonincisional
double eyelid operation, 5th International Congress of
Oriental Aesthetic Plastic Surgery, Taipei, 1996.
12. Kim YK, Kwon JD, Oh KS: Double eyelid operation with
three tiny incisions, J Korean Soc Plast Reconstr Surg
27(3):195-198, 2000.
13. Jeong DS, Kim YH, Choe J: Double eyelid operation using
the subconjunctival buried suture method, J Korean Soc
Plast Reconstr Surg 28(4):337-431, 2001.

33
After witnessing a number of problems associated with the
buried suture techniques in the past, the authors have
elected to use the incisional technique. The incision
technique using a microscope has several beneﬁts. The
technique can be applied to a wide range of patients and is
an easy method to create the desired double eyelids. The
chance that the double eyelid fold will become loose or
disappear is much smaller with the incision technique
than the buried suture techniques. When the incision
technique1 is performed with surgical microscopes, post-
operative swelling and ecchymosis are comparable with
that caused by buried suture techniques. The incision
technique is associated with some disadvantages. Exclusive
use of subcutaneous sutures is possible, but the sutures
have to be removed. The incision technique also requires
more experience.
Consultation
The advantages and disadvantages of the incision tech-
nique, buried suture technique, and nonsurgical alterna-
tives (e.g., glue and adhesive tape) are discussed with the
patient. The surgeon explains the limitations of the incision
technique and potential side effects such as postoperative
swelling, ecchymosis, infection, and asymmetry. If the
patient’s requests are unreasonable or unattainable, then
the surgeon should guide the patient toward a more
acceptable goal or refuse to perform the surgery. The
surgeon should warn the patient about the influence of
other people’s remarks regarding the postoperative result.
For example, Japanese patients are often disturbed by the
drastic early postoperative changes. In some instances,
Partial-Incision Double
Eyelidplasty
Kunihiko Nohira and Yoshihisa Shintomi
patients with excellent postoperative results may gradually
lose self-conﬁdence because of criticism from others and
may begin to complain about the result. The surgeon
should advise the patient that the ﬁnal result should be
evaluated 3 months postoperatively and that any possible
consideration of revision surgery should be deferred until 3
months after the surgery. The surgeon should also discuss
long-term changes in the appearance of the double eyelids
as a result of aging, use of contact lenses, excessive
rubbing, and other factors.
Preoperative Care
The preoperative medical history including allergies and
the use of anticoagulants is obtained, and preoperative
management is planned if necessary. Surgery should be
avoided during a female patient’s menses. The patient is
told to not apply any facial cosmetics and to arrange for a
driver on the day of the surgery. Patients who wear contact
lenses are asked to bring eyeglasses and wear them for 2 to
3 days after the surgery.
Marking
The patient is asked to sit up and look straight ahead. The
surgeon then evaluates (1) the eyebrow position and
symmetry, (2) the presence of blepharoptosis, and (3) the
presence of Hering’s law to determine whether an incipient
ptosis is present in the other eye. The double eyelid fold is
likely to become loose in patients with even minimal ptosis
unless levator aponeurosis surgery is performed. The
4

