Chinese Journal of Plastic and Reconstructive Surgery Vol.2 No.

1 Mar 2020

CJPRS
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Review

Evolution of the Incision Technique to Construct a Superior

Palpebral Fold
Fei LIU, Jun YANG

Department of Plastic and

SUMMARY Reconstructive Surgery, Shanghai
Ninth People’s Hospital, Shanghai
The construction of superior palpebral fold gained popularity in the far East and at the Jiao Tong University School of
present time is the most frequently performed aesthetic operation in the Orient. Various Medicine, Shanghai, China
incisional techniques have been reported to form upper eyelid crease, which also a
confusion for plastic surgeons who lack clinical experience. It is essential to review the
evolution of these incision techniques and outlined the pros and cons of each method.
This study reviewed the anatomy theory of superior palpebral fold, and reported incision
techniques according to different connecting tissue utilized.

KEY WORDS
Eyelid; Levator muscle; Orbital septum; Tarsal plate

©2020 Chinese Journal of Plastic and Reconstructive Surgery. All rights reserved.

Most of the East Asian populations have no superior
palpebral fold, which in the absence of a superior
palpebral fold. Surgical formation of a palpebral fold
and sulcus divides the lid into two well-defined segments
(palpebral and pretarsal). Upper eyelids with well-defined
eyelid creases have often been considered more attractive
by Asian aesthetic standards[1]. Double eyelid surgery has
gained popularity in the Far East and is currently the most
frequently performed aesthetic operation in the Orient[2].
ANATOMY THEORY
Many theories have been postulated regarding the
formation of double eyelids, and the levator expansion
theory by Sayoc[3] is among the most popular. The levator
expansion theory considers that the posterior levator
aponeurosis penetrates the orbital septum and orbicularis
oculi muscle, gives rise to the dermal extension fibers,
and creates the eyelid crease. Electron microscopy has
revealed the existence of fibers from the aponeurosis that
penetratethe orbital septum and their dermal attachment
This is an open access article under CC-BY (https://creativecommons.org/licenses/by/4.0/).
44 CJPRS
to the double eyelid but not single eyelid[4]. A recent study
has also revealed levator extension in both single and
double eyelids, and found only thinner orbicularis oculi
and thinner skin at the eyelid crease in the double eyelid
group [5]. This theory and other anatomical studies[6-8],
suggest that the main factors involved in double eyelid
formation are the expansion of the levator aponeurosis,
thickness of the subcutaneous fibro adipose tissue, and
the location of the preaponeurotic fat pad. The same
theory was also postulated in another report involving
Caucasian eyes, whereby it was suggested that the
filaments of the levator expansion penetrate the orbital
septum and orbicularis muscle and attach to the overlying
dermis, creating a superior palpebral fold when the eye is
opened. In the Oriental lid, the levator aponeurosis does
not penetrate the orbital septum or orbicularis muscle but
terminates on the superior margin of the tarsus[9].
The location of the orbital septum plays an important role
in single eyelids; the orbital septum may merge with the
levator aponeurosis as low as 2 mm below the superior
tarsal border in Asians without a crease. In Caucasians,
the septum joins the levator aponeurosis at a point 5 to
 Chinese Journal of Plastic and Reconstructive Surgery Vol.2 No.1 Mar 2020
10 mm above the superior tarsal margin [10]. The lower
septal-aponeurosis confluence in Asians allows the
preaponeurotic fat to extend more inferiorly relative to
Caucasians. This intervening fat in the preaponeurotic
area impedes crease formation[4].
TECHNIQUES USED TO CONSTRUCT A
SUPERIOR PALPEBRAL FOLD
There are two principle techniques for the surgical
creation of a superior palpebral fold: the external incision
technique andthe non-incision technique. Each has its own
advantages and disadvantages relative to the other. With
the non-incision method, suture ligation is used to create an
eyelid crease; this method and its multitude of variations
can be considered less technically demanding and time-
consuming, with less postoperative edema and downtime.
However, limitations including narrow surgical indications
and a higher relapse rate are the main drawbacks[11].Since
