Double Fold/Double Eyelid Surgery

Introduction

Many patients of Asian descent have an anatomically distinct upper lid appearance, commonly referred to as a ‘single fold.’ The appearance of a ‘single fold’ is characterized by the lack of a lid crease above the lid margin. Alternatively, some patients may have a very low-lying lid crease which is not easily visible. Most Asians view a ‘single fold’ lid to be less attractive when compared to the appearance of a ‘double fold’ lid.

The eyelid crease (supratarsal crease) exists due to the presence of anatomic attachments between the upper lid skin and the muscle that is responsible for opening the eyelid. These attachments run horizontally along a line above the lid margin. When the muscle contracts with eyelid opening, these attachments create a crease and accompanying skin fold in the upper lid. Virtually all Caucasians possess these attachments and thus virtually all Caucasians have a lid crease. In contrast, approximately 50% of Asians lack a crease in the upper eyelid, making this procedure a highly sought after surgery in Asia. In fact, the Double Eyelid procedure is the most commonly performed cosmetic surgery procedure in Asia.

Toronto Plastic Surgeon Dr. Lawrence Tong is very experienced in managing this specialized cosmetic matter utilizing the Asian Double Fold procedure, also known as Double Eyelid Surgery, Double Fold Surgery, and/or Asian Blepharoplasty. This specialized form of upper lid Blepharoplasty creates a crease in the upper lid that many people of Asian descent find more in line with their beauty ideals.

Goals and Benefits of Asian Double Fold Surgery

Like traditional Blepharoplasty, Asian Blepharoplasty is often performed to remove excess skin and fat from the upper eyelid. However, Asian Blepharoplasty has an additional and more central goal: to create a crease in the upper lid. This crease is known as a supratarsal crease. The presence of a crease also creates a skin fold that accompanies the crease known as the supratarsal fold. The name ‘double fold surgery’ comes from the fact that patients with no supratarsal crease/fold are described as having a single fold. A new fold is created during the surgery and thus a patient with the crease is described as having a double fold. Almost all Caucasians possess this ‘double fold.

However, it is a common misconception that individuals of Asian descent seek this procedure to appear less ethnic or more Caucasian. The truth is that having a double eyelid crease has long been considered attractive in Asian culture, independent of Western ideals of beauty. In fact, Double Eyelid surgery can be traced back to originating in the late 1800’s—before there was a strong Western presence in Asia. For most of Dr. Tong’s patients, the goal of Double Fold surgery is to achieve a wider and fuller appearance to the eyes while maintaining their almond shape and other Asian characteristics.¹

Dr. Tong’s Asian Blepharoplasty patients in Toronto may see a number of cosmetic benefits to the creation of a double eyelid fold, including:

• Eyes that appear larger and ‘brighter’
• Eyes that appear more expressive
• The overall facial appearance is more ‘alert’
• There is enhanced eyelid symmetry

Candidates for Asian Eyelid Surgery

Dr. Tong performs both traditional Blepharoplasty and Asian Blepharoplasty at his plastic surgery centre in Toronto.

For patients who are of Asian descent but already have a natural double fold, rejuvenation of the eye area can be achieved through traditional Blepharoplasty with modifications geared toward the Asian patient population.

For patients seeking double fold creation, they generally fall into one of two categories:

• Younger patients who seek ONLY double fold creation with minimal or no skin removal
• Older patients who seek double fold creation AND lid rejuvenation (removal of excess skin and/or fat to improve the youthfulness)

If you are in good overall health, a non-smoker, and have realistic expectations regarding your plastic surgery outcome, you may be a good candidate for traditional or Asian Blepharoplasty in Toronto with Dr. Tong.

Planning Asian Blepharoplasty

Crease Height

It is critically important to have clear communication between surgeon and patient when planning Asian Blepharoplasty. A natural looking crease height for an Asian upper lid is typically much lower when compared to a Caucasian upper lid . Since the height can be created at any level, it is important for the surgeon to know the exact level desired by the patient.² By carefully manipulating your upper lid skin with an implement, Dr. Tong can help simulate various crease levels for you to see during your consultation.

Skin and Fat Removal

Frequently, a patient may want or need excess skin or fat in the eyelid to be addressed. Older patients typically will have excess skin that would benefit from removal, as is done in non-Asian blepharoplasty. Similarly, excess fat can be removed to either enhance the appearance or to facilitate in creating the crease. Excessive fat removal is generally not recommended as it may lead to premature aging or multiple fold creation. During the consultation, Dr. Tong will discuss whether or not skin and fat removal is appropriate for you.

Tapered or Parallel Crease shape

Another consideration includes whether the crease should possess a tapered appearance or parallel appearance as it terminates medially (towards the inner corner). Whether the crease terminates in a tapered or parallel fashion is up to the patient to decide as it is mostly a cosmetic consideration. It is usually straightforward to achieve either one with surgery. However, a parallel crease may be more difficult to achieve with double fold surgery alone. This occurs when the anatomy and extent of the epicanthal fold is more pronounced. In these cases, patients may choose to simultaneously have an additional related procedure called an epicanthoplasty to help ensure a parallel crease shape. The epicanthoplasty also makes the inner lid region horizontally wider, the corner sharper, and the eye generally more attractive. Dr. Tong can determine whether epicanthoplasty would be recommended during your consultation based upon your anatomy and aesthetic wishes.

