DST and Evolution of Double Eyelid Surgery

Eyes are the window to the soul.

This is a quote that dates back to the years past that describes the fascination and importance placed on our eyes. An interesting study was conducted in 2007 to support this age-old belief. According to its findings, the eyes really do say a lot about us. The patterns on our irises (the part which gives the colour to our eyes) can indicate if we are warm and friendly, or downright neurotic and impulsive. Nonetheless, its main message is clear – our eyes speak volumes in conveying to people what we feel and think.

Apart from that, the eyes have also been subject to many debates as to how certain shapes or sizes are considered to be more beautiful and attractive as compared to others. Some may prefer almond-shaped eyes while others tend to favour deep-set or hooded ones. Subjective though the perceptions may be for ideal eyes, there seems to be a unifying belief that larger eyes are the more attractive ones, especially to men.


This belief may have been the main contributor to the popularity of eye surgery to create double eyelids. Why? It is simply because double eyelids give the appearance of larger eyes. Studies have shown that approximately 50% of people of the Asian origin do not have the upper eyelid crease. As such, the double eyelid surgery is mostly opted by Asians, so much so that it is also known as the Asian blepharoplasty.

Evolution of the double eyelid surgery

Double eyelid procedure is generally divided into two main categories – incisional and non-incisional. As the name indicates, incisional blepharoplasty involves a significant incision to be made on the upper eyelid where skin and fat is removed and the incision sewn up to create a crease. Meanwhile, non-incisional procedures involve the use of sutures in place of cutting to create a fold on the eyelid.


Back in the days

The procedure can be traced as far back as the 1st century AD, where it was initially performed to correct eye deformities. It is said that Aulus Cornelius Celus was the first person to have performed the first surgery to relax the eye muscles.

Aulus Cornelius Celus

However, literature show that it was not only until 1896 that double eyelid procedure was conducted purely for cosmetic purposes. Initiated by surgeon Mikamo in Japan, the earliest recorded cosmetic double eyelid procedure was performed on a Japanese patient to create a crease in one of the patient’s eyelids using a suture technique (a non-incisional procedure). Sutures made of silk were passed through the patient’s upper eyelid and were left in place to create sufficient depth to the crease before they were removed. This same method was adopted by another Japanese surgeon, Uchida in 1926 who employed catgut sutures to create the creases, where they were left in place for four days prior to their removal.






Blepharoplasty throughout the years

The first incisional blepharoplasty then came into play in 1929 when Maruo, yet another Japanese surgeon, reported to have combined both the suturing and incisional methods. A 7mm incision was first made across the patient’s eyelid and was later sutured to create the desired crease. Many surgeons then followed in Maruo’s footsteps in using the combination method, fine-tuning their techniques along the way.

In the years that followed, these two methods have evolved to become different blepharoplasty procedures in their own right, each with its own distinctive techniques.

Now, blepharoplasty is a widely accepted and commonly performed procedure to create double eyelids in the worldwide quest to possess eyes that appear bigger and brighter.



And now, the Double Suture and Twist

If cutting away the skin and tissue from your eyelids sounds a little extreme (not to mention scary!) for you, there is another viable alternative to having double eyelids – a non-incisional Asian double eyelid creation technique, called the Double Suture and Twist (DST) or Minami Technique.



What is DST?

DST is a technique that was published in 2001 by Dr Akihiro Minami, a renowned plastic surgeon in Japan. Designed to be a minimally invasive procedure, DST does not require significant incisions to be made, hence does not leave behind significant scars on the patient’s eyelids.

Also described as the most sophisticated suture technique with proven durability, it takes about 30 minutes to create the creases for both eyes.

Inventor of the DST technique, Dr Akihiro Minami, Japan (Left) and DST practitioner, Dr David Low (Right).

How is DST performed?

The surgeon first makes 3 small punctures on the upper eyelid of each eye. Then, using a specific twisting technique, two sutures are passed through those punctures and twisted around each other four to five times. After minimal suturing, the double sutures are tied together to create a fold on the upper eyelid. The result of this procedure is that when the patient opens his or her eyes, the underbelly of the skin is pulled inwards, resulting in a natural looking crease.Although a quick and often less painful method to obtaining double eyelids, non-incisional procedures in general are said to be less effective when compared to incisional ones, owing to its high suture breakage rate and results that can fade over time. 

However, studies have shown DST to be both a safe and relatively durable procedure. Besides that, the results are also reversible in case patients change their minds.
Furthermore, downtime for the patient is also shorter than incisional double eyelid surgeries which usually require a longer period swelling. 

