Available via license: CC BY-NC-ND 4.0
Content may be subject to copyright.
High Double Eyelid Fold Correction Using
Wide Dual-Plane Dissection
Kenneth K. Kim, MD, FACS,* Woo-Seok Kim, PhD,†Se Kwang Oh, MD, PhD,‡and Hong Seok Kim, MD, PhD‡
Background: The ability to correct unnatural-appearing, high, and deep double
eyelid folds has been limited by the lack of redundant upper eyelid skin and the
presence of prior incision line scars in patients.
Methods: From January 2000 to September 2011, 256 patients with high and
deep double eyelid folds underwent our fold-loweringprocedure. The first dissec-
tion was made at the superficial layer between the orbicularis oculi muscle and
orbital septum/retroorbicularis oculi fat. The second dissection was at a deeper
layer between the preaponeurotic fat and levator aponeurosis. The dissection
proceeded 7 to 8 mm farther cephalad to the prior fold line to separate the upper
flap and the floor from the prior fold line. The lower flap was undermined cau-
dally to obtain normal skin tension, and the lower flap was secured to the
septoaponeurosis junctional thickening or pretarsal tissue. Six months after sur-
gery, the correction of the high fold scar and change in fold height (with eyes
closed) was documented.
Results: Using the authors' technique, unnatural-appearing, high, and deep dou-
ble eyelid folds were converted to lower nondepressed folds. Although prior high
fold incision scars could be seen postoperativelyon close examination, they were
not easily visible. Complications included fold height asymmetry in 10 cases,
persistence of the prior fold in 5 cases, and redundant upper flap skin that needed
further excision in 25 cases.
Conclusions: Using a wide double-layer dissection, high folds were lowered success-
fully even in situations where there was no redundant upper eyelid skin for excision.
Key Words: high double eyelid fold, secondary blepharoplasty,
double eyelid revision, eyelid ptosis, dual-plane dissection
(Ann Plast Surg 2017;78: 365–370)
After double eyelid surgery, the resultant fold can be too low (small)
or too high (large). A fold that is too low can be easily corrected by
making a higher fold, but correcting a higher fold can be difficult, espe-
cially if the upper eyelid does not have excess skin.
1,2
Asian upper eyelid skin gets thicker in a cephalic direction to-
ward the brow. In cases of a high fold, the lower flap and upper flap im-
mediately adjacent to the fold are thick. Therefore, any fold that occurs
in this upper region of skin near the browappears unnatural, because the
fold depth is significant.
These are the characteristics of high folds in Asians: (1) The fold
is deep. (2) The lower flap below the fold is puffy. (3) The presence of
eyelid ptosis. (4) The presence of an outfold. (5) The double eyelid fold
appears unnatural (Fig. 1).
If septal area skin is used to create the double eyelid fold rather
than the pretarsal skin, the attachmentto the levator aponeurosis creates
a deep and high fold that burdens the levator aponeurosis. The extra
weight loaded by the fold creation induces iatrogenic eyelid ptosis. In
addition, because periorbital skin is thicker than pretarsal skin, the sur-
rounding area of the fold may look puffy due to fold penetration and the
discrepancy in depth of the surrounding skin. In patients with promi-
nent epicanthal folds, the high fold creates an outfold at the medial re-
gion that appears as if the double eyelid fold has been forcefully
created. All these factors lead to a harsh or tired appearance of the eyes.
An earlier technique of lowering a high fold involved excising
the old high fold and creating a new lower fold.
3
However, this tech-
nique is only applicable when there is excess skin to be removed. In ad-
dition, the original fold shape cannot be changed because the upper
margin of the skin excision is the prior high fold.
The authors developed a technique where the high fold is released
and a new lower fold iscreated togive a more natural-appearing double
eyelid fold. By releasing the high fold that was exerting excess weight
on the levator aponeurosis, the eyelid is able to lift up more easily. How-
ever, even with this lysis of adhesion of the high fold, in patients with
persistent eyelid ptosis, the levator function has to be improved by
levator-muller advancement technique.
In most cases, outfolds were changed to infolds. If a patient had
epicanthal folds, then epicanthoplasty was performed at the time of cor-
rection surgery to create a more natural curve medially.