PARTIAL-INCISION DOUBLE EYELIDPLASTY
34
patient is asked to hold a hand mirror and look at the
eyelids. The surgeon presses a curved lacrimal bougie onto
the patient’s upper eyelid skin to simulate the postoperative
result (Figure 4-1, A). Several eyelid crease heights are
simulated to help the patient choose the desired result (see
Figure 4-1, B). The surgeon also asks whether the patient
prefers double eyelids with a crease that gets lower as it
approaches the medial side (tapered type) or a crease that
runs parallel to the ciliary margin (parallel type). When the
patient chooses the tapered type, the surgeon then asks
whether the patient prefers the double eyelid to be visible
at the medial end or at a point slightly lateral to the medial
end and whether the patient prefers the crease to flare
gently upward as it approaches the lateral end or run
parallel to the ciliary margin at the lateral end.
When the patient chooses the parallel type, a natural-
looking double eyelid may be created with a crease at
approximately 8 mm above the ciliary margin. When the
patient wishes a crease to be 10 mm or more above the
ciliary margin, then the surgeon should ask the patient to
verify the desire to have such a high double eyelid fold. The
surgeon must explain that high parallel-type double eyelids
may look unnatural when the medial epicanthal fold is
present. The patient is then advised to undergo an epi-
canthoplasty if a prominent epicanthus is prominent. The
horizontal aperture of the eyelids extends with the addition
of an epicanthoplasty. Thus the appearance of the double
eyelids gives the illusion of a 8-mm crease even though a
10-mm crease was made. However, radical medial epi-
canthoplasty should be avoided because it is likely to leave
a visible scar.
After the crease height has been determined, the point at
which the bougie pressed the skin is marked with a
marking pen. The bougie tip is moved medially if the
patient prefers the tapered type with the double eyelids
visible at the medial end, or slightly laterally if the patient
prefers the double eyelids to be visible at a point slightly
lateral to the medial end. If the patient prefers the crease
to flare upward at the lateral end, the lateral portion of
the incision line is moved slightly upward. An incision line
approximately 10 mm long is then drawn by connecting
the medial point of the bougie to its lateral point (see
Figure 4-1, C). The incision line is drawn in the same
manner for patients who choose the parallel type. In
general, the skin is not excised.
It is possible to create double eyelids with an incision line
of 5 mm or less.2 However, if the incision line is too short,
the skin cannot be adequately ﬁxed to the tarsus, which
causes the medial and lateral skin to sag. For this reason,
short incision lines sometimes cause triangle-shaped
double eyelids.
Figure 4-1
A, A lacrimal bougie is pressed onto the upper eyelid. B, The double eyelid fold is
simulated. C, The incision line is drawn.
A
B
C

TURNOVER SEPTODERMAL FIXATION
35
Premedication
No premedication is given. All surgical procedures are
performed under local anesthesia. It is preferable that the
patient is awake and able to open the eyes and sit up during
the procedure.
Anesthesia
A 1-ml syringe containing 0.8 ml of 1% lidocaine with
1:100,000 epinephrine and 0.2 ml of 1% ropivacaine is used
to inject approximately 0.1 ml of local anesthesia on each
side, just beneath the skin, with a 30-gauge needle. Care
should be taken to avoid puncturing the subcutaneous
blood vessel during the injection. An additional 0.1 to
0.2 ml of local anesthesia is injected when the pretarsal
tissues are removed after skin incision.
Dissection
The authors use surgical microscopes (4× magniﬁcation)
to perform the double eyelid operation. The surgical
microscope allows the surgeon to obtain a brighter visual
ﬁeld and clearer images than surgical loupes. The surgical
microscope enables a precise surgical procedure to be
carried out even with a short skin incision (i.e., small
vessels are coagulated and cutaneous sensory nerves are
preserved). The surgeon can fully view the anatomic
details of the eyelid and precisely identify the multiple
ﬁlmy layers of the eyelid. The surgeon is better equipped
to establish the anatomic relationships of the eyelid even
when extensive scarring from a previous double eyelid
surgery is present, and the double eyelid operation can be
safely performed.
When the crease height is ≤8 mm above the ciliary margin
and the vertical height of the tarsus is ≥8 mm, the skin
can be securely ﬁxed to the tarsus using the tarsodermal
ﬁxation technique (Figure 4-2, A to C). The best candidate
for this technique is the patient who has heavy eyelids and
thick skin with a thick fatty layer. Loosening of the fold is
minimal for this patient population.
When the crease height is set at >8 mm and the vertical
height of the tarsus is <8 mm, it is impossible to ﬁx the skin
to the tarsus. In this case, the authors use the turnover
septodermal ﬁxation technique3-5 (Figure 4-3, A and B).
Fixation is less secure with this technique than with the
tarsodermal ﬁxation technique. Therefore the turnover
septodermal ﬁxation technique is only indicated for
patients who have thin eyelids with a relatively small tissue
volume.
Tarsodermal Fixation
The skin is incised along the previously marked incision line
with a scalpel. Subcutaneous blood vessels are coagulated.
A strip of orbicularis oculi muscle is then excised. A cuff of
muscle should be left on the inferior edge of the incision
because the needle passes through this muscle during
tarsodermal ﬁxation. The pretarsal tissue is excised just
beneath the orbicularis oculi muscle on the palpebral side.
Excessive removal of the pretarsal soft tissue may cause
deformity because of a flat skin adhesion to the tarsus. To
avoid the risk of bleeding during the pretarsal tissue
excision, the surgeon should take care to avoid injuring the
sensory nerve ﬁbers that run vertically along the blood
vessels. Next, the anterior surface of the tarsus is exposed
(Figure 4-4, A). The blood vessel plexus along the superior
edge of the tarsus should be carefully preserved. The orbital
fat is removed if the patient has a large volume of fat.
The subcutaneous blood vessels on the inferior edge of
the incision are coagulated by touching the muscle with
micro-bipolar forceps. This maneuver avoids accidental
bleeding and subcutaneous ecchymosis from suture needle
puncturing. The suture needle is passed through the
deepest layer of the dermis and muscle (see Figure 4-4, B).
The needle is then passed vertically through the tarsus at
an intermediate depth (see Figure 4-4, C), and the suture is
tied. Fixation is performed at three points (medial, central,
and lateral) with 7-0 Dexon thread (see Figure 4-4, D). The
skin should be ﬁxed at its original position without pulling
upward; this avoids the risk of the cilia turning upward and
causing an ectropion. The skin is closed with 8-0 nylon (see
Figure 4-4, E).
Turnover Septodermal Fixation
The skin is incised, and subcutaneous blood vessels are
coagulated. A strip of orbicularis oculi muscle is excised
(Figure 4-5, A). The exposed septum is then incised parallel
to the inferior edge of the skin incision and at a length
equal to the skin incision line (see Figure 4-5, B). This

