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What is incision Double Eyelid Operation?

Double eyelid operation is very common practice in our clinic. Eyes become larger and brighter after operation. Eyes are different between people. The operation should be custom-made. There are two kinds of double eyelid operation. One is suture method (non-incision) – stitches are buried into eyelid by tiny wounds ( there is a chapter in our website instroducing suture method). The other is incision method – incision is made to treat inner structure of eyes, such as fat. By incision method, the adherence is stronger and fading rate( loss of folds) is lower than suture method, but the recovery time is longer than suture method. 

Incision method is recommended in below cases.
1) Puffy eyes. The fat in the eyes will interfere with longevity of double eyelid fold. It is better to treat fat (incision method ) in puffy eyes. 
2) Ptosis. Levator muscle or Muller muscle should be treated. Please refer to the introduction of ptosis below.  
3) Sunken eye. Fat should be added into eye. 
4) Aged eyes. The loose eyelid skin should be excised at the same time. Below figure explains the procedure of incision method with fat excision.


Upper left: before incision method with fat excision.  Right: after

Upper left: before incision method.  Right: 3 years after. 

Upper left: before (incision method with levator surgery).   Right: after

Upper left: before (incision method with levator surgery).   Right: after

Upper left: male case before incision method.     Right: after Scar is one of the concerns about incision method.

Below shows two cases after incision method. The scars just like small wrinkles and are not visible.

small incision double eyelid method
Intermediate method or what some doctors call "small incision double eyelid method",The method is to make a small incision (about one centimeter) to remove fat and finally put sutures as the same way as suture double eyelid operation.The advantage of this method is that the recovery is between the suture and incision method (it is not as swollen as the incision double eyelid operation, and the recovery is faster), but the chance of fading is also between suture and incision methods.


  • The recovery from incision method is long?
    One of the concerns about incision method is the recovery time.  After operation, swelling is more severe in first 2-3 days and then subsides.  With some eye shadow, eyes look fine in first 1-2 weeks.  Below show a typical case after incision method.  Left upper shows the immediately result after surgery.  The swelling is caused by local anethesia.  Upper right shows picture after one week.  She looks fine with eyeliner.  Lower left shows the picture after two weeks.  Lower right shows picture after two months.

    Upper left: immediately after incision method. Right: one week after

    Upper left: two weeks after. Right: two months after

    Other cases:

    Above pictures are: Right after surgery and three days after.

    Above pictures are the same case: One week after the surgery and two weeks after.

    Below showed the scar. Almost invisible.


    The case below decided to have suture method. Left below is the picture after suture method. Later fading was noted. She underwent incision method. Below middle was the picture after incision method. Below right was the picture when she has the stitch removal on fifth day. She said that recovery from incision method was quicker than suture method.

    Fome the left to the right: After suture method -> After incision method -> Fifth day after incision method


  • Epicanthoplasty
    Epicanthal fold or Mongolian fold is a unique feature of Asian population.  The medial canthal area shows distinctive variation.  In some Asian people the epicanthal fold cover lacrimal lake (the arrow on the next second picture pointed to lacrimal lake), so that eyes look far apart.  After epicanthoplasty, lacrimal lake is not covered by epicanthal fold.

    Epicanthoplasty surgery lengthens eye fissure, so that eyes look larger and more open.  

    Above pictures: Lacrimal lake (arrow) was not coved by epicanthal fold after epicanthoplasty.

    There are two kinds of double folds at the medial end.  One is inside fold - crease taper medially to end in epicanthal fold.  The other is outside fold - parallel with upper eyelid margin. Outside fold is more popular because eyes look larger and longer than inside fold.


    After double eyelid operation, the result may end with outside or inside fold, depending on the structure of epicanthal fold.  In some people, epicanthoplasty may be needed to form outside fold.

    Below left was before picture.  Middle was picture after suture method.  Fold was higher after suture method.  Right was the result after epicanthoplasty.  Inside fold became outside fold after epicanthoplasty.

    Below left was before picture of a case with single fold.  Middle was picture after suture method.  Right was picture after epicanthoplasty.  Eye fissure became longer and closer after epicanthoplasty.

    Below left is before picture.  She underwent suture method + epicanthoplasty.  Right is after picture.  Eyes looks brighter and longer.

    Below left is before.  Right is after picture.  She underwent incision method + epicanthoplasty.