Asymmetry and Ptosis

Any asymmetries existing preoperatively will also need to be addressed by carefully adjusting what is done individually between sides. Additionally, a discussion about lid ptosis (drooping of the lid) correction may occur when asymmetry due to ptosis exists preoperatively.

The goal of the consultation is to achieve a mutual understanding as to your ideal crease height, and overall lid appearance.

The Asian Blepharoplasty Procedure

The Double Fold procedure is performed under IV sedation, in Dr. Tong’s CPSO-accredited surgical centre. Prior to the patient’s sedation, Dr. Tong and the patient will review the goal of the procedure as well as the patient’s expectations. Based on discussions during the consultation, Dr. Tong will mark the patient’s crease height on the skin of the eyelids at this time. Markings for skin removal and epicanthoplasty are also made as applicable.

Incision Method for Double Eyelid Surgery

Dr. Tong prefers to use the ‘incision’ technique for Double Fold surgery because it allows for the most accurate control of crease shape and height while creating a crease that remains permanent.³

To create the double fold, he makes a short incision in the upper eyelid. He then dissects down to the muscle layer that opens the lid (the levator aponeurosis). Some fat in the area may need to be removed if the upper lid is thick or ‘heavy’ due to fatty tissue. Dr. Tong then uses a series of fine stitches (4-5 in total) to attach the skin to the muscle layer, at the level of the desired fold. The attachments that occur naturally in a patient with a double eyelid have now been created with the stitching.

In a patient who also needs lid rejuvenation due to excess skin, Dr. Tong removes a strip of skin at the beginning of the procedure. Some fat may also be removed. The degree of fat removal may vary, depending on the amount of fat present In general, preservation of fat is desirable as too much removal can cause aesthetic complications.

Once the procedure has been completed on both eyes, the patient will be slightly awakened from sedation. Dr. Tong will then ask the patient to open their eyes so that he can evaluate for symmetry. If additional modifications are required, further adjustments are made until optimal results have been obtained. Following any adjustments, the incisions are closed using a very fine stitch that runs buried under the incision. The incisions in the eyelids typically heal to a point where they are almost imperceptible. This is due to the thinness of the skin. In addition, the incision will be well hidden by the new fold after all healing is complete.

If epicanthoplasty is to be performed at the same procedure, Dr. Tong starts the surgery by performing this procedure first. Several tiny incisions are made at the corner of the eye which allows the epicanthal skin to be shifted and transposed. The shifting allows the tight skin of the epicanthal fold to relax, eliminating or significantly reducing the appearance of the epicanthal fold. The incisions are designed to blend in with the double fold surgery incisions. When the epicanthoplasty is performed, the look of the crease can be made parallel or tapered, depending on the patient’s preference.

Suture method for Double Eyelid surgery

An alternative technique is the ‘suture method’, which can be done without making an incision on the lid. The main drawback of the suture method is lack of permanence. The suture method generally achieves a result that lasts for several years before gradually fading away.

Dr. Tong employs the Double suture and Twist Method (DST) when performing ‘suture method’ double fold surgery. It is usually performed under sedation similar to the incision method. Instead of a continuous incision along the upper lid, three small stab incisions are made at the medial, central and lateral lid, along the desired fold line.

Dr. Tong places stitches into the upper lid through these three incisions and interlocks them to create the crease. A corneal shield is placed at the beginning of the surgery to protect the eye from injury. This is done because the surgery utilizes stitches that traverse through the entire thickness of the lid.

After the (internal) stitches are placed, the height and symmetry is checked by having the patient open their eyes. Once the result has been verified, each stab incision is closed with a single external stitch. The incisions in the lids typically heal to a point where they are almost imperceptible. This is due to the thinness of the skin. In addition, the incision will be well hidden by the new fold after all healing is complete.

This method of double fold creation has some limitations. Since there are only 3 stab incisions made, there is no ability to remove excess skin or fat. Therefore it is not appropriate in patients with the need to address excess skin or fat. Additionally, the control of the shape of the crease is more limited, especially in patients who seek a parallel crease. Finally, as mentioned previously, the result is not permanent. Most patients who undergo surgery with this method should expect fold loss or partial fold loss in the future. The expected duration of results can vary but the average is 3-6 years.

How to Choose the Best Plastic Surgeon For You

Recovery after Double Fold Blepharoplasty

Double Fold Blepharoplasty Recovery Immediately after Surgery

In the anesthesia recovery area, patients awaken from sedation while monitored by our nursing staff. Double Fold Blepharoplasty is an outpatient procedure. Patients go home shortly after the effects of the anesthetic have worn off, accompanied by friends/family.