The Double Suture and Twist (DST) Technique or Minami Technique.

Is DST for everyone?

Although it can benefit everyone, it is however more suited to certain candidates, in particular, the younger generation who are below 40s.

On the other hand, DST is not suitable for those with problematic eyelids such as those with asymmetrical or sagging eyelids and/or a lot of fatty tissues around the eyelids. Candidates with these issues are usually advised to opt for the conventional blepharoplasty for best results.


Moving forward with non-incisional techniques

As seen above, double eyelid creation methods and techniques are constantly improving over time to provide patients with better and safer experiences in obtaining their desired looks.

For patients who fear surgeries, non-incisional procedures such as DST can help take a load off their minds. Without involving significant incisions, patients are able to enjoy a reduced healing period with long-lasting results that are also reversible, just in case. As such, they need not worry about permanent scars and/or taking a long time off work to recover after the procedure.

DST has the potential to emerge as the more practical method among non-incisional procedures in creating a long-lasting, natural looking crease to make your eyes appear bigger and brighter.

Looking ahead, who knows what more the future may bring to the world of double eyelid surgeries…

Thread Facial Rejuvenation

The aging process begins to appear around the 30s. This process reverses the “triangle of beauty” whose base is at the top of the face during adolescence. Around the 35s this triangle inevitably reverses with time due to the sagging of the deep tissues. Deep furrows and wrinkles begin appearing, indicating an inner change in the supporting structure of the skin.

In the last decade, there has been increasing popularity of nonsurgical cosmetic procedures performed. This reflects the increasing demand for facial rejuvenation with quick recovery period, low risk, not too costly, and provides natural results. The commonest nonsurgical cosmetic procedures include cosmetic muscle relaxation using botulinum toxin and soft tissue augmentation with dermal fillers such as hyaluronic acid. In addition, there are also several tissue-tightening devices such as infrared ligh and radiofrequency to improve skin laxity by heating the deep dermis. However, none of these modalities address the sagging of deeper tissues of the face.

Thread facial rejuvenation techniques are good adjuvants to tissue-tightening machines and injection procedures for patients who would benefit from lifting of mild to moderate sagginess, but they do not replace surgical facelift procedures for those with more severe sagginess or excessive skin laxity. Volume changes are usually due to aging process and occur both in the underlying bone and the soft tissues. Small changes due to volume loss and bony resorption can be addressed using dermal fillers.

In the midface, the cheek fat pad descends gradually from its normal position over the cheek bone. Gravity facilitates this process by providing a downward vector for tissue that has lost elasticity and underlying structural support. As the fat falls away from the lid–cheek junction, the lower lid appears to lengthen and a hollow below the eye develops, also known as the tear trough deformity. The nose-lip fold deepens as the cheek fat pad adjacent to it drops. Further descent of the cheek fat pad accentuates the jowls and flattens the cheek above. Aging in the lower face and neck begins with accumulation of fat in the jowls and below chin area, skin laxity in the neck, and prominent 'turkey neck' bands. These changes results in a loss in definition of the jawline, a rectangular-shaped face, and an increase in the neck-chin angle.

The rationale for treatment using threads is to reverse the early signs of aging by lifting and suspending tissues that have begun to drop. By repositioning soft tissues in this way, not only are sagging tissues lifted, but volume is also restored in important areas, such as the midface. These techniques are not intended to correct more advanced signs of aging where significant skin laxity is present. Similarly, excessive fatty deposits in the face, below chin area, and neck are not improved with threads alone, particularly when the overlying skin is tight. These problems require more aggressive measures such as surgical facelift. The ideal candidate for a suture lift has mild sagginess of brow, outer eye angle, cheek fat pad, jowls, or neck. Even mild sagginess in these areas can produce a sad or sullen look and lifting by a few millimeters will give a more pleasing contour. Skin laxity should not be excessive and facial volume should be fair. If there is drastic skin laxity or the face is too thin, the threads may cause excessive bunching or irregularities. Patients should have realistic expectations and understand that thread facial rejuvenation techniques do not replace conventional surgical facelift.

The face and human interactions

Psychologist Albert Mehrabian described 3 components in face-to-face communications namely,  verbal, vocal and visual. Also known as the Mehrabian Rule, this rule states that 7% of communication involves words, 38% tone of voice and 55% body language. Usually the 3 components have to be congruent to support each other in communication. When words and body language fail to agree, one tends to believe the body language. 

