A Complete Guide to Double Eyelid Surgery: Shape, Surgical and Nonsurgical Options, and more


Double eyelid surgery is the top #1 cosmetic procedure for many decades among East Asians. Various techniques are available, including buried, partial incision, natural adhesion, and incisional methods. This article provides a comprehensive overview of the available options and helps you choose the proper procedure. We also explain the difference between the various shapes (in-line, outline, and semi-out-line) and provide essential information about the potential side effects of double eyelid surgery.


Q : What is the difference between the non-incisional and the incision method for double eyelid surgery?

A : Non-incisional double eyelid surgery is a procedure that does not require a skin incision and can produce good results for some Asians with fast recovery.
In contrast, the incisional method has a wider range of surgical applications regardless of the condition of the eye. It can also improve skin sagging and provide a more precise shape that cannot be achieved through non-invasive procedures.

Q : What is the difference between double eyelid surgery and ptosis surgery?

A : Double eyelid surgery is a procedure that creates a fold in the upper lid by folding the skin, while ptosis surgery is a procedure that enlarges the eyes.
Although double eyelid surgery can sometimes make the eyes appear larger as a secondary effect, the extent of this result depends on the patient’s eye condition. In some cases, ptosis surgery may be necessary to achieve beautiful eyes. While both procedures often share the same incision site, they serve distinct purposes.

Q : How many types of double eyelid lines are there?

A : The classification of double eyelid lines can vary depending on the era and patient demands, but currently, in the 2020s, there are three main types of double eyelid lines: in-line, out-line, and semi-out-line.

1. The Dynamics of Natural Double Eyelids

The creases in the eyelids are formed by the connection between the skin and the distal fiber of the levator aponeurosis (part of the eye-opening muscles, shown as a green dotted circle in the accompanying diagram).

Schema of mono eyelid and double eyelid

If you observe the eye-opening motion of someone with double folds, you will notice that

  • the levator aponeurosis lifts the tarsal plate, opening the eyes,
  • while the orbital muscle works in a different direction during eye-opening.

This discrepancy in movement creates the double eyelid crease in Asians. The vector difference between the distal end of the levator aponeurosis and the orbital muscle supports the theory that they are antagonists to each other.

2. The Principle of Double Eyelid Surgery

Double eyelids are often absent in East Asians due to their common features of thick orbital fat under the skin. The thick fat hinders the levator aponeurosis from transmitting its pulling force to the skin, resulting in the absence of a double crease. This anatomic feature is typically not found in Caucasians, which is why double eyelid surgery is often referred to as Asian eye surgery. The surgery aims to create the “connection” between the levator aponeurosis and the skin.

3. Terms commonly used in Korean Eyelid Surgery

#1 performed plastic surgery in Korea is upper eyelids procedure with no doubt. Let me introduce some frequently used terms and distinctions regarding double eyelid surgery in Korea. These expressions are not 100% scientific but helps patients and doctors to communicate well.

  • Double eyelid surgery: A procedure to create or change the shape of a double-eyelid crease.
  • Ptosis surgery: A procedure to enlarge the eyes for droopy eyelids.
  • Upper blepharoplasty: Double fold surgery for middle-aged people.

Double eyelid surgery creates a fine line when the eyes are open. It can make the eyes look larger for those with pseudoptosis, but it can also make the eyes look smaller in some cases. For this reason, it is somewhat different from ptosis surgery, which improves the droopy eyelid and makes the eyes more extensive and vivid.
Upper blepharoplasty is similar to double eyelid surgery. Still, the amount of skin excision is different, making it more nuanced for surgical rejuvenation. For this reason, upper blepharoplasty can be considered a form of double eyelid surgery performed on middle-aged individuals. There are three surgical options for the middle-aged, and the pros and cons of each method are discussed here.

4. Types of Double Eyelid Shapes

For women, double eyelid creases can be categorized into three shapes based on fold height and epicanthus relation.

Yuna Kim Jang Won-young Jisoo Irene
二重 種類

1) Semi-Outline Shape(top two row of the figure): The most glamorous! Bleeding cutting-edge style.

This eye shape, characterized by a visible crease over the epicanthal fold, is highly desired by those seeking a more glamorous appearance. Currently, it’s the most popular choice among young people. It can be seen in celebrities such as Jang Won-young at Ive and Yuna Kim. Note that nearly all Caucasians have this lid shape.

2) In-Outline Shape(bottom row): All-time favorite! Harmonious in most Asians.

This crease is the all-time favorite, harmonious shape in most Asians. The crease on the medial side naturally aligns with the epicanthal fold, making it the most popular and natural-looking shape. Many TV celebrities like Blackpink Jisoo and Red Velvet Irene have this shape.

3) In-Line Shape: The most oriental look.

This shape, placed slightly above the eyelashes, is preferred for those who want a more natural look. Actress Bae Suzy has this kind of double eyelid. This shape is also popular among men who wish a natural appearance.

4) Single Lid (Mu-sang) Ptosis Surgery

The above three shapes are the types most women generally choose during the consultation. Mu-sang ptosis surgery is for men who do not want double eyelids but for a subtle, natural change. It is not commonly classified as a type of double fold. Still, it should be mentioned to provide a comprehensive understanding of Asian blepharoplasty options. Please refer to the following for details about men who want more attractive eyes.

