The term double eyelid is a lay term used to describe a crease that runs across the skin of the upper eyelid, and deepens into a skin fold when the eyes are open. The medical term for the double eyelid is “upper eyelid crease”, or “lid crease” for short, or “supratarsal crease”, or “supratarsal fold”.

The crease that is responsible for the double eyelid is due to fibrous connections between the underside of the eyelid skin and the levator muscle that pulls the eyelid upwards when the eye is opened. Thus, when the eye is opened, the upward pull of the levator muscle also pulls the skin inwards along the line of the crease, deepening the crease and creating the fold.

A lack of the aforementioned fibrous tissue connections between the underside of the skin and the levator muscle results in the absence of the crease and fold.

The absence of the double eyelid is extremely common amongst Oriental races (Chinese, Japanese and Korean). This is simply a racial (i.e. genetic) characteristic of these races.

Absent eyelid creases make the eyes look smaller, and less bright and alert. The eyelashes are also less visible because they tend to be angled downwards and inwards. In addition, skin laxity and puffiness tend to be more noticeable when they start to appear from aging. Thus, eyelids without a crease tend to age earlier and faster. Thus, all other things being equal, double eyelids tend to make the eyes look bigger, brighter, and more youthful, with more visible eyelashes angled more upwards and outwards. All of this results in more attractive eyes. Therefore, it is a general truth that no matter how pretty your eyes may look without double eyelid creases, they will look nice with the double eyelid crease.

The key to producing the upper eyelid crease is to create, establish and maintain that missing connection between the underside of the skin and the aponeurosis (tendon) of the levator muscle of the upper eyelid. This is achieved by using sutures (stitches) that connect those two structures along the line of the intended lid crease.

Yes, but they are troublesome and temporary. Temporary double eyelids can be created using tape or glue, but patients have to live with the inconvenience of frequently applying these aids, usually on a daily basis. In addition, long term use is often associated with skin irritation that produces redness, itch and swelling. This explains why most tape and glue users eventually seek a permanent, maintenance free, surgical solution to this problem.

Double eyelid creases can be created in different heights and shapes. The procedure can also alter the degree to which the eye opens. These three factors in turn affect the shape and size of the eyes as a whole. SUB can be adjusted for these three important parameters that in turn determine the aesthetic outcome of the procedure: crease height, crease shape, and eye opening. This makes it versatile and confers the ability to customize the result for each individual patient.

The degree to which the eye opens is known as the palpebral aperture. This can be controlled in the SUB technique by the way the sutures are positioned in the eyelid when they are placed. If the eyes are too small, which they often are, the palpebral aperture can be increased, making the eyes look bigger and brighter.

The answer to this question depends on the anatomy of the inner corner of the eye, which is known as the medial canthus. Many Oriental patients have a fold of skin that runs vertically down the inner corner of the eye called an epicanthic fold.

When present and prominent, the epicanthic fold exerts a downward pull on the skin of the medial canthal area. This has the effect of lowering the crease height in the inner corner and causes the crease to meet the inner corner. This is exactly what happens in individuals who have natural double eyelids and a prominent epicanthic fold. In this situation, it is best to design the crease to begin at the inner corner because this produces the most natural result, simulating what we see in people who have a natural crease and a strong epicanthic fold.

In any case, even if the crease were to be created to begin above the inner corner, it is likely to eventually collapse anyway due to the strong downward tension of the epicanthic fold, and the crease will then end up joining the medial canthus.

On the other hand, if the epicanthic fold is mild or absent, the crease can be designed to begin above the inner corner, at a height that is judged by Dr Huang and the patient to be attractive.

The start of the crease will remain above the inner corner because the weak or absent epicanthic fold will pull the skin down and will not cause the crease to collapse down to the inner corner.

Yes. Based on your eyelid anatomy, Dr Huang will use his judgment and experience to help you to choose the shape and height of the new crease that best suits your eyes. He will show this to you in the mirror before the surgery so that you can approve the design (tapered or parallel) and height (which you will be informed of in mm) of the double eyelid crease or amend it according to your own preferences before he actually creates it for you. Once both you and Dr Huang have come to an agreement, he will measure and mark it out carefully on your eyelids and follow those markings as precisely as possible when executing the procedure.

