What the research shows
About half of East and Southeast Asian women are born with little or no upper eyelid crease, and observers of Chinese and other backgrounds both rated a medium-height crease the most attractive (Hwang 2014). The Asian eyelid has its own anatomy, and results are seldom good when a surgeon ignores it (Kiranantawat 2015). The fat in front of the eyelid-lifting muscle reaches lower, sometimes down to the firm plate at the lid margin (Kakizaki 2009).
An incision gives the surgeon the most control: remove excess skin, muscle and fat, adjust the lifting muscle, and join the skin to the deeper layer to form the fold (Jin 2026). Small-incision methods have low pooled rates of complications and of fold loss, about 1 in 50 for fold loss (Yu 2023). Suture-only methods heal with the least swelling and scarring but lose the fold more often (Yang 2022).
With buried stitches, technique decides how long the crease lasts. One continuous stitch held the fold better and caused fewer exposed knots than separate stitches (Baek 2015). In a large clinic study, the fixation method and how puffy the eyelid was predicted crease loss, and surgeon experience did not (Inoguchi 2026). Removing upper eyelid fat at the same time about halved the chance of a repeat operation over four and a half years (Okumura 2026). Across a national dataset, about 1 in 5 two-stitch procedures were redone because the stitches loosened (Okumura 2025).
Age changes the plan. Patients aged 45 and older were more likely to have the stitches redone or removed in the first year, mostly because they disliked the eyelid shape; the authors still offer the method to older patients because it is minor and reversible (Munakata 2026). Drooping of the upper eyelid itself (ptosis) becomes common with age, affecting about 1 in 3 Korean adults over 70 (Kim 2017).
Expect some change around the eye. The brow sits a little lower after double eyelid surgery, more than after a standard upper blepharoplasty (Liu 2023). Dry eye symptoms worsen for the first weeks and usually recover by three months (Yan 2020, Pan 2026). An exposed buried stitch can scratch the eye; removing the stitch repaired the surface injury (Wang 2021).
Where surgeons disagree
- A firm fold or a natural one. Classic incision methods make a stable fold that moves less with the eye; later variations try to keep both, and surgeons still debate the balance (Jin 2026).
- Stitches or incision. Incision gave the lowest recurrence but the most pain and scarring, and patient satisfaction at two years was highest with a stitch-and-tunnel method (Yang 2022).
- The inner corner fold. Many methods exist for opening the inner corner (epicanthoplasty); a review found no single method suits every fold and no randomized comparison to settle it (Fineide 2025).
What is new
- Patients with an overactive forehead muscle had more change in crease height and more crease loss over a year (Liu 2026). In patients who habitually raise the brow to open the eyes, adding a release of the eyelid-lifting muscle corrected the habit far more often than surgery alone (Zhang 2026).
- A stepwise local anesthetic method lowered pain and early bruising and swelling, and patients were more satisfied (Fang 2025).
What is still unknown
- How results in older patients hold beyond the first year (Munakata 2026).
- Which incision technique fits which eyelid; reviewers call for methods matched to each patient's anatomy and for randomized comparisons (Jin 2026, Fineide 2025).
Key papers
- Kakizaki 2009: mapped where the eyelid layers join in Asian eyelids.
- Hwang 2014: showed a medium crease is preferred across cultures, a guide for choosing crease height.
- Baek 2015: a continuous buried stitch kept the fold better than separate stitches.
- Kim 2017: measured how common drooping eyelids become with age in Korea.
- Yu 2023: pooled small-incision results; fold loss and complications low.
- Liu 2023: pooled brow position after eyelid surgery; the brow drops most after double eyelid surgery.
- Okumura 2026: fat removal with buried stitches made the crease last longer.
- Inoguchi 2026: fixation method and eyelid puffiness predicted crease loss; surgeon experience did not.
- Munakata 2026: buried stitches in patients over 45 were redone more often.