  • Asymmetry
    Most common cause of asymmetric eyes is asymmetric folds.  Eye with lower fold looks smaller than eye with higher fold.  There are two ways to correct asymmetry.  One is suture double eyelid operation on eye with lower fold.  The other is incision double eyelid operation on both eyes.  
    The reasons of why not incise only on eye with lower fold are:

    1. The fold on operated side will be higher than the other side in recovery period.
    2. After recovery, there may be some asymmetry between operated side and natural side.

    Below show a case with asymmetric eyes.  She underwent incision method on both eyes.

  • Lateral hooding
    In young age, lateral hooding is caused by prominent bone or fat accumulation.  Fat excision at time of incision double eyelid operation can improve lateral hooding in some way. Due to aging process, lateral hooding after mid-age is caused by eye brow dropping or laxity of eyelid skin.  So that effective way to correct hooding is surgery to lift eyebrow or excision of loose eyelid skin.

    There is different severity of lateral hooding.  In severe lateral hooding, it is due to eye brow ptosis and laxity of eyelid skin.
    So that the treatment plan includes:

    1. Lift the dropped eye brow (endoforehead lift). 
    2. Excision of laxity eyelid skin.

    Below shows a case who underwent endoforehead lift and later on upper blepharoplasty.  Upper left was picture before operation.  Upper right was picture after endoforehead lift.  The eyebrow was lifted but lateral hooding of eyelid was not improved enough.  She underwent upper blepharoplasty (raising the eyelid fold and excising lateral eyelid skin).  Below left was the picture after upper blepharoplasty.  Below right was picture of scar on her scalp.  The scar of endoforehead lift is not obvious.

  • Upper blepharoplasty (plastic surgery on upper eyelid)
    hen eyebrow is in good position, upper blepharoplasty is a way to correct eyelid hooding.  There are two kinds of upper blepharoplasty.  In mild lateral hooding with good upper eyelid fold, the laxity eyelid skin can be excised without changing upper eyelid fold.  Below show the marking of eyelid skin excision.  More skin is excised on lateral side than on medial side.


    Below show a case before and after eyelid skin excision.  Curve of double eyelid fold is raised, in stead of drop, after surgery.

    The other way of blepharoplasty:  When eyelid hooding coexists with lower eyelid fold, incision double eyelid operation (to raise eyelid fold) and eyelid skin excision (similar with above case) are recommended.

    Upper left: before.  Right: after upper blepharoplasty (raise eyelid fold and upper eyelid skin excision).

    Upper left: 70 years old. Before.  Right: after upper blepharoplasty (raise eyelid fold and upper eyelid skin excision).

    The other way of lifting eyebrow is supra-eyebrow skin excision.  Under local anesthesia, some skin above eyebrow is excised (please see the below case).  The operation is suitable for women with eyebrow tattoo.  The scar is above the tattoo, therefore the scar is not obvious.  It is a relative simple operation, comparing with forehead lift.  But the lifting force of eyebrow is weaker than forehead lift.

    Below show a case before and after supra-eyebrow skin excision.  Lateral eyebrow has been lifted and lateral eyelid skin hooding is imroved (lower right picture).

    When lateral hooding was noted in women with good eyebrow position, the other option to improve hooding is sub-eyebrow skin excision.  The below case is a case of lateral hooding with two history of eyebrow tattooing.  The lower tattoo was excised, resulting with improved lateral hooding (below right picture).

    Below case presented with eyebrow ptosis and lateral eyelid hooding.  She was not prepared for forehead lift (major surgery).  She underwent supra-eyebrow skin excision combined with skin excision upper blepharoplasty.  Both problem (eyebrow ptosis and lateral hooding) has been improved in some way (right picture).


  • Puffy eyelid
    Using incision method, the fat inside eyelids could be treated.  Fading rate would be less, comparing with suture method.  Eyes look brighter after surgery, like the case showed below.  But the folds were usually narrow and puffiness improved a little bit after surgery.

    The other cause of puffy eyelids is lower eyebrows.  It is recommended to have forehead lift (even in youngs) firstly to raise eyebrows.  After recovery from forehead lift, incision double eyelid was done.  Double eyelid operation only would end with inside folds.

    Below left was before.  Middle was after forehead lift.  Left was result after double eyelid operation. He was 18 years old.

  • Ptosis
    Tarsus is located at the lower edge of upper eyelid, the place of eyelash attachment.  Ptosis means that tarsus drops to lower position than normal, so that pupil is coved by upper eyelid.  Sleepy eye looking is noted.  The left eye of below picture is ptosis eye .