People see, observe and judge others via their facial expressions. Facial expressions are therefore essential for daily life to enable effective communication.

Often times, people express concern that their facial features are communicating unintended signals.

 Often times, people express concern that their facial features are 

communicating unintended signals such as disapproval (frown lines), tiredness or disinterest (droopy eyelids), aging (forehead wrinkles and crow’s feet), worry (droopy angle of mouth, eyebrow  and frown lines).

Hyperactive corrugator muscles can send out unintended signals of worry or disapproval. 

Dental and skull deformity can also impair the ability to express oneself, with an observer potentially misinterpreting  one’s emotions or personality. For example, people with short chin, protruding incisors,  or gummy smiles may appear unintelligent. People with huge jaw  tend to appear more aggressive and a smile may appear more like a grimace. Those with flat cheek bones or saggy face often have down-turned angle of the mouth, thus looking angry or sad.

A small eye with single eyelid and wide inter-eye distance is sometimes misinterpreted as disinterest or tired

In other words, the face can malfunction as an organ of communication. As a great deal of human communication takes place without the need for words,  facial expression is immensely  significant in non-verbal communication. As aesthetic medical treatment is increasingly accessible, more people are seeking such services to improve their quality of life in terms of social interactions, carrier development and personal satisfaction.

Droopy brow and deep nose-lip fold with saggy mouth angle may appear as sad or angry.

DST 缝制无痕双眼皮

交叉式勾双眼皮（Double sutures and twisting method /DST) 手术法是最复杂的双眼皮手术 。

相对而言，传统的缝合法具有较高的损伤率和不清晰的皱折，其将随着时间的消逝而退化。

交叉式勾双眼皮（Double sutures and twisting method /DST)不仅可以解决这些不足，还可以保有缝合法的优势，如皱折几乎无痕、自然，并有潜在的可逆性、恢复迅速快（仅需要几天而非几周）。

在埋线法手术 中，折痕的生成是通过永久性地埋入无排斥反应的线（聚丙烯纺织纤维，用于心瓣膜手术），至眼睑的深度软组织。分析显示埋入线通常不会断裂，但埋入线可能切 穿上眼睑的软组织。

交叉式勾双眼皮(DST)矫正了这个问题，并让埋入线更结实，还降低了让埋入线切穿软组织的可能性。首先，把埋入线的一端固定在上眼睑 最结实的组织——睑板（其由坚固的软骨组成）；埋入线的另一端与临近的埋入线链接，正如两个连接在一条链上。在打结前，眼睑皮肤下方被捏入埋入线。这就形 成一个坚固且互锁的折皱，极为有效地防止了其切穿或断裂。


以下为部分完成的 交叉式勾双眼皮 例子：-

A History of Asian Double Eyelid Surgery

Is double eyelid surgery an attempt at Westernization of the Asian Eyelid?

Here is an abstract from PMC:

Asian Blepharoplasty

Marilyn Q. Nguyen, M.D., Patrick W. Hsu, M.D., and Tue A. Dinh, M.D.

Semin Plast Surg. 2009 August; 23(3): 185–197.
doi: 10.1055/s-0029-1224798

The “double eyelid” operation, or surgical creation of a supratarsal crease, is the most commonly performed aesthetic procedure in Asia. Whereas this procedure is considered by some to be an attempt at Westernization of the Asian eyelid, the first published description of the procedure was in the late 1800s, long before the existence of a strong Western presence in Asia.

Early publication in the Japanese medical literature favored the suture ligation method. In 1896, Mikamo described the “double eyelid” feature and how it was considered an indicator of beauty by writers and artists of that time period. Single eyelids that did not possess a distinct supratarsal crease were described as “monotonous and impassive.” He estimated the incidence of the single eyelid in Japanese women to be approximately 17 to 18% and thus concluded that the double eyelid was the physiologically normal appearance. Mikamo's technique was a modification of a surgical procedure used to correct entropion that was first described and used in the ophthalmology literature. He referenced Kamoto by saying that the procedure not only corrected entropion but also created a “clear double eyelid and a more attractive look.” In this first publication on Asian blepharoplasty, Mikamo described how three sutures were passed through the full thickness of the eyelid to include the tarsus. Each suture was placed approximately 3 mm apart, 6 to 8 mm superior to the lid margin, and removed after 4 to 6 days. He emphasized maintaining an appropriate distance between the lid margin and the suture line such that the double lid remained commensurate with those of Japanese women who had a naturally occurring crease. This again highlights the fact that the initial operation was not intended to Westernize the eyelid but to create an overall more expressive look.

