JJ Plastic Surgery

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Eyelids
Primary double eyelid surgery Nonincision Partial-incision, incision

[ Primary Double Eyelid Procedure ]

Double Eyelid and Single Eyelid

One of the most important functions of the upper eyelid is to alternately protect and expose the eye to its repetitive shutter-like excursion movement. Along with the alternat¬ing motion of the closing and opening phases, the upper eyelid changes its external shape continuously. In the clos¬ing phase, the lid is extended wide to cover the cornea and bulbar conjunctiva of the eyeball; in the opening phase, the lid is retracted to expose them. During the opening period, the enveloping cover (skin and palpebral conjunctiva) should be folded to eliminate redundancy in temporary cov¬erage. Although conjunctival folding is not observed when looking at the face, the pattern of skin fold formation in the opening phase of the upper eyelid is characteristic of each East Asian individual.1 This pattern and manner of folding the outer skin determine the shape of the eyes, particu¬larly in the upper border of the palpebral aperture. Usually, the skin is folded in the middle of the eyelid, and the edge of the skin fold is located above the eyelash to expose the cornea completely in the fully opened state. The edge of the skin fold and the eyelid margin with the eyelashes parallel to each other form the upper border of the palpebral aper¬ture (double eyelid) together. In a double eyelid, the upper border of the eye consists of two outlines as if the upper eyelid were composed of dual layers (Fig. 1).

In contrast, the single eyelid has only one border, because the skin fold is formed below the lid margin. The edge of the skin fold hides the real lid margin and pushes the eyelashes from above in the opening phase (Fig. 2). Compared with the double eyelid, the palpebral aperture is reduced by the lower skin fold. The single-lined upper border is a unique feature of East Asian individuals (Korean, Chinese, Japanese, and Mongolian), while the double line is the most prominent eyelid fold pattern in Caucasian, Afri¬can American, and South Asian individuals.

Fig. 1 Typical double eyelid in East Asian women. In a double eyelid, the upper border of the eye consists of two outlines because the edge of the transverse skin fold is formed above the lid margin. The edge of the skin and lid mar¬gin create the dual-lined upper border of the eye, and the eye is fully exposed when opened.

Fig. 2 Typical single eyelid of East Asian women. In the opening phase, the skin is folded at a level too low, and the skin crease is hidden under the upper part of the palpebral aperture (a) and the eyelashes get pushed down (b). In comparison with the double eye¬lid, the palpebral aperture looks reduced by the distal skin fold, which lies at a lower level.

Anatomy of the Upper Eyelid

The upper eyelid is a layered structure, divided into the anterior, middle, and posterior lamellae. The anterior lamella is composed of the skin and underlying orbicularis oculi muscle. The posterior lamella consists of the tarsus and underlying conjunctiva. The middle lamella consists of the orbital septum and fat separating the orbital contents from the preseptal structures.2 In the sagittal sectional anatomy, the inverted triangle-shaped upper eyelid has a thick upper portion with three distinctly separated lamel¬lae and a thin distal lid margin in which the anterior and posterior lamellae are attenuated and condensed firmly together (the skin, orbicularis oculi muscle, and tarsus). The intervening orbital septum and orbital fat (middle lamellae) extend only to the fusion line, which can be iden¬tified as a skin crease on the outer surface. The condensed distal lid margin is attached to the levator mechanism (levator aponeurosis, superior levator palpebralis muscle, and Müller muscle) and actively retracts at the beginning of the opening phase (Fig. 12.3). Meanwhile, the anterior and middle lamellae above the fusion line (transverse skin crease) are passively folded according to the opening movement.

With the superior levator palpebralis muscle contract¬ing, the distal lid margin (red-colored surface) directly con¬nected to the levator mechanism begins to retract upward, leaving the upper anterior lamella (above the fusion line, green- and blue-colored surface) static in situ. As the degree of opening increases, the anterior lamella just above the crease is passively lifted from its distal end (green-colored surface). At this level, the transverse skin crease becomes prominent and is folded further as opening pro¬gresses. With the further opening, the distal skin of the ante¬rior lamella (green) is flipped up and enters just behind its upper skin (blue-colored surface) to create a fold.