5. Surgical Methods: Non-Incisional vs. Incisional

Surgical options are divided into two categories: incisional and non-incisional. The advantages and disadvantages of each procedure are diagramed below.

double eyelid surgical method
Incisional vs Non-incisional

1) Non-incisional double eyelid surgery (Buried or No incision method)

non-incisional double eyelid surgery
Schema of non-incisional technique 안성형외과학 3판 군자출판사

This technique uses tiny holes to connect the lids’ front(skin) and back(conjunctiva) layers. It results in minimal swelling, pain, and bleeding. Patients can return to their daily routine and apply makeup after three days.
The surgical procedure and revision are also simple, making it more popular among patients and doctors. However, not everyone is a candidate for this method, and one who benefits from this method should follow some specific conditions. Please click the link for more information about non-incisional double eyelid surgery candidates. Several modifications have been introduced to overcome some limitations of the buried technique: excise fat and put more stitches through the hole (natural adhesion, partial incision) or excision of the skin right after the non-invasive manner (hybrid method).

double eyelid surgery before and after
Double eyelid surgery before and after : non-incisional technique
Non-incisional double eyelid surgery operation video

1-1) Partial incision

The partial incision technique has slightly larger holes than the conventional buried method and varies based on the surgeon’s approach.

1-2) Natural adhesion

The natural adhesion method involves excising fat through the holes. Thus, it is a concept that improves the puffy upper lid and simultaneously induces adhesion during the healing process. The latter relies on magical thinking and lacks scientific evidence, although the former seems logical. Though this used to be a hot procedure recently among Korean patients, it is nothing new in the technique itself but just a buzzword in the beauty industry.

1-3) Hybrid method

The hybrid technique involves incising and removing the skin layer, followed by the buried technique to create the double eyelid. This method is an alternative for doctors with less experienced, and there is a limited indication for this procedure. It is why this method has never been used among experienced surgeons.

2) Incisional method

incisional double eyelid surgery
Schema of incisional technique 안성형외과학 3판 군자출판사

This technique is used when non-incisional methods are not viable, such as sagging skin, puffy eyelids, or severe ptosis. This method cuts the skin along the intended crease line, removes skin, fat, and muscle as needed, and sutures the back layer to the front layer to create the fold. Incisional double eyelid surgery is more suitable for eyelids with excessive skin. It is a more predictable method for removing orbital fat and achieving the desired shape. The downside is that swelling and bruising are worse than with the buried way, so it’s advisable to take at least one or two weeks for recovery.

double eyelid surgery before after
Incisional double eyelid surgery before & after
Incisional double eyelid surgery operation video

6. Medial and Lateral Epicanthoplasty during Double Fold Surgery

For those seeking more significant changes, performing both medial and lateral epicanthoplasty during double-fold surgery is recommended. Medial epicanthoplasty prevents fold loosening, while lateral epicanthoplasty can widen the eyes horizontally. The procedure is popular among Asian teenagers who prefer larger, wider eyes.

medial epicanthoplasty
medial epicanthoplasty
lateral widening of eye
lateral widening of eye(lateral and inferior epicanthoplasty)

7. Double Eyelid Surgery Height

The typical height for double eyelid surgery in young women is usually between 6 to 9mm. However, it should be determined based on the desired shape, orbital structure, and skin thickness, rather than being treated as a standardized procedure.

8. Pre-Surgery Precautions for Double Eyelid Surgery

The surgery is held under local anesthesia because the doctor needs to check the shape of the eyes during the operation. But to minimize pain during local anesthesia, the doctor usually provides light sedative drugs, making you sleep for about 5 minutes. Suppose you take aspirin or warfarin. In that case, you should stop taking it, and your primary physician will advise you when to start. Medications for hypertension, diabetes, and thyroid can be continued until the day of surgery. For more information, please read the article Seven Things You Should Know Before Plastic Surgery.

9. Post-Surgery Precautions for Double Eyelid Surgery

You can shower the next day, whether for incisional or non-incisional surgery. At this time, avoiding scrubbing the surgical site with your hands is recommended. Just gently splash your face with water is allowed. Light jogging can help reduce swelling, and vitamin K ointment and low-level laser therapy can also help with bruising. Tips for fast recovery after plastic surgery will be discussed here.

10. Revision Surgery

Typically, at least six months should have passed since the first surgery if revision is required. The common causes of secondary double eyelid surgery include:

1) Loosening of the double eyelid fold

Fold loss is the most common cause of revision surgery in double eyelidplasty and will discuss in more detail.

2) Dissatisfaction

Revision surgery may be performed due to dissatisfaction with the subjective or objective appearance, including the fold shape or height, lash eversion, and depth of the folds, among others. Setting realistic goals during the consultation is wise, as some requests may not be achievable.

3) Decreased height

Over time, the height of your double eyelids may decrease, which is a common occurrence as you age. Revision surgery in this case is not complicated. However, it’s still necessary to consult with a doctor about any potential changes that may occur after the surgery.

4) Multiple folds

There are various causes, such as adhesions in unintended locations or new wrinkles due to poor fixation of the double eyelids. To loosen adhesions sufficiently, the lid skin needs to be dissected into two layers. If necessary, fat grafting may be helpful.

11. Side effects of blepharoplasty

The side effects and complications after eyelid surgery will be discussed in this article.

Leave a Reply

Your email address will not be published. Required fields are marked *