PATIENTS AND METHODS
From January 2000 to September 2011, 256 patients (227 women,
29 men) underwent high double eyelid fold-lowering revision surgery.
There were no primary cases. The average age was 39 years. Although
the patient was seated, the fold height was measured by lifting the brow
until the uppereyelashes started to evert. The average foldheight which
was measured from the gray line of the eyelash margin to the double
eyelid fold at the midpupillary line was on average 13.5 mm.
Design and Anesthesia
The desired lower fold height was determined based on the pa-
tient's preferred height and shape. The new fold typically started below
the epicanthal fold medially as an inward fold. The point 7 to 8 mm
cephalad to the patient's prior high fold was marked for anticipated dis-
section. The incision site was injected with 2% lidocaine with 1:100,000
epinephrine up to the area marked for dissection.
Upper Flap Dissection (Dual-Plane Dissection)
On the newly designed lower fold line, an incision was made
through the skin and the orbicularis oculi muscle. The dissection was
Received May 6, 2016, and accepted for publication, after revision August 2, 2016.
From the *Division of Plastic and Reconstructive Surgery, David Geffen School of
Medicine at University of California, Los Angeles, Los Angeles, CA; †Department
of Energy and Electrical Engineering, Korea Polytechnic University, Siheung;
and ‡Ohkims Plastic Surgical Clinic, Ilsan, South Korea.
Presented at the presented at the 2011 Korean Society of Plastic and Reconstructive
Surgery Meeting and the 2012 Korean Society for Aesthetic Plastic Surgery
Meeting, Seoul, South Korea.
K.K.K. Planned physics and mechanical model of the paper and wrote a significant
portion of the article. W.-S.K. worked out physics and mechanical model of the
article. S.K. participated in surgery and collected data. H.S.K. is the originator
of the technique and wrote a significant portion of the article.
Conflicts of interest and sources of funding: none declared.
Reprints: Hong Seok Kim, MD, PhD, Hyosan Building, 5th Floor, 861 Janghang-
dong, Ilsan-dong-gu, Gokyang City, Kyung-gi-do, South Korea. E-mail:
ohkims743@naver.com.
Supplemental digital content is available for this article.Direct URL citations appear in
the printed text and are provided in the HTML and PDF versions of this article on
the journal’s Web site (www.annalsplasticsurgery.com).
Copyright© 2016 The Author(s). Published byWolters KluwerHealth, Inc. This is an
open-access article distributed under the terms of the Creative Commons
Attribution-Non Commercial-No Derivatives License 4.0 (CCB Y-NC-ND),
where it is permissible to download and share the work provided it is properly
cited. The work cannot be changed in any way or used commercially without
permission from the journal.
ISSN: 0148-70 43/17/7804–0365
DOI: 10.1097/SAP.0000000000000905
AESTHETIC SURGERY
Annals of Plastic Surgery •Volume 78, Number 4, April 2017 www.annalsplasticsurgery.com 365
made in a cephalic direction under the orbicularis oculi muscle but
above the orbital septum (Fig. 2). The dissection released the anterior
portion of the prior fold scar and the dissection proceeded 7 to 8 mm
farther cephalad, anterior to the retroorbicularis oculi fat. The second
posterior dissection started at the caudal orbital septum and raised a
plane between the preaponeurotic fat and levator aponeurosis (Fig. 3).
Thus, this dual-plane dissection fully separated the prior upper fold in-
cision from the prior levator aponeurosis attachment site (see Video,
Supplemental Digital Content 1, http://links.lww.com/SAP/A201). Fur-
thermore, the adhesion of the prior fold to the prior levator aponeurosis
site was also buffered by the new nonscarred region of the orbital sep-
tum and fat, thus hindering readhesion (Fig. 4).
Lower Flap Dissection
When a high fold is converted to a low fold, often, the lower fold
flap is under tension. To reduce this tension of the fold, the lower flap
was released from the tarsal plate in a caudal direction until no tension
was seen on the lower flap. Specifically, the plane of dissection was be-
tween the orbicularis muscle and the pretarsal fascia. The maximal cau-
dal dissection proceeded until the follicle of the eyelash was seen. Maximal
caudal dissection was reserved for severely contracted lower flaps.
