Referred to as the open or incisional technique, this method of performing double eyelid surgery is suitable for patients with excess upper eyelid skin, thick eyelid skin or severe ptosis. This technique is performed by excising excess skin and soft tissue and fixing the skin to the underlying eyelid structures such as the levator aponeurosis, the septo-levator complex, or the tarsal plate. Depending on which underlying structure the crease is fixed upon, the fold will differ in its appearance and function.
Low suture fixation at the tarsus.
Tarsal Fixation (Low Fold Fixation)
This earlier technique involved suture fixations to the tarsus. The tarsus is a cartilage located between the levator aponeurosis and the eyelashes. As a cartilage, the tarsus is rigid unlike a muscle, and lacks elasticity that is required for a dynamic eyelid crease. Therefore, placement of fixations on the tarsus was problematic as the crease appeared static and unnatural. Static folds are constant and visible even when the eyes are closed; they lack the dynamic eyelid fold movement where the fold forms when the eyes open and becomes relatively faint as the eyes close. Tarsal fixation was the first incisional double eyelid method used due to the simplicity and ease of making a fold. Unfortunately, because of the ease of this technique, it is still being performed despite its unsatisfactory results.
High suture fixation at the levator aponeurosis.
Levator Fixation (High Fold Fixation)
The earlier tarsal fixation technique later transitioned whereby surgeons began using the levator aponeurosis as a base for suture fixation. Anchoring onto the levator created a more dynamic fold; however, the fold tended to be unnaturally high and deep. Additionally, due to the deep-set location of the levator, instances of chronic swelling on the eyelid occurred. Although levator fixation did yield more elasticity to the double eyelid crease relative to the tarsal fixation, it still did not achieve the ideal dynamicity observed in natural double eyelid folds.