many Asians with single eyelids have thick soft tissue
(retro-orbicularis ocular fat, preaponeurotic fat, thick
orbicularis muscle) and redundant skin that contribute to
puffiness in the eyelid, under such conditions the suture
technique does not provide an effective and permanent
result due to the heavy imposition of the thick eyelid
layer on the fixating sutures[10,12-15]. In addition, a patient
with excess skin requires excision of redundant soft
tissue[11,16], and the upper eyelids of Eastern Asians have
additional problems, such as excess skin, thick fat pads,
or blepharoptosis, that cannot be resolved by non-incision
methods. As a result, the incision technique is more
frequently performed in upper eyelid crease formation.
Various incisional techniques have been reported to form
upper eyelid creases[17]. The abundance of techniques
is often confusing for young plastic surgeons with little
clinical experience since they are unsure which technique
should be followed, as well as the indication for different
techniques. For this reason, it is essential to review the
evolution of these incision techniques and outline the pros
and cons of each method.
CLASSIFICATION OF
INCISION TECHNIQUES
An appropriate classification will help us to reach the
essence of each method. In 2016, Fei’s report concluded
three key factors in double eyelid surgery: motor power,
connecting tissue, and skin adhesion. In these three
factors, the connection tissue is an appropriate structure
to classify the different methods[18]. The aim of all double
eyelid surgeries is to connect the motor power to the
newly generated skin crease, and the differences among
these techniques are that they use different connecting
tissues. Indeed, the evolution of double eyelid surgery
is actually an evolution of the connecting tissue. In this
study, we analyzed the incision techniques according to
the connecting tissues that they utilize.
TARSAL PLATE
The tarsal plate was the first connecting tissue to be used
to create an upper eyelid creaseby Mikamo in 1896 [19, 20].
This method was described in detail by Sayoc in 1954 [21],
wherein the author described “the incision cuts through
the skin, subcutaneous tissue, orbicularis, and down to the
tarsus. A strip of orbicularis was removed and exposes the
tarsus to which the skin has to be sutured.”A skin-tarsus-
skin fixation was subsequently used to construct an upper
eyelid crease.
Use of the tarsal plate as connecting tissue was the
first method to be used in history of this surgery,
and many plastic surgeons currently perform this
method with individual modifications [22-26]. Although
effective to construct a superior palpebral fold, several
drawbacks have been reported as this fixation method
is often followed by prolonged edema and discomfort.
Furthermore, it gives the eyelids a hard and flat appearance
because the dermis of the pretarsal skin flap adheres
directly to the tarsal plate. The incision line may also look
like a groove on the eyelid skin. A number of reports have
claimed that this technique is simple to perform and creates
durable but static folds. A static fold is characterized by
depressed scars, deep fold depth, stretched eyelid lower
flap, and an immobile fold line with the surrounding
tissues. In addition, the lower flap appears excessively full
due to the deep fold line created by tarsodermal fixation.
The depth discrepancy between the skin and the tarsus
creates the appearance of fullness in tarsal fixation[27].
Techniques that use the tarsal plate as a connecting tissue
have the following characteristics:
(1) The upper eyelid crease is stable post-operation. In
order to expose the tarsus, the orbicularis is regularly
removed using these methods. A scar then forms between
the tarsus and the eyelid skin below the crease line. This
scar is wide, which guarantees the persistence of the
superior palpebral fold.
(2) A depressed scar can be observed in many cases. Because
the tarsus is stiff and excessive thinning of the pretarsal
tissue causes a step below the crease line, the crease formed
by these methods tends to be static and depressed.
(3) Risk of blepharoptosis. The anatomy of the levator
muscle shows that levator aponeurosis proceeds down to
CJPRS 45
 Chinese Journal of Plastic and Reconstructive Surgery Vol.2 No.1 Mar 2020
the tarsus and covers 2/3rd of the width of the tarsal plate.
It can be easily removed with the orbicularis in order to
