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Cosmetic: Ideas and Innovations

Depth of Upper Lid Crease Construction in Asian Blepharoplasty

Chen, William P. D. MD

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Plastic and Reconstructive Surgery - Global Open: July 2022 - Volume 10 - Issue 7 - p e4427
doi: 10.1097/GOX.0000000000004427
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Question: The depth of a constructed upper lid crease is an important factor in evaluating its aesthetic appeal. What are the factors that influence depth of crease construction?

Findings: A graduated scale of “eight levels of depth” allows a better understanding of the interplay between tissues engaged, sutures selected, and pitfalls to avoid in upper lid crease construction (Asian double-eyelid surgery).

Meaning: One can control the depth of a crease through thoughtful consideration of these factors.


Double eyelid surgery aims to add a lid crease to an upper lid that is without one. Current approaches tend to favor the use of an external incision as it facilitates direct access to the eyelid skin, orbicularis oculi, tarsus, preaponeurotic fat, and the levator aponeurosis; nevertheless, the original suture methods1 first used in the early 20th century are still popular in Asia. The history of both approaches is well covered in these references.1–5 The author published a paper6 in 2020 pertaining to scoring of abnormal crease height and crease depth findings in revisional cases. Of the two parameters of crease height and depth, Chen5,6 discussed the importance of accurate placement of crease height in primary cases, while there has not been any substantial paper alluding to the depth level of a crease in any detail beyond Fernandez’s2 original paper in 1960.


The published methods by which the upper lid crease is constructed include the following, as shown in Figure 1:

  1. Skin-tarsus-skin attachment (of Putterman3; shown as a black dot, exit suture tied on inferior skin surface).
  2. Skin—>levator aponeurosis—>skin attachment (variant of Fernandez2 for superficial crease‚ shown as a green dot; exit sutures tied on skin side).
  3. Levator to orbicularis (variant methods of Park4) as a dark red circle, with one arm of orange hyphenated exit suture taking inferior orbicularis oculi (represented as passage 1) and the other arm of skin on upper wound edge (passage 2); or of levator—>tarsus3 attachment (second variant of Putterman,3 not drawn here).
  4. Buried suture methods1 using nondissolvable full-loop sutures to anchor high above the superior tarsal border, looping around levator-Mueller muscle complex and then slanting infero-anteriorly to the orbicularis oculi in front, with suture knot buried beneath skin surface (blue arrows represent trans-lid suture; buried knot lies subcutaneous along upper tarsal border).
Fig. 1.:
Showing the four main categories of eyelid crease construction. Black dot: skin-tarsus-skin attachment; green dot: skin-levator-skin attachment; red circle: levator-to-orbicularis/tarsus attachment; and blue suture loop: nonincisional buried sutures methods. These correspond to levels 4, 3, 5, and 8.

Fernandez2 discussed his two methods of crease construction, with one yielding a superficial crease and the other a deeper crease. He seemed to have favored his superficial crease technique attaching skin-to-aponeurosis, which yielded a dynamic crease in his hands. (A dynamic crease is one which is apparent with the eyelids open, and which fades on downgaze.) The trapezoidal debulking method of Asian blepharoplasty used by Chen5,6 since 1996 also favored {skin—>levator aponeurosis—>skin} attachment for crease construction.


It is this author’s belief that the depth of crease construction can be further categorized into eight attachment levels, depending on attachment of upper lid skin to various tissue types and sutures used (Table 1). These levels can be investigated through clinical examination as well as review of operative reports obtained during evaluation of patients with revisional issues.6 From Table 1 and Figure 1, the four classical methods can be represented as level 4 (black dot), level 3 (green dot), level 5 (red circle), and level 8 (blue buried suture loop), respectively. Patients may sometimes complain of a crease being too deep and too obvious when the upper lid is in downgaze. A deep crease is more often associated with attaching skin-to-tarsus as Fernandez2 previously observed, represented as level 4 here. When dissolvable sutures are buried as in level 5, it enhances crease formation by causing some tissue reaction and fullness in the pretarsal segment.

