Doctor's Column

Double eyelid surgery and upper blepharoplasty may seem the same, but their essence is different.

Dr. Kim Sung-hoon of SH Plastic Surgery anatomically analyzes the causes of upper blepharoplasty failure and explains the critical differences from incisional double eyelid surgery.

Along with an in-depth explanation of essential pre-surgery concepts such as 'eyebrow compensatory movement,' 'extent of skin excision,' and the 'ZONE division concept,' we will continue with successful cases in the next edition.

Face Designer Kim Sung-hoon

"The surgery went well, but why does it look weirder?"

A few days ago, a female patient in her 40s visited my clinic.

"I was told the surgery went well... but people keep telling me I look scary now..."

Looking closely at her face, the distance between her eyes and eyebrows was too narrow, and the double eyelid line was thickly covered.

She mentioned that she had undergone [upper blepharoplasty] at a previous clinic.

Although the sagging was resolved to some extent, the eye expression had actually become more stuffy, and looking at the overall impression, a heavy look around the eyes stood out noticeably.

What was the problem? The surgery was technically successful, but the outcome was not satisfactory.

Cases like this are more common than you might think.

Today, I will summarize the 'fundamental difference between incisional double eyelid surgery and upper blepharoplasty' and the reasons for failure like this patient's case.

Terminology Explanation

First, let me explain the terminology.

Sang (上, Upper), An (眼, Eye), Geom (瞼, Eyelid)

This literally refers to all surgical procedures performed on the upper eyelid.

Medically, it includes non-incisional and incisional double eyelid surgery, ptosis correction, sub-brow lift, epicanthoplasty, upper canthoplasty, and lateral canthoplasty.

However, among patients, "upper blepharoplasty" usually refers to the incisional double eyelid surgery that middle-aged and older individuals in their 40s and above undergo to improve sagging.

For example:

Incisional upper blepharoplasty that excises skin when it is sagging,

Ptosis correction performed when the eyelid-lifting muscles are functionally weak,

Incisional double eyelid surgery that creates a double eyelid or adjusts its height for cosmetic purposes,

Or eye shape correction (ptosis surgery), sub-brow lift, and even forehead lift can be grouped into the category of upper blepharoplasty depending on the case.

In other words, simply calling "middle-aged incisional double eyelid surgery" upper blepharoplasty is not medically accurate.

Generally, however, surgeries aimed at resolving the discomfort caused by drooping eyelids after middle age—

that is, 'incisional upper eyelid surgery' that includes skin excision along with functional improvement—are often referred to as upper blepharoplasty.

Therefore, when explaining this, I always summarize it like this:

"It is not simply a surgery to create double eyelids."

It is a complex reconstructive and cosmetic surgery that must simultaneously consider the overall complex functions and structures of the upper eyelid,

including sagging, muscle function, fat structure, and skin thickness."

In fact, there is far more tissue to manipulate than in incisional double eyelid surgery.

Because it is a delicate surgery that requires considering the skin, muscle, fat, and even the position of the eyebrows,

it should never be compared on the same level as a simple cosmetic double eyelid surgery.

Difference between the two terms

Then, let's look into the difference between those two terms!

It is this different from a simple incisional double eyelid surgery that merely cuts the skin.

To resolve eyelid sagging, you must consider not only the skin, but also the muscle, fat, and even eyebrow movement.

There are many tissues that must be handled carefully, and each one must be delicately coordinated

to lead to a natural and comfortable result.

That is why this surgery requires that much more meticulous planning and experience.

3 reasons why it fails

Excision without considering skin thickness

Because it is a surgery to resolve eyelid sagging, the amount of skin to be excised is relatively large.

However, the skin of the eyelid is divided into Zone I, Zone II, and Zone III according to thickness,

and this classification is an important criterion that determines the success of the surgery.

• Zone I is the thinnest skin, which is the position where the double eyelid folds naturally.

• Zone II is of medium thickness where the skin gradually thickens, and generally, the double eyelid should be created close to Zone I.

• Zone III is where the skin is thick and lacks elasticity, so creating a double eyelid here will make it look obviously operated on,

which can look very unnatural.

If possible, the double eyelid should be created in Zone I, but if a lot of skin is excised, Zone II gets cut away, making it difficult for the eyelid to fold, ultimately resulting in a structure where Zone I and Zone III meet.

