The Art of Creating a Double Eyelid
A Blemish-Free Blink
Singapore’s premier cosmetic surgeon, Dr. Woffles Wu, shares the art of creating a double eyelid – without the scars. Dan Childs reports.
It’s the single most popular cosmetic surgery among Asians worldwide. Technically speaking, it’s a tiny adjustment – the addition of a minute crease above each eyelid.
But to those who opt for the procedure, known as double eyelid surgery, this little crease makes a huge difference. The double eyelid is a characteristic that many say gives the eye an attentive, more beautiful appearance, like putting the right frame around a beautiful picture. Though the operation is regularly criticised as a “westernisation” of the Asian eye, it might come as a surprise to some that the Asian fascination with the double eyelid began long before the 19 th-century Western incursions into China and Japan.
In fact, the feature is something that most Asians already have. Depending on which country you check, between 50 and 70 per cent of Asians are born with these creases in their eyelids. The remaining third to half of the Asian populace can only attain this subtle yet important crease through surgery – an option that has granted double eyelids to countless Asians since the popularisation of the technique in the 1960s.
However, along with the desired double eyelid, many patients also wind up with less aesthetically pleasing changes. This is because the traditional method of installing a double eyelid involves cutting the skin, which results in a particularly visible scar. It is this scar that Singapore cosmetic surgeon Dr. Woffles Wu sought to eliminate with his revolutionary stitching technique – and with 15 years of favourable results under his belt, it looks as if he has succeeded.
A glance at conventional double-eyelid technique
The conventional, or open, technique of double eyelid surgery is the method of choice for most doctors worldwide. Though surgeons have refined the technique over the years to give a more natural appearance, the enduring characteristic of this method is its use of an incision to create the double eyelid.
“In traditional double eyelid surgery, surgeons have always had to use a knife or a laser to cut through the skin,” Dr. Wu says. This incision gives access to the tarsal plate – a thin band of cartilage that runs along the bottom edge of each upper eyelid. Stitch the skin of the eyelid to this band, and it will stay put and form a crease when the eyelid opens. To illustrate this concept, Dr. Wu likens the upper eyelid to a curtain.
“Imagine standing in front of this curtain, and every time you lift it, the curtain lifts up smoothly, with no pleats,” says Dr. Wu. “This is much like the eyelid before the procedure. But say instead that you have a Venetian blind instead of a curtain. A Venetian blind is like an accordion – it collapses on itself on regular intervals. In this way, it resembles a double eyelid.”
In terms of creating this extra fold, the conventional method is tried and true; the downside is that the incision inevitably produces a scar. However faint this blemish, Dr. Wu says it presents a big problem to those who desire a natural look
“When you think about the problem with traditional open double eyelid technique, the minute the patient closes his or her eyes you can see a kind of line,” he says. “Considering the fact that we blink about 30 times a minute, a person standing in front of this patient will certainly see the scar.
“So often we see people with eyelids that they’ve had done, and their eyelids are so artificial looking and appear as if they’ve just had surgery – whereas the whole objective of double eyelid surgery is to make people look like they were born with them.”
Thus, to achieve this goal Dr. Wu focused eliminating the scar by precluding the need for the incision. The solution came in the form of a few, very well placed stitches.
A flip of the lid – introducing the scarless technique
Using stitches to create the extra fold in the eyelid is not a new concept. However, most doctors view this suture technique as a temporary fix, as it normally involves the suturing of one area of soft tissue to another. It was only during a trip to Thailand that Dr. Wu first saw an intriguing variation of this technique – one that appeared to offer a more permanent solution.
“The principle was attractive: pass the needle and thread through the skin of the eyelid, creating a loop through the skin, and continuing into the cartilage of the tarsal plate,” he says. “You then pull the loop so it closes tightly, so tightly, in fact, that the loop cuts into the skin and makes a tiny, imperceptible scar. This scar tissue holds it in place.”
No longer a simple soft-tissue-to-soft-tissue union, this new type of stitch affixes the skin of the upper eyelid to the relatively tough cartilage of the tarsal plate. Dr. Wu adopted this technique and modified it, boiling the procedure down to one skilfully executed flip of the eyelid.
“The technically difficult issue is how to get the stitches through without causing damage to the eyeball,” he says. “I devised this special technique that does exactly this.
“The upper eyelid sits directly on top of the eyeball. So if you were simply going to push the needle straight through, chances are that you’ll hit the eyeball. In order to prevent this, I use a special needle. I pass this needle through the skin until the tip of the needle comes to rest on the upper border of the cartilage.”
Then, with an instrument in his left hand, Dr. Wu flips the eyelid open, using the needle as a fulcrum. Like an umbrella that has been folded inside out by a strong gust of wind, the underside of the eyelid pops up and safely away from the eyeball. All that remains is to pass the needle back through the eyelid to complete the loop.
“It’s all one fluid movement,” he says. “I’ve probably done easily a thousand of these operations, and I’ve never hit the eyeball once.”