Levator Manipulation
In some patients, eyelid ptosis was still evident even with the re-
lease of the attachment of the high fold to the levator aponeurosis. In
FIGURE 1. Appearance of a high double eyelid fold. The surgically created high fold starts above the medial epicanthal fold. Pretarsal
fullness can be seen. A deep and puffy fold with eyelid ptosis gives a harsh or tired appearance to the eyes.
FIGURE 2. (Left) Illustration of high double eyelid fold before revision surgery. (Right) Initial dissection at the plane under the orbicularis
oculi muscle but above the orbital septum.
FIGURE 3. Illustration of the second component of the
dual-plane dissection. The dissection starts at the caudal orbital
septum, and a plane between the preaponeurotic fat and levator
aponeurosis is raised.
Kim et al Annals of Plastic Surgery •Volume 78, Number 4, April 2017
366 www.annalsplasticsurgery.com © 2016 Wolters Kluwer Health, Inc. All rights reserved.
cases of residual eyelid ptosis, the levator apeonuerosis was separated
from the Müller muscle. The tarsal plate was sutured to the levator apo-
neurosis and the Müller muscle with 6-0 nylon. To advance the eyelid
by 1 mm, the levator aponeurosis needed to be advanced 3 mm.
Fixation and Skin Suturing
The upper end of the dermis of the lower flap was sutured to the
septoaponeurosis junctional thickening (SAJT) with 7-0 white nylon.
4
In cases where the SAJTwas excised during a prior surgery, the fixation
was made tothe pretarsal tissue. On average, 5 to 7 siteswere connected
from the lower flap to either the SAJT or pretarsal tissue. Skin suturing
was performed with 8-0 nylon in a continuous running fashion.
Taping and Forced Folding Suturing
To prevent the prior dermal incision scar from readhering to the
prior fold site on the levator aponeurosis, a 3M skin tape was applied on
the skin. The tape kept the skin taut and helped avoidthe prior fold from
reoccuring. The tape was used for 2 weeks. In addition, horizontal
mattress sutures were placed at the incision sites using 7-0 nylon. This
increased the downward, depressive force of the new incision site and
helped the new fold to occur over the prior incision fold. The sutures
were in place for 3 to 4 days.
RESULTS
From January 2000 until September 2011, 256 patients underwent
correction of high double eyelid folds. There were 227 women and
29 men. The average age was 39 years.
For at least 6 months, height of the new double eyelid folds, re-
currence of prior eyelid folds, and asymmetry of the eyelid folds were
measured and monitored. Average follow-up was 1.3 years. On average,
the newly created double eyelid fold height was 7.8 mm. This was a
57.7% reduction from the average preoperative fold height of 13.5 mm
(Figs. 5, 6).83.24% of patients were satisfied with the results, and there
was minimal visibility of the prior high fold (Fig. 7). Complications in-
cluded fold asymmetry in 10 cases, persistence or recurrence of prior
folds in 5 cases, and excess upper eyelid skin needing further skin ex-
cision in 25 cases. The recurrence of prior folds occurred within
2 weeks. There were 127 cases of mild to moderate eyelid ptosis that
needed concomitant ptosis correction surgery (Table 1).
DISCUSSION
Double eyelid revision surgery is highly common in Asian pa-
tients. Common reasons for revision surgery are high fold, low fold,
and weakened fold (loosening of the fold). Among these revision
surgeries, high fold correction is the most difficult. High folds can
occur for 2 reasons. One reason is excessively high placement of the
fold during initial surgery. The other reason is underlying or borderline
eyelid ptosis.
FIGURE 4. Separation of the anterior and posterior lamella
scarring is buffered by the fresh edges of the nonscarred
middle lamella.
FIGURE 5. (Above) Before high double eyelid fold reduction surgery with eyes open and closed. (Below) Six months after high fold
reduction surgery.
FIGURE 6. (Above) Before high double eyelid fold reduction
surgery with eyes open and closed. (Below) Two months after
high fold reduction surgery.
