Exact surgical technique will vary surgeon to surgeon depending upon his or her training, experience, and preferences. Likewise, variations in preexisting patient eyelid-facial anatomy will require a customized approach in each individual.
While Dr. Meronk has developed his own personal algorithm for achieving different lid heights and shapes based upon a number of variables considered both preoperatively and intraoperatively, what follows below is a simplified overview of general principles.
Local anesthesia with light sedation is preferred so that the surgeon can verify the shape and position of the eyelid and crease during surgery by asking the patient to open and close his or her eyes.
Because Asian skin is said to be "more reactive," incisions are best make with a scalpel instead of the laser to minimize scarring.
The skin is incised with a scalpel at a height dictated by measurements of certain existing anatomical landmarks. The incision may be tapered into the epicanthal fold towards the nose (if desired) and/or flared slightly upwards at its outer end (if desired).
Most typically, a small strip of skin above this initial incision is excised using scissors. The amount of skin removed varies depending upon the proposed height of the new crease as well as preexisting anatomical conditions. In some cases, no skin is removed.
The incision is carried deeper into the eyelid through the orbicularis muscle and orbital septum until the orbital fat is exposed.
Small strips of orbicularis muscle and orbital septum are excised. The amount and location of orbital fat removed has a significant influence on the height, shape, and depth of the new crease. In most cases, no fat is removed.
The levator aponeurosis (tendon) is identified just beneath the fat. In contrast to an older form of incisional double eyelid surgery known as "anchor blepharoplasty," the levator aponeurosis is not aggressively exposed or detached from its connection to the tarsal plate, a step that is, in our opinion, unnecessary to formation of a natural-appearing crease and invites a higher incidence of serious complications such as ptosis, lid retraction, or peaking of the eyelid margin.
Wound closure employs a "deep-fixation" technique to create an attachment between the aponeurosis and the dermal layer of skin. Following suture removal, internal scars at these points of fixation act much like "spot welds."
The final crease height and shape are the result of both selective tissue removal and precise internal tissue rearrangement. The operation may be used to create tapered, parallel, lateral flare, and, rarely, semilunar shaped creases or to correct incomplete or multiple creases. The incisional approach is considered the "gold standard" in Asian double eyelid surgery.
While some older incisional methods create deep fixation through the use of permanent internal stitches sewn into the tarsus, we have found this approach to be less stable and more likely to cause crease irregularity and scarring. We have developed our own method of deep fixation that leaves behind no suture fragments.
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While a laser may be substituted for the scalpel, its use as a cutting tool in eyelid surgery has diminished greatly in recent years. The collateral heat damage caused by the laser may have negative consequences on the final scar, especially in young Asian skin. For more on the laser and eyelid surgery.