Full-incision Double eyelids and Sagging (skin laxity) removal—what changes? The scope of what's possible

Full-incision is a procedure that creates a Double eyelids line while removing excess skin from the upper eyelid. It is suitable for those with strong skin overlap or thick eyelids where the line tends to settle poorly with the non-incision method[1]. However, if the cause of difficulty opening the eye is a decrease in the force that lifts the eyelid (ptosis), cutting the skin alone will result in an unsatisfying outcome[2][3].

What is being done inside the eyelid during full-incision?

It is not merely a surgery that cuts and sutures the skin. Through the incision, we confirm and adjust the amount of the muscle that closes the eyelid (orbicularis oculi) and fat, and fix the double eyelid line by connecting the skin and deep tissues.[1]The method of fixation varies by surgeon, and techniques that secure the dermis, orbicularis oculi, and deeper tissues together have also been reported.[1]The difference from the buried method lies in whether a fold is created with thread, or whether the connection of tissues themselves is reconstructed.

What changes and what does not change with eyelid skin removal

What changes is the amount of skin covering the eyelid and the resulting appearance of the double eyelids. Reducing skin makes the line harder to hide and reduces heaviness above the lashes. On the other hand, the height at which the eyelid opens basically does not change even if skin is cut. If concerns about difficulty opening the eyes or looking sleepy in the evening stem from weakened eyelid-lifting power, skin treatment alone will not achieve the desired outcome.[2][3].

When ptosis is present, is skin removal alone sufficient?

It is often insufficient, and correcting both simultaneously is the standard approach. The American Society of Plastic Surgeons' guidelines recommend performing both upper eyelid blepharoplasty and ptosis correction for patients with overlapping ptosis and skin sagging.[2]Textbooks also clearly state that if ptosis is present, ptosis correction should be performed together with upper eyelid surgery.[3]Whether the examination allows these two conditions to be evaluated separately determines which surgical technique will be chosen.

What troubles can arise?

The most common result is that the line height or shape differs from what was expected. A study analyzing 7 years of complaints about Double eyelids surgery in Asian populations reported that when skin sutures entrap the muscle that lifts the eyelid, or when too much orbicularis oculi muscle or orbital fat is removed, the line becomes pulled upward, resulting in excessively deep Double eyelids.[4]The same study also showed that multiple Double eyelid lines are more common in revision cases, while lines that break midway are more common in initial surgery.[4]A surgical technique has been reported for recreating Double eyelids that became too wide, while preserving the original scar.[5].

When should the result be evaluated?

Assessment is done in two stages: after swelling subsides, and then again after additional time passes. The American Society of Plastic Surgeons guidelines recommend confirming issues such as asymmetry or difficulty closing the eyelids at 1–3 months post-surgery, and ideally evaluating again at 9 months to 1 year as a benchmark for good clinical care.[2]Avoiding final judgment based on appearance immediately after surgery allows for a calmer assessment of whether revision is necessary.

What to confirm during consultation

First, have the doctor examine whether your concern stems from skin Sagging (skin laxity) or from decreased strength in the muscle that lifts the eyelid.[2][3]Second, you should also confirm how the overhang at the medial canthus (epicanthal fold) relates to the shape of the Double eyelids. The Japanese Society of Plastic Surgeons guidelines introduce reports indicating that performing Double eyelids formation and medial canthoplasty simultaneously yields more natural-looking Double eyelids.[6]Additionally, confirm with the doctor's examination the specific approach to determining line height, how scars will appear, and the plan for revision if the result does not match your expectations.