Table 1. - The Levels of Attachment Listed Here in Ascending Numerical Order Correlates Roughly to the Increasing Depth of Crease Construction Using the Route Listed
Level 0 Skin-to-skin closure (removable stitches, usually does not produce crease)
Level 1 Skin-orbicularis oculi-skin (removable sutures, usually yields shallow or no crease)
Level 2 Skin-orbital septum 7 -skin
Level 3 Skin-levator aponeurosis-skin (removable external sutures, yields dynamic crease)
Level 4 Skin-tarsus-skin (using removable external sutures)
Level 5 Levator aponeurosis-to-inferior orbicularis fixation sutures (when using dissolvable buried sutures)
Level 6 Subcutaneous skin-levator aponeurosis-skin subcutaneous (when using permanent buried knots; static crease)
Level 7 Subcutaneous skin-tarsus-skin (permanent buried knots; static crease)
Level 8 Nonincisional buried suture methods (crease indentation is generated by compression from permanent buried ligatures around orbicularis and levator muscles; no skin incision was made in this variant)
The levels of attachment listed here in ascending order correlate the increasing depth of crease invagination following construction using the technique listed, verified through analysis of operative summaries. For level 3 attachment of skin-Lev. apon-skin, this dynamic crease corresponds to Fernandez’s original description2 of what he coined a superficial crease. In level 5, buried absorbable sutures were used. In levels 6–8, permanent buried sutures indicate the use of nonabsorbable sutures, examples being nylon or prolene, irregardless of its caliber. All levels from 3 to 8 typically will produce a consistently noticeable eyelid crease.

Level 6 and 7 constructions represent cases where permanently buried, nondissolvable sutures were used in incisional methods, and this can lead to a persistent deep-set crease (Figs. 2 and 3), with some patients complaining of strain, fatigue, or pain in their upper lids and cranial region. (See video [online], which displays Zeiss microscopic-assisted suture removal in a 32-year-old woman who had developed severe eye strain and pain, work disability, with headaches persisting 6 months following upper lid crease procedure via an incisional method. Record showed placement of five buried nonabsorbable 7-0 nylon sutures on each upper eyelid, involving {skin—>tarsus—>skin}. Symptoms were relieved 2 months after removal of all buried sutures.) The application of trans-lid nonabsorbable sutures in buried suture methods encircles the orbicularis oculi and the levator-Mueller muscles within its suture loops, and constitutes the deepest level of attachment, level 8. In the author’s review of medical records, it is associated with a deeper crease, often static, and frequently seen with high crease placement due to the necessity for its needle passages to slant upward to lift the lid fold out of the way. These sutures may erode through the lid tissues resulting in regression of crease formation. Mizuno8 discussed his management of suture-related complications.

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Fig. 2.:
Twenty-three-year-old man 2 years after “partial incision anchoring blepharoplasty” with verified history of using three buried 7-0 nylon sutures per eyelid. Crease height of RUL measured 8 mm centrally, and anatomic tarsal height was 7.5 mm. Deep crease is apparent on downgaze. Chief complaints were of eye strain, headaches, and occasional duplication of crease. (The verified record of the use of buried nondissolvable sutures to levator aponeurosis is consistent with level 6 construction.)
Fig. 3.:
Twenty-nine-year-old woman 3 years after external incisional method LUL with nasally joining shape at 8 mm, with prominent static crease exemplifying deeper crease. (The verified record of the use of nondissolvable buried sutures to tarsus is consistent with level 7 construction.)

Currently, many papers on Asian blepharoplasty tout their ability to produce a natural, dynamic crease. Some9–11 used multiple layers of crease fixation. When the flap linkage paper9 is analyzed,10 it describes the use of buried nonabsorbable sutures anchoring levator to tarsus (level 6 or 7), then an intermediate pass of {skin—> orbicularis—>lev. apon.—>orbicularis —>skin}. Removable sutures would combine level 1 (skin—>orbic.) plus level 3 (skin—>levator apon.), followed by a third pass of {skin—>aponeurotic flap/bridge tissues} removables, which would be level 3 once again. Zubiri11 also used buried nonabsorbable sutures to tarsus (level 7) combined to levator aponeurosis and orbicularis (level 5+). With these examples9,11 of crease construction, one may deduce that such combination will result in crease depth level at least equivalent to the deepest level reached among its component fixation method, and likely more. Indeed, this is often corroborated by the authors’ research on revisional effort scoring,6 where very deep creases with the highest scores (combining crease height, depth, and shape abnormalities) were often seen with operative reports confirming the use of buried nylon sutures fixated to the tarsal plate (level 7 depth of construction) at a crease height higher than the superior tarsal border.


By including classical crease construction methods in double eyelid surgery with more recent variants including the use of buried permanent sutures among different tissues, this proposed description (based on review of operative summaries and correlation with suboptimal findings) attempts to provide a framework that allows for a practitioner to quickly assess a technique’s possible impact on eyelid crease depth, and aids in depth control. It has limitation in that the data for this difficult topic are inherently hard to collect in large number, although this author had published a series of 64 cases collected over a period of 13 years.6 The author hopes that presenting this topic on eyelid crease depth will stimulate further interest, which will lead to improved patient care.


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10. Chen WPD. Commentary on: “tarsal-fixation with aponeurotic flap linkage in blepharoplasty: bridge technique.” Aesth Surg J. 2020;40:NP655NP656.
11. Zubiri JS. Subdermal placement of sutures in double eyelid surgery. Aesthet Surg J. 2013;33:722–732.
Copyright © 2022 The Author. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.