expose the tarsus more clearly, but this also increases the
risk of blepharoptosis.
(4) Restriction of crease height. Because the skin-tarsus-
skin fixation is applied, the crease height is restricted to
below the width of the tarsus.
Another unique technique using the tarsal plate as a
connecting tissue is the palpebral marginal incision
technique [28]. In order to prevent obvious scarring on the
crease site, the incision is moved to the palpebral margin
and buried sutures are applied to connect the skin crease
with the tarsus. This method is a type of open surgery,
which has broader indications. The direct eyelid incision
provides an adequate workspace, and the palpebral
margin incision is located 1–1.5mm above the lash line,
and thus can be covered by upturned lashes. Furthermore,
the palpebral margin incision keeps the upper eyelid skin
complete and protects the subcutaneous vascular network,
thereby benefitting postoperative recovery, such as by
inducing minimal injury and reducing swelling.
ORBITAL SEPTUM
The orbital septum originates from the arcus marginalis
of the frontal bone and consists of two layers. The
outer (superficial) layer descends just posteriorly to the
orbicularis oculi muscle and reaches the levator aponeurosis
with loose attachment of connective tissue before it
disperses inferiorly. The inner (deep) layer runs closely
abreast, reflects at the levator aponeurosis, and continues
superiorly and posteriorly to the levator sheath [7,29-30].The
orbital septum is confluent with the aponeurosis below the
upper border of the tarsus, and the inferior extension of the
preaponeurotic fat prevents the aponeurosis from inserting
into the subcutaneous tissue or the muscle septum[29, 31-33].
Previous reports have found that a sheet of fibrous tissue
arises from the periorbita and separates it into two distinct
layers in the distal part. The anterior layer extends to the
eyelid margin and covers the tarsus entirely, while the
posterior layer reflects and attaches to the anterior layer of
the levator aponeurosis[34].The orbital septum can transmit
the motor power of the levator muscle to the eyelid crease
as a connecting tissue[14,35].
In 1975, Flowers presented a technique of suturing the
cut edge of the septum to the dermis of the pretarsal flap
to create a crisp invagination. However, he later noted
that the folds formed by this technique had a tendency to
weaken or be lost[36-37].
Jae Seung Lee made a modification according to Flowers’
46 CJPRS
“septal-aponeurotic vehicle”, in which the septum was
not routinely opened, but the redundant portion of the
orbital septum hanging below the fusion line was sutured
to the pretarsal skin-muscle flap. This acts as a substitute
for anterior levator insertion into the muscle septum[38].
Certain pretarsal fibrofatty layers were removed to induce
adhesion between the pretarsal muscle fascia and the
pretarsal levator expansion.
Hong Seok Kim used septoaponeurosis junctional
thickening (SAJT) to create an eyelid fold [39]. In this
technique, the septum inner layer joins the levator
aponeurosis at the conjoined junction above the tarsal
plate. The septum outer layer extends inferiorly to the
tarsus where it connects with the orbicularis oculi muscle
fascia and interdigitates with the distal portion of the
levator aponeurosis to the ciliary margin[29,40-41]. As both
the inner and outer layers of the septum fuse at the distal
levator aponeurosis anterosuperior to the tarsal plate,
thick septal tissue exists in this region; this portion of the
septum is named the SAJT. Partial or complete loss of
the crease line still occurred when adequate tension was
not maintained at the lower flap during the fixation step.
Li made a modification to this technique by turning the
orbital septum downward and fixing to the upper border
of the lower orbicularis oculi muscle and the posterior
pretarsal fascia[42].
The main shortcoming of utilizing the orbital septum as
the connecting tissue is that disappearance of the double-
eyelid crease may occur after surgery. Because the orbital
septum is not a direct extension of the levator muscle,
the motor power will decrease during the transmitting
process, and pretarsal tissue hypertrophy may occur,
including severe eyelid swelling. Moreover, the suture is
often only fixed to the inner layer of the orbital septum
instead of being tightly secured to the levator aponeurosis.
There is often loose connective tissue between the inner