In the single eyelid, the middle lamella is well devel¬oped and abundant orbital fat extends to a lower level. Therefore, the anterior and posterior lamellae fuse at a lower level than they do in a double eyelid, and the height of the condensed distal lid margin (red) is too low. As a consequence, the skin of the anterior lamella is folded at a much lower level (lower tarsal crease) in the opening phase and hides the entire lid margin, including the eyelashes. Furthermore, the upper portion of the palpebral aperture is partially eclipsed by the skin fold, despite the full open¬ing of the eyelid. Hence, in a severe case, the frontalis acts to lift the eyelid skin fold to provide adequate vision, as in a patient with a blepharoptosis. Meanwhile, in a double eyelid, the fold is formed at a higher level and the edge of the fold lies above the lid margin and does not obstruct the normal visual field (Fig. 12.4).3

Fig. 12.3 Opening process of the upper eyelid. (a) In the rest¬ing phase, the outer skin of the upper eyelid is expanded. (b) At the beginning of eyelid opening, the skin just above the crease (green zone) is rolled up with the lid margin elevated. (c) In the fully opened phase, the green zone skin is completely behind the upper skin.

Resting phase	Opening phase	Resting phase	Opening phase
A. Single eyelid		B. Double eyelid
a Resting phaseOpening phaseResting phaseOpening phaseSingle eyelidDouble eyelid

Fig. 12.4 Single and double eyelid. The most important anatomic difference between a single and double eyelid is the level at which the fusion between the anterior and posterior lamellae occurs, and thus the level at which the anterior skin is folded. The pattern of the skin fold in the opening phase determines the shape of the eye. (a) In a single eyelid of an Asian, the skin fold is formed at a lower level and the folding skin hides the real lid margin and eyelashes as well as the upper part of the palpebral aperture. (b) In contrast, the skin fold of a double eyelid lies at the upper level and the fold edge is formed far above the eyelashes.

Artificial Double-Eyelid Formation

[ Non-incision & Partial incision Suture ligation technique for double eyelid folding / Non-incisional Blepharoptosis correction ]

10 Point suture technique

Duration of procedure
It takes less than 30 minutes

Anesthesia
Local anesthesia with light sedation

Hospitalization
None

No stitch to remove when non-incision/ 3days after Partial incision

Recovery Period
Normal activities after 2 days, 70% of swelling fade away within 7days

What is JJ 10 point Suture ligation Method?

Unlike previous non-incision methods, your eyes will not easily return back with JJ 10 point non-incision. With our unique stitches, your new double eyelids are formed by connecting the eyelids to the muscle that opens and closes the eyes.

Additional to our stitching method, looping helps disperse the eye’s effort to resist the double eyelids, making it more difficult to return back to your eyes.

Since JJ 10 point non-incision method is done with small holes, the outcome looks more natural with less scars.

Who is Suture Method for?

Those who have double eyelid fold, but it disappear when swollen or tired-Those whose eyelids are thin and doesn’t lag

Stable and Balanced loops
JJ 10 point non-incision suture method makes five identical loops on the eyelids. A single loop or stitch might have faster recovery periods but they tend to get loose easily. With five balanced loops that we make, your double eyelids becomes stable.

Along the natural skin creases
A double eyelid line should be designed along the natural skin creases on the skin of the lid. Even in a simple non-incision technique, irregularity can be happen by the undesirable design.

Partial-incision technique
For a puffy eyelid, the septal fat should be removed through small incision on the double eyelid line before suture ligation procedure. Partial-incision technique means suture ligation method with the septal fat removal.

From Ch 12 Double-Eyelid Surgery :
Nonincisional Suture Techniques p 161Aesthetic Plastic Surgery of the East Asian Face, 2016 Thieme Written by Dr Jin Joo Hong and Hae Won Yang

The most important anatomic difference between a single and double eyelid is the level of the lid crease and skin fold formation, which is the result of the thinning and fusion of the anterior and posterior lamellae. In a double eyelid, the skin fold lies within the lid above the eyelash in a relaxed forward gaze, because the fold-forming lid crease is well defined and sufficiently high. The creation of an artificial connection of skin (anterior lamella) and levator (posterior lamella) at a higher level is the main feature of the double-eyelid procedure.
Traditionally, the procedure can be divided into two major categories: nonincisional suture ligation (buried suture technique) and the external-incision technique. While the nonincisional technique connects the skin and the deeper active levator mechanism with a simple thread loop, the external-incision technique consists of reducing the volume of both lamellae and fixing them together with scar adhesion. The external-incision technique also requires a buried suture to connect the skin and levator mechanism, so a suture loop ligation is common to both techniques. Regardless of the use of an incision, a buried suture loop in the lid is an essential part of double-eyelid creation. In fact, the nonincision suture ligation technique entails forming a fold with suture ligation without dissection. Various surgi¬cal approaches for nonincisional suture ligation have been reported. The nonincision suture ligation technique has been developed for correction of blepharoptosis as well as for the simple formation of the double-eyelid fold. From the conjunctival side, the retractor can be plicated to increase the tension of the levator mechanism.