Annals of Plastic Surgery •Volume 78, Number 4, April 2017 High Double Eyelid Fold Correction
© 2016 Wolters Kluwer Health, Inc. All rights reserved. www.annalsplasticsurgery.com 367
In cases where the upper eyelid skin has redundant skin, prior
high folds can be excised, and a lower fold can be made. In cases where
there is minimal or no excess upper eyelid skin, the amount a fold could
be lowered was limited when prior techniques were used. The exci-
sion of the high fold creates greater tightening of the upper eyelid skin
and leads to upper eyelid ectropion or lagophthalmos. Relying on the
principle that only scar excision can eliminate prior folds created a lim-
itation to fold reduction in upper eyelids that lack redundant skin. Sim-
ply releasing the upper fold adhesion during creation of a lower fold
leads to recurrence of the upper fold in addition to development of a
new lower fold scar. This creates a triple fold.
5–7
A triple fold occurs
when the original high double eyelid fold and the newly created lower
double eyelid fold form simultaneously.
To solve the problem of having an insufficient amount of skin
in patients with an undesired high fold, we made an incision at the
desired lower fold height. The dissection then proceeded in cephalic
direction to release the adhesions. We performed a dual-plane dis-
section to interrupt the levator aponeurosis connection to the prior
fold at 2 separate layers (between the orbicularis oculi muscle and
orbital fat and between the orbital fat and levator aponeurosis).
Another key point is the need to make a wide dissection to allow
sufficient mobility of the anterior, middle, and posterior lamellae. Thus,
the contact point of the prior scar from the posterior orbicularis mus-
cle separates from the anterior orbital septum. Also, the contact point
of the prior scar from the posterior orbital septum/fat separates from
the anterior levator aponeurosis. Wide, dual-plane dissection and the
unique mobility of the upper eyelid prevent the scars from readhering
at the same contact points (Fig. 4).
Rather than fully releasing the prior adhesions, Kim and Youn
2
corrected high folds by placing a fibromuscular flap or graft in the re-
gion of the prior fold after resecting the entire depth of the prior fold
scar. Other techniques relied on using fat or dermal fat grafts as a buffer
to prevent prior folds from reattaching to the levator aponeurosis.
1,5,8
Fat grafting has a negative effect of unpredictable resorption. In addi-
tion, fat grafting can lead to prolonged swelling, graft necrosis, clumping,
migration, or an unnatural appearance. We did not excise the prior fold
scar or apply grafts. Because we used the preexisting scar, there was
no volume deficit so we did not need additional tissue. In addition, con-
tour irregularity was minimized. Another disadvantage of using prior
techniques that resect scar tissue to lower the fold is that the shape or
design of the double eyelid fold cannot be changed. Because our tech-
nique is not limited by the prior fold scar, we can design a new lower
fold that best matches the patient’s face and overall eye shape. Also
with eyes open and closed, the resultant scarring from the prior high
fold is minimal.
In cases where there is concomitant eyelid ptosis, ptosis correc-
tion brings the levator aponeurosis down to the tarsus.
9–11
Therefore,
there is a greater shift in tissue planes between the middle lamella and
the posterior lamella. This increased movement of the tissue aids in
preventing a prior fold from reoccurring as the scar edges of the upper
and lower layers are further separated. In addition, we placed the tarsal
fixation lower than that in typical tarsal fixation (2 mm below the upper
border of the tarsal plate).
12
By bringing the levator aponeurosis farther
down (caudal) to the level of the new fold height, the double eyelid fix-
ation point was at the same level as the height of the new low fold. If
the levator was fixated 2 mm below the upper border of the tarsus, then
a deep double eyelid fold and eyelash ectropion could occur as the skin
of the lower flap gets pulled cephalad by the cephalically locatedlevator
aponeurosis.
In terms of the causes of high fold occurrence, besides placing
the fold excessively high, the other reason is underlying or borderline
eyelid ptosis. During consultation, some patients bring photographs of
high folds and express their desire for their double eyelid folds to look
like the photos. These pictures often reveal patients with excellent leva-
tor function and thin eyelids. However, some patients desiring double
eyelid surgery present with underlying or borderline eyelid ptosis. Bor-
derline eyelid ptosis refers to cases when eyelid ptosis is not present but
likely to occur when any additional weight is loaded onto the levator
aponeurosis (by connecting the high fold to the levator aponeurosis).