Double Fold Blepharoplasty Recovery at Home

At home, patients should try to rest and relax as much as possible. You may perform non-strenuous activities, but should avoid straining your eyes by watching television, or reading. To help decrease swelling and bruising around the eyes, sleep in a reclining chair, or use multiple pillows to keep the head elevated. Pain is typically mild, but the eyes may be sensitive to bright light over the first few days. Dr. Tong will prescribe medication that can be used during this time. There is usually some mild bruising that lasts 5-7 days.

Follow-Up Visits after Double Fold Blepharoplasty

The first appointment with Dr. Tong occurs one week after surgery to have stitches removed. The majority of patients return to work (non-strenuous) at 7-10 days, or sooner if the appearance of bruising is not an issue for you . Dr. Tong will likely allow you to start light exercise (e.g. walking) at 1 week after surgery. Avoid strenuous activity until 4-6 weeks after surgery.

Things to Expect as you Heal from Double Fold Surgery

Initially after Asian Blepharoplasty the eyelid creases will look slightly higher than expected . This occurs as a result of swelling, and the height will settle to its natural position after a few weeks. Asymmetry may also be seen initially for the same reasons. After the initial post-op visit, you will follow up with Dr. Tong at 6 weeks, 6 months, and one year after surgery. Post-op photos will also be taken at these visits.

Like any procedure, the Asian Double fold procedure has risks and complications associated with it. The risks are low, but do exist. At your consultation, Dr. Tong will go over the pertinent potential risks and complications associated with Double Fold surgery.

Frequently Asked Questions About Double Fold Blepharoplasty

Will I still look like myself after Asian double eyelid surgery?

As a highly skilled plastic surgeon, Dr. Tong believes that people should still look like themselves after cosmetic surgery. Obviously, patients have this surgery because they want to change their appearance to some degree. Dr. Tong understands that not all patients want the same thing. Some patients want a more subtle result, while others may choose a look that is more evident. The consultation process is meant to determine what is best for you, based on your personal preferences and your individual anatomy. Dr Tong performs double fold surgery to meticulously address each patient’s concerns while preserving the unique features of their appearance as desired.

Will I have visible scars after Asian eyelid surgery?

No. The scars are placed where the fold occurs. This means that when the eyes are open, the skin that sits over the fold will hide the scar. Initially, the scars may have a light pink colour, which would be visible when the eyes are closed. Eventually though, the scar will typically heal to an appearance where they are difficult to see, even with the eyes closed. Scars in the eyelids typically heal very well due to the thinness of the skin. Dr. Tong is careful to place incisions in such a manner that no scarring will be visible once you fully heal from the procedure.

Can I wear contact lenses after double fold blepharoplasty?

Absolutely. You will be able to resume wearing your contacts after asian eyelid surgery but not immediately. Placing contact lenses usually involves stretching the upper lid open leading to pulling on the incision which could affect the result. Therefore we typically advise patients to wait 3 weeks after surgery to use contacts.

Is Asian eyelid surgery permanent?

If a patient undergoes the non-incisional double fold surgery technique, the fold itself may disappear over time. The time for this to occur is generally several years, but varies from patient to patient, and with the specific non-incisional technique utilized. It is best to consider the non-incisional double fold technique (also known as the suture technique) to be a non-permanent procedure.

If the incisional technique is used, the crease will be permanent. This does not mean that the result will stay the same forever because as your face ages, the result will change with time. The duration the Asian blepharoplasty results depends on the patient’s age at the time of the procedure. Older patients will likely see the results of their double eyelid surgery for life. Younger patients, however, may wish to come in for a touch-up after a few decades. This is because the skin of the eyelid naturally loses elasticity and begins to “hood” over time. The fold itself is still present but the skin above the fold stretches to hide the appearance of the crease space. This natural aging process may eventually create a heavier, more “hooded” appearance to the eyelids. The process is no different than what happens in non-Asian and Asians that naturally have a double fold. If this occurs, it can be remedied with a traditional blepharoplasty procedure where the skin is removed. However, the fold itself does not need to be re-created.

Learn More About Double Fold Surgery in Toronto

When considering facial plastic surgery, we believe that only a fully-educated patient can make a confident decision about his or her surgery and surgeon.
During your Double Fold surgery consultation, Dr. Tong will give you his undivided attention to ensure that you feel comfortable discussing your goals and asking questions about your procedure and its proposed outcome. You will also have the opportunity to view photographs of many examples of results Dr. Tong has achieved with Asian Blepharoplasty. There is a great deal of information to digest, and Dr. Tong will make sure that you are informed every step of the way.

To learn more about how Dr. Tong can help you with Asian Blepharoplasty in Toronto, schedule a Double Fold Blepharoplasty consultation with Dr. Tong by giving us a call at (416) 972-0999. You can also let us give you a call; just fill out our contact form and we will be in touch on the same or the next business day. No doctor’s referral is needed.

See Dr. Tong’s work in our Asian Blepharoplasty before and after photos.