layer of the orbital septum and the levator aponeurosis;
therefore, when the surgeon holds the inner layer of the
orbital septum and the levator aponeurosis together after
opening the anterior portion of the orbital septum, the
underlying levator cannot easily be grasped,which leads
to fold diminution.
LEVATOR APONEUROSIS
The levator palpebrae superioris distally gives rise to two
lamellae below Whitnall’s ligament: the anterior lamella
that becomes the aponeurosis, and the posterior lamella that
becomes Müller’s muscle[43]. The levator aponeurosis is also
composed of two layers: the anterior layer that becomes
contiguous with the posterior layer of the orbital septum, and
the posterior layer that attaches to the tarsus [44-45].
 Chinese Journal of Plastic and Reconstructive Surgery Vol.2 No.1 Mar 2020
In natural double fold eyelids, the levator aponeurosis
inserts onto the intramuscular septum [46] or the
subcutaneous tissue [47] ; in these cases the levator
aponeurosis effectively transmits the pulling power of the
levator palpebrae muscle to create the supratarsal fold
such that it pulls the eyelid skin to form the supratarsal
fold when the eyes are open. Extension of the levator
aponeurosis to the skin surface is the anatomical
base for double-eyelid formation. Using the levator
aponeurosis as a connecting tissue was soon noticed
by many plastic surgeons, and quickly became a
mainstream technique[2, 29,47-50].
To create a less-static double-eyelid fold, dermis to
levator aponeurosis fixation has been advocated by
Fernandez, with the aimof forming a ‘dynamic’ and
superficial crease[51]. However, with some modification,
this fixation technique has some discrepancies with the
anatomy of natural double eyelids. These techniques
put more weight on durability or firmness rather than
on the natural look of the folds because in natural folds
there are soft tissues,some thickness of muscle and
levator insertion, between the supratarsal crease and
the aponeurosis. Moreover, direct dermal fixation to the
levator aponeurosis still creates a deep and excessively
strong-appearing fold due to a depth discrepancy
between the skin and the levator aponeurosis. The soft
tissue of Asian eyelids tends to be thick because of thick
orbicularis muscle and preaponeurotic fat. Therefore, a
direct fixation of the dermis to the levator aponeurosis
creates a deeply pinched and high fold.
In 1999, Park described an orbicularis-levator fixation
method for double eyelidplasty in which the orbital
septum is divided laterally and medially to expose the
entire levator aponeurosis [52]. The pretarsal orbicularis
oculi muscle extends about 3 to 4 mm beyond the skin
incision; this thick muscle is grasped and the suture is
passed through. The supratarsal crease is formed by
a fixation between the orbicularis oculi muscle and
the levator aponeurosis by permanent buried sutures.
According to Park, this technique provided stronger
adhesion than the previously described levator-skin and/
or dermis fixation procedures, and decreased the risk
of suture spitting out due to the superficial placement.
This method of levator aponeurosis (or other extending
tissue)-to-inferior subcutaneous plane fixation has been
widely accepted, and several modifications, such as
Kim’s septoaponeurosis junctional method[39], the “kiss
technique” [53] (the white line sutured to the inferior
orbicularis oculi muscle), and the flexible suspension
technique[54] (the inferior orbicularis oculi muscle sutured
to the septal extension), have been described. William
P.D. advised that this technique should avoid the use
of any buried permanent anchoring sutures that are
nonabsorbable, avoid penetrating the full thickness of the
levator aponeurosis, and avoid encircling the orbicularis
oculi, levator, and Mueller’s with any permanent buried
suture loops. Each of these three layers serves a different
function and requires their own space; bonding them
together creates an undesirable union[55]. To create the
eyelid crease, it does not require a complete encircling
of the levator-Mueller muscle complex [56]. This often
produces a ligature-induced crease indentation yielding a
static, harsh crease. Indeed, it is only necessary to direct
a fraction of the levator aponeurotic fibers to the under-
surface of the skin to yield a natural, dynamic crease.
However, limitations still exist in Park’s method[57,58].
Although a permanent suture material is used for the