The diagnosis of eyelid ptosis can be missed at the time of consultation
because patients tend to open their eyes fully when looking at the mirror
with the surgeon. In addition, the excitement or nervousness of being
in a doctor's office induces a sympathetic response that activates the
Müller muscle, thus masking borderline eyelid ptosis.
13,14
When a high
FIGURE 7. (Left) Before high double eyelidfold revision surgery with eyes closed. (Right) After high fold reduction surgery with minimal
visibility of the prior high fold incision site. There is no contour deformity.
TABLE 1. Patient Satisfaction With Surgery Outcomes (Of 256 Patients, 197 Responded to the Survey, 83.24% Patient Satisfaction)
Satisfaction Score Very Unsatisfied (1) Unsatisfied (2) Neutral (3) Satisfied (4) Very Satisfied (5)
N (%) 3 (1.52) 5 (2.53) 25 (12.69) 132 (67.00) 32 (16.24)
Ptosis surgery was performed in 127 patients (49.6%).
Kim et al Annals of Plastic Surgery •Volume 78, Number 4, April 2017
368 www.annalsplasticsurgery.com © 2016 Wolters Kluwer Health, Inc. All rights reserved.
FIGURE 8. A spring dynamics model for a high fold and a low double eyelid fold in typical Asian eyelid structures. A mechanical model
based on spring dynamics was used to analyze the movement of the eyelid. The spring constant k in the equations (X1) to (X6)
(below) signifies stiffness of the spring which corresponds to the upper eyelid skin. (Above) Illustration reflects a high fold with eyes
closed andopen. (Below) Illustration reflects a low fold with eyes closed and open. Neglecting the damping constant of the spring, the
force equilibrium equations of each system for the high fold and the low fold can be expressed as (X1) and (X2) respectively,
∑Fx¼F−kx ¼mHgþmH
d2x
dt2
∑Fx¼F−kx ¼mLgþmL
d2x
dt2
where m
H
and m
L
are the mass of the eyelid in a high fold and low fold respectively, g means gravitational acceleration, and F is the
force that lifts the eyelid by the levator muscle.
15
When the velocity becomes zero when the eye opens most widely, the second order
time derivatives of the displacements in (X1) and (X2) become zero.Equation (X3) and (X4)show the relation between the maximum
displacement of the eyelid and force. Therefore, the maximum displacement of the eyelid in cases of a high fold and a low fold can be
derived as shown in (X5) and (X6).
∑Fx¼F−kxH;max ¼mHg
∑Fx¼F−kxL;max ¼mLg
xH;max ¼F−mHg
kðX5Þ
xL;max ¼F−mLg
k
The equations (X5) and (X6) say that the maximum displacement should be inversely proportional to the mass of the eyelid.
Therefore, the maximum displacement in the case ofa highfold (above right)should always be less than that in case of a low fold (above
left) as shown in the illustrations. Consequentially, the spring model can explain why eyelid ptosiscan occur just from the creation ofa
high double eyelid fold without any direct effect from the levator muscle. Conversely, Figure 8 demonstrates clinically how eyelid
elevation increases (resolution of eyelid ptosis) with correction of a high fold to a lower double eyelid fold.
(X1)
(X2)
(X4)
(X6)
(X3)
Annals of Plastic Surgery •Volume 78, Number 4, April 2017 High Double Eyelid Fold Correction
© 2016 Wolters Kluwer Health, Inc. All rights reserved. www.annalsplasticsurgery.com 369
double eyelid fold is created in these patients, the levator muscle has to
lift the extra weight that is attached to the levator aponeurosis (Fig. 8).
We created a spring model to demonstrate the effect of a high
fold vs a low fold on levator muscle weight load. The physics calcula-
tion based on the spring model equation reveals that a high fold induces
a greater weight load on the levator muscle compared to a low fold.
Therefore, high double eyelid folds can induce eyelid ptosis without
any intrinsic effect from the levator muscle. By contrast, eyelid eleva-
tion increases (resolution of eyelid ptosis) with lowered double eyelid
folds (Figs. 5 and 6). Incision in itself and excessive use of cautery can
induce scarring on eyelid soft tissue. In addition, when a firm anchoring
fixation of the skin to the levator aponeurosis is performed to create the
fold, it obstructs the lymphatic flow of the lower flap.
