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Fold Depth Alteration

Another aspect of the eyelid crease is the depth of the fold. Patients may seek revision surgery because their eyelid crease is too deep or too shallow. This detail of the eyelid fold may be subtle but important nonetheless, as a fold that is too deep can make a person appear harsh while a fold that is too shallow can give someone the appearance of lacking sharpness and clarity.

The surgeon must have an expertise in eyelid surgeries to calibrate the depth of the crease by understanding the individual’s thickness of skin, fat, and muscle, and muscle strength, as these components may vary from person to person.


A sharp, crisp crease is more appealing as well as desirable. A fold that is too shallow can occur when the surgeon fails to calibrate the fold properly, or due to loosening over time due to age. In addition, there is a higher chance of loosening if the patient has previously undergone the suture technique (see Suture Technique). In order to correct a crease that is too shallow, the fold must be reinforced with either the incisional technique, the suture technique, or 3D suture technique.


A fold that is too strong can cause the crease to look static and unnatural. A static fold is when the fold does not change with eye movement (i.e., the fold should soften with eye closure and sharpen with eye opening). A deep fold typically results when the skin is attached to the eye elevating muscle too high (i.e., was not attached to a surgically created septo-levator complex) or when the skin is attached to the tarsus. In order to correct this problem, the surgeon must dissect and release the fold and place the new fold at an ideal anatomical location with adequate depth.


Many times, patients can experience heaviness of their eyelid when they have ptosis, the weakening of the eyelid elevating muscle. Patients that have undergone double eyelid surgery may also experience another form of heaviness due to puffiness (swelling) of their eyelid. If the patient is experiencing heaviness of the eyelids as a result of ptosis, the surgeon must strengthen the eye muscle by performing ptosis correction (see Ptosis).


There are two types of puffiness that can result in heavy eyelids–fullness in the area between the lash line and the crease or puffiness above the crease up to the brow.

  • Sausage – When fullness occurs between the lash line and the crease, it is referred to as “sausage”. When the patient’s face is viewed from the side, the “sausage” area will protrude under the crease, appearing unnatural and unattractive. The cause of “sausage” can be due to the spontaneous development of ptosis or induced ptosis, where a patient’s eye muscle develops intolerance to a high fold. If this occurs due to spontaneous ptosis or induced ptosis, the heaviness can be alleviated by ptosis correction. If the heaviness occurs because the patient’s fold is too high, it can be corrected by lowering the fold.
  • Crease to brow puffiness – Puffiness in the area between the fold and the brow can be corrected by removal of skin or with a brow lift. There are two types of brow lifts: (1) traditional brow lift or (2) sub brow lift. A traditional brow lift (otherwise called forehead lift) involves lifting of the forehead and brow from or above the hairline and subsequently, the eyelid is lifted. A sub brow lift is done by excising a portion of skin immediately under the brow. Some individuals may require such brow lift when getting double eyelid surgery if their brow skin is too puffy or extremely thick.