This protocol ensures that you have major input on how your crease will turn out, and that you will know exactly what you are getting beforehand, with nothing left to the imagination or guesswork. Dr Huang has found from working with hundreds of patients over the years that this interactive way of working with the patient and this degree of patient involvement in decision making allows him to have maximum control over the outcome, which in turn has resulted in high levels of patient satisfaction, which ultimately is what it is all about.

It is important to be aware that the issue of swelling and the downtime caused by swelling is relative, and depends on two main variables. The first is how much local anesthesia is injected. More anesthesia means more swelling, but it also means less pain. In fact, when the local anesthesia is adequate, there will be no pain at all, which is the most desirable scenario for patient comfort. Dr Huang prefers not to compromise on the local anesthesia, as it is important to him that the patient has a comfortable, pain free experience.

The second factor is the number of stitches inserted, the way they are inserted and how tightly they are tied. Complex techniques tend to employ a higher number of stitches in an intricate manner and with high suture tension. This results in more swelling that takes longer to subside, but in return, these techniques reward us with low failure rates.

In general, patients can normally expect bruising to subside fully by two weeks. At two weeks, the swelling is about 50% subsided. However, by 10 days postoperatively, patients can wear eye makeup, and this allows the residual swelling and bruising to be effectively camouflaged. So the downtime is effectively 10 days. By the end of the first month, about 70% of the swelling has gone, and this improves to 90% at 3 months and 100% at 6 months.

According to the Singapore Medical Council (SMC), only plastic surgeons and oculoplastic surgeons (a subspecialty of ophthalmology) are allowed by regulations to perform upper blepharoplasty, including double eyelid surgery. This regulation is found in the SMC’s Guidelines for Aesthetic Practices for Doctors, which can be accessed in the link below:

Click HERE to download PDF
But some general practitioners (GPs) are offering and performing double eyelid surgery…

Yes, that is true. Therefore, patients need to be aware that this practice violates the SMC’s guidelines.

Why are these GPs able to continue to offer and perform this procedure if they are not allowed to?

Because of inadequate enforcement of regulations to ensure compliance of these regulations by doctors.

How do I tell if the doctor offering an upper blepharoplasty is a GP or a plastic or oculoplastic surgeon?

The safest way is for you to verify this yourself by checking if the doctor in question is on the list of recognized specialists on the Ministry of Health’s website click HERE to check.

You can perform this search according to the doctor’ name or search by specialty. Either way, you will be able to determine if the doctor is a GP or specialist.

If your search reveals that the doctor is a plastic surgeon or ophthalmologist, you can be assured that your doctor is a bona fide specialist. Otherwise, he or she is not, no matter what appearances may otherwise suggest.

The long term result of surgically created double eyelids depends not on the sutures inserted to create them in the first place, but on scar tissue that forms around the sutures over time. This is because the sutures will eventually cut through the eyelid tissues and cease to maintain the physical connection between skin and levator aponeurosis. They then simply remain buried within the eyelid tissues. However, by that time, fibrous scar tissue would have formed around the sutures, and it is these fibers of scar tissue that maintain the skin-muscle connection in the long term. Therefore, the permanent result is due to the patient’s own scar tissue, and not the sutures anymore. The more scar tissue is produced, the more likely the crease will be permanent.

Since the permanence of the result depends on adequate scar tissue formation, it follows that if not enough scar tissue is produced, the crease could become weaker (i.e. shallower) with time and may even eventually disappear. This is known as failure.

A higher number of sutures placed in an intricate manner and tied tightly are the key factors to producing more scar tissue which strengthens and stabilizes the skin to muscle connection and increases the likelihood of the crease becoming permanent.

How are these sutures placed in the eyelid?

They can be placed in one of two ways:

(1) by first making an incision along the eyelid, then placing the sutures inside the eyelid. This is known as incisional, or Open Upper Blepharoplasty (OUB).

(2) by inserting the sutures in the eyelid without any surgical incision. This is the non-incisional or Suture Upper Blepharoplasty (SUB).