1,16
Increased fi-
brosis and swelling from the lymphatic obstruction adds to the weight
the levator muscle has to lift, compared to the motion of the prior
non-fettered levator. This can induce iatrogenic eyelid ptosis. Therefore,
it is imperative that eyelid ptosis correction be performed at the time of
double eyelid surgery in patients with eyelid ptosis or borderline eyelid
ptosis, who wish to have a high double eyelid fold.
CONCLUSIONS
Excessively high double eyelid folds can create deep folds and
an unnatural appearance. The 3 lamellar structures of the upper eyelid
and the mobile component of the posterior lamella allow for a dual-
plane dissection method to effectively correct a high fold without con-
tour irregularity of the lid. Converting a high fold to a low fold reduces
the weight load on the levator aponeurosis. This in turn can resolve iat-
rogenic ptosis occurring from high double eyelid folds that burden the
eye-elevating mechanism in patients without preexisting ptosis. The
technique is applicable to patients without redundant skin, and a lower
double eyelid fold can be created without being limited by prior high
fold design. Scarring of the prior high fold is minimally noticeable with
eyes open and closed.
REFERENCES
1. Kim YW, Park HJ, Kim S. Secondary correction of unsatisfactory blepharoplasty:
removing multilaminated septal structures and grafting of preaponeurotic fat.
Plast Reconstr Surg. 2000;106:1399–1404.
2. Kim BG, Youn DY. Manag ement of adhesion using a pretarsal fibr omuscular flap
or graft in secondary blepharoplasty. Plast Reconstr Surg.2006;117:782–789.
3. Chen SH, Mardini S, Chen HC, et al. Strategies for a successful corrective Asian
blepharoplasty after previously failed revisions. Plast Reconstr Surg. 2004;114:
1270–1277.
4. Kim HS, Hwang K, Kim CK, et al.Double-eyelid surgery using septoaponeurosis
junctional thickening results in dynamic fold in Asians. Plast Reconstr Surg Glob
Open.2013;1:1–9.
5. Shin KS, Chung S, Cho IC. Treatment of complicated Oriental blepharoplasty.
Korean J Plast Reconstr Surg. 1996;1:75.
6. Khoo BC. Secondary blepharoplasty in Orientals. Probl Plast Reconstr Surg.
1991;1:520.
7. Lee YH, Hwang K. Fascia-fat graft in secondary blepharoplasty. J Korean Soc
Plast Reconstr Surg. 1990;17:201 .
8. Uchida J. Plastic Surgery. 1st ed. Tokyo: Kumwon Press; 1967:1–168.
9. Fasanella RM, Servat J. Levator resection for minimal ptosis: another simplified
operation. Arch Ophthalmol. 196 1;65:493–496.
10. Jones LT, Quickert MH, Wobig JL. The cure of ptosis by aponeurotic repair. Arch
Ophthalmol. 1975;93:629–634.
11. Park DH, Baik BS. Advancement of the Müller muscle-levator aponeurosis
composite flap for correction of blepharoptosis. Plast Reconstr Surg. 2008;122:
140–142.
12. Baik BS, Ha W, Lee J W, et al. Adjunctive techniques to tradition al advancement
procedures for treating severe blepharoptosis. Plast Reconstr Surg. 2014;133:
887–896.
13. Schmidtke K, Büttner-Ennever JA. Nervous control of eyelid function. A review
of clinical, experimental and pathological data. Brain.1992;1:227–247.
14. Baldwin HC, Bhagey J, Khooshabeh R. Open sky Müller muscle-conjunctival
resection in phenylephrine test-negative blepharoptosis patients. Ophthal Plast
Reconstr Surg. 2005;21:2 76–280.
15. Halliday D, Resnick R, Walker J. Fundamentals of Physics.NewYork:John
Wiley and Sons; (2000), Chap. 7.
16. Cook BE Jr, Lucarelli MJ, Lemke BN, et al. Eyelid lymphatics II: a search for
drainagepatterns in the monkey and correlationswith human lymphatics. Ophthal
Plast Reconstr Surg. 2002;18:99–106.
Kim et al Annals of Plastic Surgery •Volume 78, Number 4, April 2017
370 www.annalsplasticsurgery.com © 2016 Wolters Kluwer Health, Inc. All rights reserved.