    The way of correcting ptosis  is to excise part of levator (external approach) or Muller's muscle (internal approach) and then approximate the edge of muscles.  The procedure lift tarsus, therefore ptosis is corrected.


    1. External or anterior approach: The procedure (operation on levator) is done associating with incision double eyelid operation.
    2. Internal or posterior approach: Muller's muscle and conjuntiva are excised (Muller's muscle- conjunctiva resection, abbreviated as MMCR).  The scar is inside.  Internal approach is not combined with double eyelid operation.  Double eyelid operation could be done on three months after MMCR.

    Ptosis correction is indicated when below situations are noted:

    1. Asymmetric eyes
      Ptotic eye looks smaller.  You can see the right eye of below case was smaller due to ptotis.  Right picture showed the result of MMCR, done on her right eye.  The picture was taken on four months after surgery.  Her eyes looked more symmetric.
    2. Forehead wrinkles
      In patients with ptosis, Frontalis (muscle under forehead skin) activity will increase to raise eyebrows and eyelids.  Horizontal forehead wrinkles are obvious due to contraction of Frontalis muscle.

    Due to forehead wrinkle, physician in another clinic injected Botox for the below case (below left picture).  Although Botox was effective to eliminate forehead wrinkles, asymmetric eyes was noted (right eye was smaller) ( below middle picture).  Right picture was taken on six months after MMCR (done on her right eyes) and suture double eyelid operataion (done on both eyes).  No more forehead wrinkles were noted and her eyes are brighter. 

    1. Sunken eyelid
      In previous section, the treatment of sunken eyelid has been mentioned.  Ptosis is one of causes of sunken eyelid.  If fat is injected and no ptosis correction is done, ptotis gets more severe due to the weight of fat on eyelids.  Please refer to the case below.  Left is before.  Right is after appearance of fat injection.  Sunken was corrected, but ptosis got severe.

      The eyes of below case was sunken and ptosis (right picture).  Left was picture on 5th days after MMCR and suture double eyelid operation.  Her eyes are more beautiful after operation.

    2. Revision double eyelid operation
      For cases who had double eyelid operation with unfavorable higher folds, levator surgery or MMCR usually had to be done to lower the folds.  Below case underwent revision double eyelid surgery 10 years ago with recurrence of ptosis. 
    Levator surgery would be not easy due to previous operation scar. After MMCR (it was a easier procedure because there was not scarson conjunctival sides), eyes looked brighter.  She is happy with the result.

    Left eye of below was ptosis eye.  After levator surgery with incision double eyelid operation, eyes looks symmetric.

    Below case underwent incision double eyelid operation and right levator surgery.  Right picture is after surgery.

    Below two cases underwent incision double eyelid operation and levator surgery on both eyelids.  Right picture is result after surgery.  Eyes look quite big.

    One of reasons of asymmetric eyes is ptosis.  Left eye of below case is ptosis, so that left eye looked smaller.  After correction of left eye ptosis by levator surgery and incision double eyelid operation, eyes look symmetric.

    Right eye of below case was ptosis. After correction by levator surgery, eyes look quite beautiful.


  • Four-lid blepharoplasty
    If problems of upper and lower eyelids coexist, blepharoplasty on four lids can be done at the same time.  Problems of four eyelids can be corrected in one recovery time.  Below case presented with sagging upper eyelid and baggy eyelid.  After four-lid blepharoplasty, she looks at least ten years younger than before surgery.  Right picture was taken on 8 months after surgery.

    Below case is similar with above case.  After four-lid blepharoplasty, she looks prettier and younger than before. Right is picture taken on 2 years after surgery.

    Below case presented with sunken upper eyelid and baggy eyelid.  Fat block was put into upper eyelid to correct sunken problem.  In the same time baggy eyelid was corrected.  She is satisfied with the result. Right picture was taken on 6 months after.

    Eyes of below cases are prominent.  She also presented with multiple upper eyelid folds and baggy eyelids.  She underwent four lid blepharoplasty.  Right picture is taken on 8 months after surgery.

    Below case presented with puffy eyelid, sagging eyelid and baggy eyelid.  Right is the picture on 2.5 years after excision of upper eyelid fat, excision of sagging upper eyelid and baggy eyelid surgery.  She is satisfied with the result.

    Below case was 23 years old, presented with puffy eyelid and baggy eyelid.  She underwent four lid blepharoplasty.  Operation procedure included incision double eyelid operation with fat removal and baggy eyelid operation.  Right is taken on 4 months after surgery. Eyes look more spiritual than before.

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