As a result, the difference in skin thickness above and below the double eyelid line becomes extremely large, leading to eyelids that do not fold, or look unnatural and thick.

The uppermost area, right below the eyebrow, is very thick, has a lot of fat, and is firm.

If this area comes down to the double eyelid line,

it will have difficulty folding, and the double eyelid can end up looking unnatural and awkward.

Sometimes, even 6 months or a year after surgery,

this is precisely why it still looks like thick swelling.

Cutting off a lot of skin does not necessarily yield good results.

Rather, the amount of excision should be minimized, but

Only by considering what kind of skin will fall over the double eyelid line

can you create a more natural and long-lasting result.

This is why it requires much more delicate anatomical judgment and technique than a simple incisional double eyelid surgery.

2. Surgery without considering compensatory eyebrow movement

When the eyelids sag, people instinctively raise their eyebrows to secure their field of vision.

This is called compensatory eyebrow movement; if it persists for a long time, the forehead muscles become overactive,

and forehead wrinkles also worsen.

When the sagging of the eyelids is resolved through surgery, there is no longer a need to lift the eyebrows.

Then, the eyebrows that had been raised drop back down to their original position, narrowing the distance between the eyes and eyebrows,

and as a result, side effects occur where the eyes look smaller and the double eyelids appear hooded.

In fact, in many cases, patients say after surgery, "My eyes have become smaller."

This is an optical illusion caused by the dropping of the eyebrows, and the "change in eyebrow position" must be predicted before surgery.

3. Design without considering the limitations regarding eyelid wrinkles

Although it is an excellent method for excising upper eyelid skin and reconstructing the double eyelid, it has limitations in improving wrinkles at the inner or outer corners of the eyes.

In particular, the wrinkles at the inner corners of the eyes are connected to the forehead, so with a simple upper blepharoplasty incision, wrinkles may remain or even become deeper.

In such cases, it should be combined with a forehead lift or a sub-brow lift to expect more natural and balanced results.

Otherwise, the center of the eye is smoothed out, but wrinkles still remain at the inner and outer corners, which can lead to an unnatural result.

Before surgery, the direction and origin of the wrinkles, as well as the condition of the surrounding structures, must be comprehensively evaluated to plan the surgery.

Reflections of Face Designer Kim Sung-hoon

"Rather than performing the surgery skillfully, it is more important to 'design it so that it turns out well.'"

Surgery is a technique, but the outcome is a matter of anatomical design.

In particular, it is not simply about "making a double eyelid,"

but a design process that must consider the organic balance between the eyes, forehead, eyebrows, fat, and skin.

Rather than a surgery that pulls the eyes,

you should understand it as a surgery that "retunes" the structure of the eyes.

FAQ

Q1. Does the post-operative swelling last long?

A. It depends on the case, but because more skin is excised, the swelling tends to last longer than with incisional double eyelid surgery.

Q2. Which looks more natural, incisional double eyelid surgery or upper blepharoplasty?

A. It depends on the purpose and anatomical condition. If there is no sagging of the eyes, incisional double eyelid surgery is better, but if there are functional issues, the latter is more suitable.

Q3. Is a forehead lift also mandatory?

A. If the eyebrows have descended significantly, this alone may not be enough. The decision to combine procedures is made through a thorough consultation.

Q4. Does the incision leave significant scarring?

A. Scars around the eyes heal relatively quickly, and they are often concealed by natural wrinkles or lines.

Q5. Is ptosis correction also possible with this surgery alone?

A. It is partially possible. However, if the function of the eye-opening muscle is weak, a separate ptosis correction may be required.

Q6. How often is revision surgery usually needed?

A. It generally lasts for more than 10 years. However, touch-up surgery may be needed depending on aging or changes in eyebrow position.

In the next installment, we will introduce a successful case where drooping eyes and wrinkles were completely improved by combining this with a forehead lift.

We will look into the before-and-after changes and the reasons behind them through the eyes of facial designer Kim Sung-hoon.

SH Plastic Surgery Clinic

※ This post reveals actual before and after photos of the surgery to provide accurate information.

Please note that these photos were posted with the patient's consent, and bruising and swelling may vary and differ from person to person.