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Eyelids
Primary Double Eyelid Procedure

[ 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

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.

(From, Aesthetic Plastic Surgery of the East Asian Face, 2016, Thieme, p151 12 Double-Eyelid Surgery: Nonincisional Suture Technique)

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