fixation between the orbicularis oculi muscle and the levator
aponeurosis, the adhesion is not sufficient andeach time the
eyes open, as the levator moves upward, a strain develops
between the levator and orbicularis. Because the levator
aponeurosis is a thin layer of dense connective tissue,
the recurrent cutting force from the suture material may
gradually weaken the fixation, leading to potential relaxation
of the eyelid. Furthermore, as the levator aponeurosis
undergoes senile attenuation, this type of adhesion is
somewhat unsteady, and recurrence is a common problem.
Even Park mentioned that frequent relapse was a common
complication without a good solution [59].
To resolve the drawbacks mentioned above, in 2016, Fei
made a modification of pretarsal levator aponeurosis[18].
A horizontal incision was made at the bottom third part
of the vertical length of the tarsus, and the dissection
proceeded superiorly to form a pretarsal levator
aponeurosis flap. This flap was elevated over the tarsal
plate and passed between separated orbicularis muscle
layers, and was then fixed with the upper lid skin
subdermally to create the eyelid crease. Fei demonstrated
several benefits of this technique. First, unlike the use
of suturematerial or formed scar, levator aponeurosis is
the natural anatomic mechanism of force transmission,
thereby allowing dynamic upper eyelid motion. Second,
when pretarsal levator aponeurosis is interposed with
subcutaneous skin, it forms an adhesion plane rather
than discrete point adhesion with the skin, which induces
more stable cicatrization and long-lasting palpebral
crease. Third, the motor power of the levator muscle
can be strengthened by resecting a certain amount of the
levator aponeurosis for a wider eye opening, which can
repair mild blepharoptosis in double eyelidplasty. The
levator aponeurosis flap functions as a fibrous connection
to mimic the congenital crease fold. When the eyes are
closed, the thickness of the levator aponeurosis flap
allows the fold to remain superficial. When the eyes
are open, the firm component of the stretched levator
aponeurosis flap creates a well-defined, yet not overly
depressed fold, which in turn, creates a natural-appearing
fold line when the eyes are both closed and open.
CJPRS 47
 Chinese Journal of Plastic and Reconstructive Surgery Vol.2 No.1 Mar 2020
Extension of the levator aponeurosis inserting onto the
skin surface is the anatomical base for double-eyelid
formation. By utilizing the levator aponeurosis as a
connecting tissue to establish a direct force transmission
mechanism, a palpebral crease is created in a more
natural way in terms of anatomy and physiology. With
modifications such as the levator aponeurosis flap, this
surgical technique provides stable formation of double
eyelid creases as a classic skin-pretarsal fascia-skin suture
without the complication of dent formation.
CONCLUSION
The incision technique to construct a superior palpebral
fold is one of the most popular cosmetic surgeries
worldwide. Achieving the desired result when attempting
superior palpebral fold formation requires a thorough
understanding of the unique anatomic features of the
Asian upper eyelid. Moreover, it is worth bearing in mind
that a surgeon cannot perform the same operation on
every Asian upper eyelid, and the ability to individualize
each operation is essential to success in the contemporary
environment.
The surgeon must be familiar with the characteristics
of the congenital or “natural” superior palpebral fold: A
smooth upper eyelid with a shallow fold line when eyes
are closed, an eyelid crease that is not fixated onto the
tarsus and is capable of changing with eye movement,
and appropriate depth of the fold when the eyes are fully
open. In the meantime, patients should be counselled
and educatedas to what can be realistically achieved with
surgery. It is during this consultation that the desires and
goals of the patient should be discussed.
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(Go on to page 39)
Center, Shanghai (16CR2010A), Clinical Research
Program of the Ninth People's Hospital, Shanghai Jiao
Tong University School of Medicine (JYLJ031), and
Fundamental research program funding of Ninth People’s
Hospital affiliated to Shanghai Jiao Tong university
School of Medicine (JYZZ027). The authors have
no financial interest in any of the products or devices
mentioned in this article.
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