In Dr Huang’s algorithm, patients who have excess skin and/or puffiness (due to prominent fat pads) will require an open or incisional approach, so that the excess skin and fat can be removed at the same time as inserting the sutures to create the double eyelid. On the other hand, patients who do not have a significant amount of loose skin and/or puffiness are good candidates for the SUB technique.

SUB is minimally invasive, scarless and quicker to perform than OUB. These sutures create a permanent, natural looking new crease without the need for invasive surgery and scars. In addition, the eyes will open bigger and will look brighter and more alert.

There are many techniques for creating scarless double eyelids with stitches. They range from simple to complex and some are more reliable than others. The simpler techniques uses fewer sutures and they are inserted more simply. They have shorter recovery times but they are less reliable, and their failure rates are high, because they are more likely to produce insufficient scar tissue. The more complex techniques use more sutures placed in more complex patterns and are tied more tightly. They cause more swelling and the swelling takes longer to subside but they are more reliable because they create more scarring between the skin and levator muscle. Hence they have lower failure rates.

Dr Huang’s SUB technique falls into the complex category, so the swelling is not the fastest to subside, but it is reliable, with a less than 1% failure rate. Dr Huang believes that in the final analysis, the long term result is what matters the most. Therefore a more complex technique is justified because this is what produces long term reliability, and long term reliability with a maintenance free, permanent crease is what patients want.

The most well known of the reliable techniques is the Double Suture and Twisted (DST) technique developed by Dr Akihiro Minami.

SUB is different from the DST technique, yet shares with the same principles: enough suture material and sufficient complexity and suture tension to produce enough scarring to be reliable. In fact, Dr Huang uses more sutures per eyelid (four sutures versus two in the DST procedure). The four sutures are spread along the whole eyelid, so SUB allows better control of the crease along the entire length of the crease from inner corner to outer corner (as opposed to controlling just the middle portion of eyelid in the DST technique).

Dr Huang has been using the SUB technique since the early 1990s. In treating many hundreds of patients over the years, he has continuously tweaked and refined the technique to its current state of being a sophisticated, versatile and reliable technique for creating natural looking creases with a low failure rate of less than 1%.

Crease height refers to how high or low the crease will be. It is measured in millimeters from the eyelash margin with the eyes closed. A low crease usually measures 6 to 7 mm, a medium crease is 7 to 8 mm, while a high crease is typically 9 to 10 mm from the eyelash margin. Dr Huang performs this measurement carefully using a pair of fine measuring calipers.

The crease height is determined according to the overall size of the eyes and the level of the eyebrows. To obtain natural results, smaller eyes with low set eyebrows should be given low creases, while larger eyes with higher eyebrows will look better with higher creases. In addition, patients who use eye makeup regularly would benefit from a slightly higher crease, because eye makeup (especially dark eye makeup) makes the crease look lower.

There are two main crease shapes: tapered and parallel. A tapered crease is lower in the inner corner and higher in the outer corner. A parallel crease is of equal height in the inner and outer corners.

Since he uses four sutures per eyelid, Dr Huang is able to fine tune the crease shape to different degrees of tapering, from mild tapering to a more pronounced tapering that produces a lateral flare in the outer corner of the eye, according to the needs and desires of the patient. In his experience, the majority of Oriental patients look nice with a tapered crease, and the degree of tapering is customized for each patient.

In this case, a medial epicanthoplasty will need to be performed together with the SUB.

Symmetry is always an important goal in any cosmetic surgery procedure. When it comes to double eyelids, several factors involving the patient’s own anatomy can affect the outcome in terms of symmetry. Most important is the position of the eyeballs within the eye socket. If one eyeball is sitting deeper in the eye socket than the other, the eye looks smaller and more deep set on that side. The eyebrow will also be lower, and that will make the upper eyelid look heavier, with more skin hanging over the crease compared to the other side. The additional overhang of skin will make the crease look lower than the opposite side, all other things being equal. In this situation, Dr Huang will sometimes deliberately create a slightly higher crease on the more sunken side, in order to compensate for the eyeball asymmetry.