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Scarless Double Eyelids by Suture Upper Blepharoplasty (SUB)

What are double eyelids?

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”. (Fig. 1)

Double Eyelid Surgery
(Fig. 1)

What causes the double eyelid?

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. (Fig. 2)

Scarless Double Eyelids Surgery(Fig. 2)

What causes the double eyelid to be absent?

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. (Fig. 3)

Double Eye lid without surgery(Fig. 3)

Why do so many Oriental people lack double eyelids?

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. (Fig. 4)

(Fig. 4)

Why is it desirable to have double eyelids?

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 even better with the double eyelid crease. 

Can double eyelids be created non-surgically?

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.

How are double eyelids surgically created?

Double Eyelid Surgery Procedure

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 levator muscle. This is achieved by using sutures (stitches) that connect those two structures along the line of the intended lid crease. (Fig. 6)

Double Eyelid Surgery procedure(Fig. 6)

How do surgically created double eyelids become permanent?

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 muscle. 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.

How does a surgical result eventually fail?

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.

How do we ensure that enough scar tissue forms so that the surgically crease will be permanent and it doesn’t fail?

More sutures placed in a more complicated manner and tied more tightly are the key factors to producing more scar tissue which strengthens and stabilizes the skin to muscle connection and makes it more 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). (Fig. 7)

(Fig. 7)

(2) by inserting the sutures in the eyelid without any surgical incision. This is the non-incisional or Suture Upper Blepharoplasty (SUB). (Fig. 8)

(Fig. 8)

How do we decide between the two methods?

In Dr Huang’s algorithm, patients who have excess skin and/or puffiness (due to prominent fat pads) will require a 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.

What are the advantages of SUB?

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.

But I’ve heard that suture techniques are more likely to fail

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 higher, because they are more likely to be 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.

How does Dr Huang’s technique compare with other “reliable” techniques?

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 improved and refined the technique to its current state of being an advanced, versatile and reliable technique for creating natural looking creases with a low failure rate of less than 1%.

What do you mean by saying that it is versatile?

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.

Crease height

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. (Fig. 9)

(Fig. 9)

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.

Crease shape

There are two main crease shapes: tapered and parallel. A tapered crease is lower in the inner corner and higher in the outer corner. (Fig. 10)

(Fig. 10)

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 best with a tapered crease, and the degree of tapering is customized for each patient.

A parallel crease is of equal height in the inner and outer corners. (Fig. 11)

Double Eye Lid Surgery, Parallel crease
(Fig. 11)

This crease shape can be suitable for Oriental patients who have deep set, relatively hollow upper eyelids and a lack of an epicanthic fold (see below). This crease shape is in fact typical of Caucasian eyelids, which explains why it is suitable only in a minority of Oriental patients who may have slightly Caucasian eyelid anatomy.

Should my crease begin at the inner corner of the eye or above the inner corner?

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. (Fig. 12)

Epicanthic fold, double eyelid surgery
(Fig. 12)

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. (Fig. 13)

Epicantic Eyelid Surgery Procedure
(Fig. 13)

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. (Fig. 14)

epicanthic fold eyelid surgery procedure
(Fig. 14)

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.

What if I have a prominent epicanthic fold but I want my crease to start above the inner corner?

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

Eye opening (palpebral aperture)

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. 

What about the issue of symmetry?

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.

Will I have any say in how my double eyelids will be created?

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 precision and control over the outcome, which in turn has resulted in extremely high levels of patient satisfaction, which ultimately is what it is all about.

How long is the procedure? What about anesthesia and recovery?

The procedure takes about 30 minutes to complete and is usually done under local anesthesia as a day surgery procedure. The injections sting a little, but once the local anesthesia has been administered, there is no pain during the procedure. For greater patient, it can also be completed under intravenous sedation. Postoperative pain is mild and well controlled with oral painkillers. Downtime is about 10 days, due to swelling and bruising.

Why do different surgeons make different claims about how much swelling and downtime there will be?

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 him that the patient has a comfortable, pain free experience.

The second factor is the number of stitches inserted, way they are inserted and how tightly they are tied. More complex techniques tend to employ more stitches in a more complicated manner and with greater suture tension. This results in more swelling that takes longer to subside, but in return, these techniques reward us with much lower 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.

Who can perform upper blepharoplasty?

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 the SMC’s Guidelines for Aesthetic Practices for Doctors, which can be accessed in the link below:

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 (see link below):

You can perform this search according 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.

International recognition

The quality of Dr Huang’s work in cosmetic eyelid surgery and ptosis repair have received international recognition, and he is a sought after speaker on these subjects. He has been regularly invited to present his work at international plastic surgery meetings in Japan, Korea, and China, as well as in South East Asia.

You can therefore be assured that you will be in the hands of an internationally recognized expert as his patient.

Cosmetic Surgery Clinic