PARTIAL-INCISION DOUBLE EYELIDPLASTY
36
A
B
C
Figure 4-2
Tarsodermal ﬁxation. A, The cross-section view of a single eyelid is shown. B, After
the skin incision is made, the pretarsal tissues are excised. C, The suture thread is
passed through the deepest layer of the dermis and muscle and then through the
tarsus.

RECOVERY
37
exposes the orbital fat beneath the septum. The orbital fat
is retracted superiorly, and the thin ﬁbrous membrane is
incised. The levator aponeurosis, which has a shiny smooth
surface, is exposed beneath this membrane (see Figure 4-5,
C). A suture needle threaded with 7-0 Dexon is passed
through the deepest layer of the dermis and muscle at the
inferior edge of the incision (see Figure 4-5, D) and through
the inferior edge of the incised septum at approximately 5
points. The sutures are tied (see Figure 4-5, E). If the skin
is sutured to the end of the levator aponeurosis, ectropion
may result from excessive pulling on the skin. By leaving
the septum attached to the levator aponeurosis, the skin
can be pulled with an appropriate amount of force. When
the incision is made more than 15 mm above the ciliary
margin, the pretarsal skin will sag. Therefore the incision
should be made less than 15 mm from the ciliary margin,
and in some cases, a few millimeters of the skin above the
incision line may need to be excised. The skin is closed
with 8-0 nylon (see Figure 4-5, F).
Postoperative Care
The eyelids are cooled for an hour after the surgery.
The patient is allowed to bathe and to apply facial cosme-
tics (excluding the upper eyelids) on the ﬁrst postoperative
day. The patient is instructed to clean the eyelids twice
each day using wet cotton and to apply antibiotic ointment.
The sutures are removed on the fourth or ﬁfth post-
operative day.
Recovery
The patient is instructed to not apply eyelid cosmetics for
2 weeks after suture removal and to gently wipe the suture
lines every day. The patient is also instructed to avoid
pulling the skin when inserting or removing contact lenses
during the ﬁrst 2 postoperative weeks. In most patients,
ecchymosis does not occur and eyelid swelling is reduced
within 2 weeks postoperatively. The eyelids will reach their
Figure 4-3
Turnover septodermal ﬁxation. A, The preseptal tissues are removed, and the septum is incised. B, The suture thread is passed through the dermis and muscle at the inferior
edge of the incision and then through the inferior edge of the septum.
A
B

PARTIAL-INCISION DOUBLE EYELIDPLASTY
38
Figure 4-4
A, The pretarsal tissues are excised, and the sensory nerves are preserved. B, The
suture needle is passed through the deepest layer of the dermis and muscle. C, The
suture needle is then passed through the tarsus. D, Fixation is carried out at the
medial, central, and lateral points. E, The skin is closed with 8-0 nylon.
A
B
C
D
E