Thanks to this speedy manoeuvre, the whole procedure takes only 20 minutes to perform – 10 minutes per eye. It has virtually no recovery time, uses only a small dose of local anaesthetic, and utilises just three to four stitches for each eyelid. And, unlike its predecessors, this stitching technique is a permanent fix.
“There are other suture methods available, but these all involve going through the skin and soft tissue only. Consequently, the result is a very weak fold,” Dr. Wu says. “In a way, this technique has given many the misconception that the stitching technique of double eyelid surgery is necessarily temporary and doesn’t last. Even today, there are very few doctors who offer any form of stitching technique.
“What I’m doing is adding a whole new dimension of permanence by making it a full thickness loop suture. And because there is no cutting involved, when the patient closes their eyes, there is absolutely no scar on the eyelid.”
A visible improvement
Aside from solving the problem of scars on the upper eyelid, Dr. Wu says his stitching technique offers other advantages – one of the most important being a more natural appearance.
“Very seldom do you see an upper eyelid procedure done by the traditional method that looks natural. They are often over-glamorised, over-stylised double eyelids,” he says. “I actually call it the Taiwanese Auntie look, because it’s so common to see all these Taiwanese ladies who had the procedure back in the 60s and 70s when better methods were not yet available.
“Patients really don’t want that sort of look anymore. They just want them to look natural.”
One factor that contributes to the natural-looking results of Dr. Wu’s stitching procedure is the fact that the double eyelids formed through this technique will actually drop with age – thus keeping consistent with the natural aging pattern of the rest of the face.
“Consider someone with natural double eyelids – as his or her face ages, their eyelids will drop a little bit lower and lower over time,” Dr. Wu says. “This is natural. Precisely the same thing happens with double eyelids created using this technique. Compare this with somebody who has had the open technique. The rest of the face ages while the upper eyelids remain plump and high. So that becomes quite incongruous.”
The technique is also fully reversible, even years after the surgeon performs it. Dr. Wu says that if the patient decides that he or she does not like the results, he simply makes a small nick with a scalpel beneath the upper lid to release each stitch. After a short while, the crease will fall back out of the eyelid.
“With the traditional open technique, once you’ve made that cut it’s set in stone for the rest of the patient’s life,” he says. Dr. Wu adds that the reversible nature of his stitching technique makes it especially useful for teenagers – an age group in which double eyelid surgery is particularly popular.
“Sometimes when the parents come in and see me, they are very afraid that their teens are going to have something done that they will regret later on in life,” Dr. Wu says. “But the great thing about this technique is that if your child suddenly decides one or two years later that she doesn’t want this after all, she can come back in and we can reverse it. This really puts the parents’ hearts at ease because they know it’s not something that can’t be reversed.
“We have been able to rescue a lot of patients who have changed their minds about this procedure.”
Dr. Wu notes that his stitching method is not appropriate in every situation – particularly when dealing with patients who have a lot of fat in their eyelids that needs to be removed, or if the skin is too excessive. For these patients, the open technique is still the best way to go. But in the majority of double eyelid cases, the stitching technique offers the patients a scarless, fully reversible alternative.
The importance of finding a trained surgeon
The demand for double eyelid surgery across Asia has made it a staple in the practices of plastic and cosmetic surgeons alike. However, the popularity of this operation has emboldened many unlicensed practitioners and untrained beauticians to offer it – often with disastrous results.
“I think the double eyelid procedure, even when using a stitching technique like this, should only be performed by a trained plastic surgeon,” Dr. Wu says. “I don’t think general practitioners should be doing it, and I certainly don’t think beauticians have any business doing it.
“In Singapore and Malaysia, it is illegal for anyone other than a doctor or a licensed, registered nurse to administer anaesthesia. No one else is supposed to be doing this. So it just baffles me how beauticians are able to do a procedure like double eyelid surgery without anaesthetic.”
The solution to the problem, he says, is for the relevant ministries of health to examine these cases and step up monitoring efforts. As for individual consumers, the best protection is thorough research and a consultation with a licensed surgeon who specialises in the procedure.
The bottom line
Dr. Wu says the side effects of his stitching technique are minimal. Swelling is generally minor and subsides in 24 to 48 hours, depending on how many stitches are used. Patients usually return to work two to three days after the procedure.
As Dr. Wu is one of the only surgeons in Singapore who currently perform this technique. This is roughly comparable to what many Singaporean doctors charge for the traditional open technique, while it is about two thirds of what Dr. Wu charges for conventional double-eyelid surgery. “This stitching technique is less expensive because it’s less work for me,” he adds. But in terms of results, Dr. Wu says less is certainly more when it comes to this technique.
“My stitching double eyelid technique is scarless and gives a natural appearance. It’s permanent if you want it to be, it’s safe, the results are predictable, you have a very fast recovery time and it’s completely reversible. How many other procedures in plastic surgery can answer all of these points?