Non-incisional blepharoptosis correction/ Transconjunctival Müller Tucking
In the unilateral or bilateral mild ptosis case, transconjunc¬tival Müller tucking can be done with the double-eyelid operation. The preoperative design of the dou¬ble fold line should be performed along the natural skin crease. The locations of Müller tucking sutures are marked on the vertical line of the medial and lateral limbi. The sur¬gical procedure is usually performed under local anesthesia using 2% lidocaine mixed with 1/100,000 epinephrine and mild intravenous sedation. Small incisions are made with a needle or no. 11 blade on points that the needle would penetrate. Everting the upper lid, a traction suture is made on the upper margin of the tarsus with nylon 5–0.
For Müller muscle tucking, 7–0 nylon thread is intro¬duced through the skin to the upper margin of the tarsus. The suture is passed through the tarsus to the point of the conjunctiva near the superior fornix and returned through the same point on the conjunctiva to the tarsus, tucking the Müller muscle. The suture exits through the tarsus to the skin and is knotted to tighten the thread. The same proce¬dure should be performed at other sites of Müller muscle tucking, and then the traction suture is removed. Next, the common procedure for the double fold is performed. The knots of the threads should be buried within the skin so that they are not exposed.

[ Incisional Blepharoplasty procedure ]

Duration of procedure
1hour

Anesthesia
Local anesthesia with light sedation

Stitch Removal
4 days After the Surgery

Recovery Period
Normal activities after 2 days, 70% swelling resolution with 7days (almost same as non-incision technique)

What is JJ Incisional blepharoplasty?

This method makes an incision and removes the fat, muscle and reset the levator muscle tension to make a double eyelid line in a single eyelid patient.

Who is JJ Incisional blepharoplasty for?

Clients who have sagging eyes or excess fat on their eyelids
Clients who need bigger or higher eyes (patients in need of stronger levator palpebrae muscles)
Clients who have thick eyelids
Clients who want clear line on their eyelids that will not loosen easily.
Clients who need reoperation from previous unsatisfactory procedure

Concern about long recovery period and remaining scar
Many people worry about long recovery period and scar because this method makes bigger incisions compared to non-incision and partial incision methods. Actually, recovery period is not prolonged by incisional procedure if only done in a meticulous manner, because wound healing and swelling is not depend on the length of the incision but the severity of the surgical trauma and height of the designed line. In my practice, the recovery time for incisional blepharoplasty is almost same with non-incisional procedure. Within 7 days, 70% of the swelling can be faded and can get back to normal daily life. Although the scar on the line is inevitable, it can be well hidden in the natural skin crease and make the skin fold naturally. So, even in the first procedure, we can

Inside and Outside Folds

The lid margin may be closed (“inside fold”) or open (“out¬side fold”) at the medial end according to whether or not the two upper outlines of the eye, the edge of the skin fold and the true lid margin with the eyelashes, are joined together medially. In an eye with an inside fold, the trans¬verse skin fold is conjoined to the epicanthal fold. To open medially, the fold crease should be located separately and higher than the start of the epicanthal fold. Currently, one of the most popular lid margin shapes is midway between the inside and outside folds(In/out fold). However, there cannot be a position midway between open and closed. Therefore, in the “in/out” or “neutral” fold, the medial side is open with a small gap, but the height of the double lid gradu¬ally increases laterally. Thus, it is actually an outside fold, but because of its minimal opening medially and increas¬ing height laterally, it can be seen as an inside fold from a distance (Fig. 6).


In-fold	out-fold	in/out-fold

Three types of double fold. The lid margin may be closed (“inside” fold) or open (“outside” fold) at the medial end according to whether or not the two upper outlines of the eye, the edge of the skin fold and the true lid margin with the eyelashes, join together medially. (c) In the “in/out” or “neutral” fold, the medial side is open with a small gap, but the height of the lid margin is gradually increasing laterally

'Appropriate line height' is more important than in/out shape'

Too vertical and strong Epicanthal fold
Inout-fold impossible, In-fold operation is recommended
However, even in the in-fold shape, the double eyelid fold should begin as early as possible from the innermost side. If the inner line is too low, it looks narrow and smaller palpebral aperture.

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Operating hours

Weekdays

09:30~19:00

Saturdays

09:30~17:30

break time

12:00~13:00
Tel.

(+82)2.544.8807

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