RECOVERY
39
Figure 4-5
A, The preseptal tissues are excised. B, The septal incision line is marked. C, The orbital fat is retracted superiorly, and the edge of the septum is pulled inferiorly. The levator
aponeurosis is seen below the septum. D, The suture needle is passed through the deepest layer of the dermis and muscle at the inferior edge of the incision and then through
the inferior edge of the septum. E, Fixation is carried out at ﬁve points. F, The skin is closed with 8-0 nylon.
A
B
C
D
E
F

PARTIAL-INCISION DOUBLE EYELIDPLASTY
40
ﬁnal normal appearance with minimal visible redness in 3
months.
Clinical Cases
Case 1: Tarsodermal ﬁxation technique in a 28-year-old
woman (Figure 4-6, A to G).
Case 2: Turnover septodermal ﬁxation technique in a
31-year-old woman (Figure 4-7, A to E).
Figure 4-6
Tarsodermal ﬁxation. A, Preoperative view. B, Immediate postoperative view (eyes
open). C, Immediate postoperative view (eyes closed). D, Five-day postoperative
view (eyes open). E, Five-day postoperative view (eyes closed). F, Four-month
postoperative view (eyes open). G, Four-month postoperative view (eyes closed).
A
B
C
D
E
F
G

CLINICAL CASES
41
References
1. Shintomi S, Nohira K: Double eyelidplasty; partial incision
technique. In Inchida M (ed): Aesthetic surgery practice 1,
Tokyo, 2000, Bunkodo, pp 46-48 (in Japanese and Hangul).
2. Flowers RS: Aesthetic surgery of the eyelids. In Marchac D
(ed): Transactions of the 6th International Congress of Plastic
and Reconstructive Surgery, Paris, 1975, Masson.
3. Flowers RS: The art of eyelid and orbital aesthetics.
Multiracial surgical considerations, Clin Plast Surg
14(4):703-721, 1987.
4. Yang SY: Oriental double eyelid: a limited-incision technique,
Ann Plast Surg 46(4):364-368, 2001.
5. Lee JS, Park WJ, Shin MS, et al: Simpliﬁed anatomic method
of double-eyelid operation: septodermal ﬁxation technique,
Plast Reconstr Surg 100(1):170-178, 1997.
Figure 4-7
Turnover septodermal ﬁxation. A, Preoperative view. B, Immediate postoperative
view (eyes open). C, Immediate postoperative view (eyes closed). D, One-year
postoperative view (eyes open). E, One-year postoperative view (eyes closed).
A
B
C
D
E

43
In previous publications1-7 the author discussed the
concept of upper eyelid crease conﬁgurations and the
essential steps required for the predictable placement of
a lid crease in Asian patients. The method relies on the
accurate measurement of the central height of the upper
tarsus, which is used to guide the placement of the external
incision line to form the crease. It is this author’s opinion
that the ideal crease shape for Asians of Han origin tends
to be either the nasally tapered crease or the parallel crease
conﬁguration. Medial upper lid fold is often present in the
medial portion of the upper eyelid of the Asian eye,
regardless of the occurrence of a crease, and should be
neither considered pathologic nor automatically removed.
Trapezoidal debulking of the preaponeurotic platform is
essential to clear any redundant tissues along the superior
tarsal border of the upper eyelid so that a proper vectoring
can occur between the distal components of the levator
aponeurosis and the skin during both straight-ahead
gaze and upgaze to create a lid crease. Tissues may form
a barrier for proper vectoring within a narrow 2- to
3-mm zone overlying the upper boundary of the upper
eyelid tarsus. These tissues are eliminated through excision
of a small amount of skin, orbicularis, distal orbital septum
(the most inferior extent of the septum), and selective,
small excision or repositioning of preaponeurotic fat.4
Surgical Steps
Marking
Use 1 ml of anesthetic (2% xyloxaine with 1:100,000
dilution of epinephrine) to achieve sensory anesthesia of
Skin-Levator-Skin Fixation
Technique
William Pai-Dei Chen
the upper lid. The author recommends use of the shaved
tip of a wooden cotton-tipped applicator dipped in methyl-
ene blue to mark the proposed crease. Evert the tarsus, and
use a caliper to measure the central width of the tarsal
plate. (It is usually between 6.5 and 8.5 mm wide.) Carefully
transcribe it onto the external skin surface over the central
part of the eyelid skin (Figure 5-1). This point directly
overlies the superior tarsal border and will serve as a
reference point for the overall crease height along the
central third of the eyelid, regardless of whether the crease
shape is to be nasally tapered, parallel, or laterally flared.
5
Figure 5-1
Marking of the eyelid for surgical creation of a crease. The central height is based on
the measured tarsal height of that eyelid. The crease shape in this photograph is for
the creation of a nasally tapered crease design.

