Doctor, why does (do) my double eyelid(s) disappear?

Most patients are happy with the results of double eyelid surgery which make their eyes bigger and more animated. Unfortunately, in a significant proportion of patients these double eyelid may disappear with time causing them to seek help for restoring the double eyelid. 

Some patients whose surgically created double eyelids

disappear, loosen or fade.

Diagrams showing two main ways of creating double eyelids.

The main reason for the disappearance of the double eyelid is the loss of the attachment between the levator muscle (or tarsal plate in the suture technique) and the skin. The factors for this loss may be divided into surgeon factor and patient factor. In the case of the surgeon factor, the main one include:

a. Failure to choose the appropriate method for double eyelid creation. Essentially, double eyelid can be created by the suture technique or the incision technique. Suture technique is suitable for eyes with thin skin without puffiness (resulting from fat) and if this technique were used in eyes with puffy eyelids, the failure is high.

b. Failure to clear the appropriate amount of tissue between the skin and the levator muscle. In the incision technique, the tissues (orbicularis muscle and fatty tissue) between the skin and the levator muscle should be adequately cleared to allow proper adhesion between the structures. Failure to do this will result in loosening of the adhesion.

Diagrams showing loosening of the adhesion between the skin

and the muscle after the suture technique.



Diagrams showing detachment of the skin from the

 underlying muscle after incision technique.

In the case of the patient's factors, the main ones are:

a. Excessive postoperative swelling. The patient must follow the doctors' instruction to control the swelling by using medications and ice pack. In Failure to do can result in excessive and prolonged swelling that affect the adhesion between the skin and the levator muscle. This applies to both the suture and incision techniques.

b. Failure to take care of the lids. Excessive rubbing of the eyelids can also loosen the adhesion and this should be avoided.

In the next blog, I shall mention how I restore the double eyelids in these patients.

Kissing Naevus of the Eyelids

A kissing naevus is a type of congenital compound naevus that affects equal portions of the upper and lower eyelid. Because of its extension to the lid margins, the edges of the tumour touch or ‘‘kiss’’ during closure of the lidsAlthough not cancerous, it can cause considerable cosmetic disfigurement to the patient. This woman has had this kissing naevus for life and was very conscious of it. Whenever she went out she cover her left eye with her hair. To remove the blemish, the skin bearing the naevus was excised and reconstructed using a combination of graft and flap as shown below.

Pre-operative appearace of the left kissing naevus.

Pre-operative appearace of the left kissing naevus.

 

The initial plane of closure was marked and the skin

infiltrated with lignocaine and adrenaline.

The kissing naevus was removed leaving a raw area that

 needs to be closed. The lower eyelid defect was closed by

sliding flaps after excising a triangular area of skin.

The triangular skin (arrowed) was kept to be used as skin graft.

The lower eyelid was closed by sliding the skin on

either side of the defect. The triangular skin was

fashioned to closed the remaining raw area.

The appearance of the eye at the completion of

reconstruction.

The appearance of the eye at one-day

post-operative.

Doctor, Do You Create Double Eyelids with Staple? (雙眼皮釘書機)

Recently, a few patients seeking double eyelid surgery asked me if I have staples for creating double eyelids. Apparently, they have come across newsreel on Taiwanese TV which mentioned staple is the latest technique in double eyelids surgery (雙眼皮釘書機)! However, staple is a misnomer for this device as it is only used to create full thickness holes. The instrument is used in suture technique to ensure that the stitches are passed through the same level inside and outside. The device is useful mainly for new surgeons learning double eyelid but rarely used by experienced surgeons.

"Staples" for double eyelid surgery.

The picture above is a diagramatic representations

of the steps that follow.

The skin was marked for the desired height of double eyelid.

The sites where the staple is used to create the holes are

arrowed.

The staple is used to create full thickness eyelid holes.

Two small holes are created on the skin.

Two corresponding holes are found on the inside of the eyelid.

Suture is passed through the inside of the eyelid.

Suture passed through the skin.

Suture is passed through the skin.

The suture is passed under the skin.

The suture is tied.

Double eyelid is formed.

Asians Having Double Eyelids Wants to Appear Like Westerner ?

I am constantly amazed by some fanatic Asian Americans who think that having double eyelid surgery is a betray to the racial origins of the patients and some even label such surgery as a form of "ethnic cleansing". They often post news articles wih derogatory titles like Plastic surgery boom as Asians seek 'western' look (by Kyung Lah, CNN).   This kind of dogmatic thinking is as wrong as assuming Westerners going for sun tan in order to look like Africans!

For the purpose of illustrations, lets look at these three groups of women (see below). The first group is Chinese women with single eyelids, the second Chinese women with double eyelids and the third Western women with double eyelids. Correct me if I were wrong, I don't think those Chinese women with double eyelids look anything like the Western women who have deeper eye sockets and more prominent noses.

Chinese with single eyelids.

Chinese with double eyelids.

Western women with double eyelids.

Otherwise, Hollywood movies would have their Western stars replaced by thousands of Chinese who have had double eyelid surgery.

Do you create double eyelids in males and females differently?

Double eyelid surgery (Asian blepharoplasty) is not only popular with Chinese females to make their eyes bigger and easier to apply eye make-up, it is increasingly popular with Chinese males. About 1/4 of my double eyelid patients are males. However, there is a difference in creating double eyelid in female and male and this difference must be appreciated to avoid dissatisfaction. As a thumb of rule, Chinese females with natural double eyelids have their creases higher than those Chinese males with natural double eyelids (the same is true for Caucasians and Africans). This anatomical difference should be borne in mind when creating double eyelids in Chinese males otherwise the patients may appear non-Chinese and feminine.

Chinese females with natural double eyelids that are regarded as attractive

have good show of skin between the skin crease (double eyelid) and

the eyelashes.

On the other hand, Chinese males with natural double eyelids that are

regarded as attractive have little show of skin between the skin crease

(double eyelid) and the eyelashes.

For the Chinese females, I usually perform incisional technique or suture technique (if the eyelid is not puffy with fat) at a height of 6mm. A bit of fat is trimmed off  in the incisional technique to make the eyes appear slightly deeper but not excessively. In the Chinese males, the height should be set lower and I usually choose 5mm with little excision of skin or fat so that less skin is shown between the double eyelid and the eyelashes.

Chinese females with 6mm double eyelids, skin and fat excision.

Tapering double eyelids.

Chinese females with 6mm double eyelids, some fat and skin

excision. Parallel creases.

Chinese males with 5mm doubel eyelids. Minimal skin excision.

Tapering double eyelids.

Chinese males with 5 mm double eyelids. Minimal skin excision.

Parallel double eyelids.

Chinese males with 5mm double eyelids. Some skin excision.

Tapering double eyelids.