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Section: Options

Preoperative Considerations

To avoid an inappropriate, unexpected, or disappointing result, surgery must take into account individual pre-existing anatomical limitations as well as the expectations (both realistic and unrealistic) of each patient.

Age: Young patients with healthy skin and strong eyelid structure are the best candidates. Results in those over 40 can be more unpredictable due to age-related anatomical changes that may interfere with crease creation.

Amount of Change: Some patients may be seeking only a minimal amount of change, while others may desire a moderate or even aggressive approach.

Men and women often vary in their relative concerns about altering specific eyelid features. For instance, women are more apt to request a more defined and higher crease, which aids in the application of makeup.

Being overly aggressive with the intent of making the eyes appear non-Asian or "Western" is a mistake. Almost always, the new creases will look unnatural, mismatched to the rest of the face, and, "surgical."  It is always wise to stay conservative.



Semilunar Lateral Flare

Shape: The patient should decide whether he or she desires a parallel or tapered crease. Only occasionally is a semilunar crease appropriate on the Asian face (for instance, in a patient with very high brow position or in a patient of mixed Asian and Occidental heritage).

The most natural appearing crease shape on the Asian face is tapered. If the epicanthal fold is especially well-developed, a tapered crease is usually the best choice. If a parallel shape is chosen, there will often be a slight discontinuity between the end of the new crease and the start of the epicanthal fold.

Since the parallel crease does not meet the epicanthal fold, a small area of "disconnect" between crease and fold may, in some patients, look slightly artificial. Still, this is a popular shape in females because it allows for a larger platform of exposed skin on which to apply cosmetics.

A semilunar crease peaks upward and looks unnatural on the Asian face. Its only application is in patients of mixed descent (part Asian, part Occidental) or those few Asian patients who have a large socket, high nasal bridge, and very high eyebrows.

While a lateral flare may be added to any of the above, it is rarely recommended or selected. The vast majority of inborn creases in Asian eyelids are tapered, and so a flare upward can appear unnatural.

Height: Patients requesting double eyelid surgery may be seeking the creation of a crease from scratch or a change in the height of an existing inborn crease. A typical Occidental crease may sit 7-11 mm above the margin of the lid, while most inborn Asian creases tend to sit lower, usually between 2-5 mm.

A patient with a thin eyelid (not much fat) and a high starting eyebrow position can, generally, support a higher crease than a patient with a thick lid and low brow position.

The following values may be useful for classification of crease heights:

Low range Medium range High range
2 to 3 mm 4 to 6 mm 7 to 10 mm

In expressing a height preference, it is important to understand that even in the hands of an expert, surgery and subsequent healing are not such precise processes that a doctor can fully control the result. Thus, selecting a "low," "medium," or "high" range crease should be viewed more as an expression of a preference you would like the doctor to try to achieve.

"Splitting hairs" by requesting, for instance, a "low-medium" or "medium-high" crease assumes a level of surgical precision beyond what can usually be achieved.

Most Natural: The most natural appearing crease on the Asian face is a low tapered, while the most unnatural is the high semilunar, with high parallel a close second. (Note: A high crease cannot be tapered.)

From Most to Least Natural

Low tapered
Medium tapered
Low parallel
Medum parallel
High parallel
High semilunar

View combinations of different
crease heights and shapes

Continuity: If a discontinuous or incomplete crease is present, it may be "completed" without changing the preexisting crease shape and/or height. Multiple poorly-defined creases may be converted into a single dominant crease.

Asymmetry: Significant eyelid, socket, or facial asymmetry will almost always "pass through" the operation and still be present to some noticeable degree after surgery. For instance:

If ptosis (a drooping eyelid caused by a deficiency of the internal eyelid lifting mechanism) is present, double eyelid surgery alone will not lift it to a better position.

If brow positions are unequal, this will impact on the final position of the creases.

If the eyes sit at different positions in the socket (higher vs. lower, or deep-set vs. bulging), such eye-orbital asymmetry will still cause a visible effect after surgery.

Inadequate Fat: Without sufficient orbital fat separating the eyelid's front and back sections, a well-defined crease cannot exist. If double eyelid surgery is performed on such a patient, any resulting crease may be unpredictably high and multiplied. More on hollowness and the Asian upper eyelid

Other Considerations:

Just because one person desires to have his or her eyelids look like those of another (often, a model in a fashion magazine) does not mean that such a result is technically possible. While a photo may serve well as a starting point to communicate desires, no patient should ever realistically hope to look like somebody else.

Rates of healing typically vary with the aggressiveness of surgery. Tapered creases look more natural faster than parallel creases, and low creases look more natural faster than medium height creases. Though rarely chosen, high parallel creases take the longest to heal and yield the least natural result.

Next: Crease Surgery FAQs

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Frank Meronk, Jr., M.D.
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