SKIN-LEVATOR-SKIN FIXATION TECHNIQUE
44
If the plan is to preserve or enhance an existing crease,
measure the tarsus to conﬁrm the existing crease and
verify that it is indeed the correct crease line to use.
If the crease is to be nasally tapered with either a laterally
leveled or flared conﬁguration, mark the medial third of
the incision line to taper toward the medial canthal angle
or merge with the medial upper lid fold. Mark the lateral
third in the chosen conﬁguration (e.g., leveled or flared).
For the parallel crease, draw the measured height of the
superior tarsal border across the width of the eyelid skin.
In summary, the height of the tarsus determines the overall
central position of the surgical crease; the design of the
medial and lateral thirds of this crease (i.e., the lower line of
incision) determines the shape, according to the patient’s
preference.
PEARL—In Asian blepharoplasty that involves skin
excision, the lower line of incision will determine the shape
and height of the surgically created crease.
Skin Incision
To create adequate adhesions, it is necessary to remove
some subdermal tissue. Mark a strip of skin approximately
2 to 3 mm above and parallel to the lower line of incision.
In the patient who desires a nasally tapered conﬁguration,
taper this upper line of incision toward the medial canthal
angle, or merge it with a medial upper lid fold, if present.
As a result, the segment of skin to be excised is often less
than 2 mm above the medial portion of the crease.
Continue with the incision using a #15 surgical blade
(Bard-Parker) along the upper and lower lines, incising just
below the subcutaneous plane (Figure 5-2). Control any
ﬁne capillary discharge with a bipolar Wet-Field cautery
(Mentor O & O Inc., Norwell, MA). Preferably, the strip of
skin bounded by the upper and lower lines of incision is
excised only after the orbital septum is opened along the
superior line of incision and the skin–orbicularis–orbital
septum flap is turned inferiorly along the superior tarsal
border (see following pages).
The excision of a strip of skin is not necessary in all cases;
however, the author believes that doing so facilitates the
removal of subsequent layers of the lid tissues, thereby
allowing adequate crease formation.
Opening of Orbital Septum
At this point, the pretarsal and supratarsal orbicularis oculi
muscles still cover the superior tarsal border as well as
(possibly) some distal portions of the septum orbitale and
the anteriorly directed terminal ﬁbers of the levator apo-
neurosis beneath the septum. To open the septum, retract
the upper incision wound superiorly and use a ﬁne-tipped
monopolar bovie cautery (in the cutting mode) to incise
through the orbicularis and orbital septum in a bevelled
manner along the upper skin incision line.
In the Asian eye, the orbital septum may be only 2 to
3 mm above the superior tarsal border. It is readily opened,
which exposes the underlying preaponeurotic fat pads
(Figure 5-3).
Preaponeurotic Fat Pads
Depending on the degree of fullness of the upper lid
(Figure 5-4), sharp scissors or a monopolar bovie cautery
(in a low-power cutting mode) may be used to excise a very
small amount of the preaponeurotic fat pad. Control any
bleeding points with a bipolar Wetﬁeld cautery. (The fat
excision often requires a small local supplement of lido-
caine in the space beneath the preaponeurotic fat pad.)
If a patient with dermatochalasis and obliteration of crease
manifests even a very minimal concavity in the supratarsal
sulcus, do not remove any fat. Fat removal will worsen the
hollowness and result in multiple redundant folds superior
to the desired location of the crease. Instead, reposit the
Figure 5-2
Skin incision has been accomplished over the upper and lower lines of the marked
crease.

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