After these initial case reports by Mikamo, little was published until the 1920s, when increased Western presence introduced new concepts of beauty and changed the Asian attitude toward aesthetic surgery. The suture ligation technique continued to be the only method and was described by several authors including Uchida. In Uchida's article, he described his results with 1523 eyelids in 396 males and 444 females. The crease was designed similarly to Mikamo's description; it was placed 7 to 8 mm from the ciliary margin, and the sutures were removed on postoperative day 4.

Maruo described the first external incision technique in 1929. His technique required an incision across the lid 7 mm from the ciliary margin. Closure of the incision included a trans-lid passage from the conjunctiva to the superior tarsal border of the anterior skin edge to the tarsal plate.

Over time, a greater Western influence was clearly seen and reflected in the procedures that followed. Hata described creating a higher crease at 10 mm in 1933, and in the 1940s to 1950s, multiple authors including Hayashi, Inoue, Sayoc, Mitsui, Fernandez, and Boo-Chai described techniques including excision of muscle and fat to create a deeper-set eye in addition to creating a double eyelid.

Today, the literature contains abundant material on both suture ligation and external incision techniques, as well as a new focus on procedures to eliminate the epicanthal fold. The surgeon should be aware of the broad range of surgical options in modifying the eyelid and tailor procedures according to each individual patient's preferences, which can vary widely even between different Asian populations. According to the 2006 cosmetic demographics published by the American Society of Plastic Surgeons, Asian Americans compose 6% of the cosmetic patient population with blepharoplasty ranking as the third most commonly requested surgical procedure behind rhinoplasty and breast augmentation. Although most patients desire the creation of a supratarsal crease, the expectation of the size, shape, and height of the crease can differ significantly between different subsets of the Asian population. All in all, most surgeons agree with the idea that the double eyelid procedure should create a lid that remains within the norms for the Asian face, rather than Westernize the eyelid altogether.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2884917/

The Math Behind Beauty

A plastic surgeon computes the perfect face.

By Bruno Maddox|Friday, June 01, 2007

“What is Beauty?” 

Marylin Monroe (1957) by Milton H. Greene
Image courtesy of Marquardt Beauty Analysis

Very little has surprised me more, in my years as a public intellectual, than how often I get collared on the street by some desperate pedestrian demanding an answer to this most fundamental question. Almost never. It hardly ever happens. 

Which is odd, because people still care about Beauty—quite a lot in fact—especially here in Southern California, if I can be the first to make that observation. Last night in my room at the Sunset Marquis I reached out for what I assumed was the room-service menu and passed a few fleeting surreal moments trying to imagine what “Upper Leg with Bikini” might taste like, for a mere $100. It turned out that I had grabbed the Beauty Menu by mistake and that for $240 someone was prepared to come to my room and give my skin a “Firming Renovateur.” 

But while people may care about being beautiful as much as they ever did, it seems they have largely stopped trying to figure out what Beauty actually is.

It wasn’t always thus. The ancient Greeks, for their part, were convinced that an explanation of, and definition for, Beauty was as concrete and discoverable as the answer to why the days got shorter in winter or why your toga weighed more after you’d gone swimming in it. Indeed, no less a thinker than Pythagoras, he of hypotenuse fame, logged some impressive early results. In music, Pythagoras showed that the notes of the musical scale were not arbitrary but reflected the tones produced by a lute string—or any string—when its length was subdivided precisely into such simple ratios as 2:1 or 3:2. In architecture and design, similarly, he managed to show that the shapes people found most pleasing were those whose sides were related by the so-called golden ratio. 

The golden ratio, briefly, is the proportional relationship between two lines a and b such that (a + b) is to a as a is to b; in other words, the ratio between the whole and one of its parts is the same as the ratio between its two parts. This doesn’t sound like much in algebra form (a/b = (a + b)/a) and still less when expressed as a decimal (1:1.61814). But draw a rectangle—or build a Parthenon—with sides of a and b, and the sheer cosmic rightness of the thing leaps out at you. If you were to be stranded on a desert island with one particular rectangle, that’s the one you’d go with. Palpably, it’s the first rectangle that occurred to God when he realized he needed another four-sided, right-angled shape to complement his juvenile masterpiece, the square.

This was good enough for Plato, the 800-pound gorilla of ancient Greek intellectual life, to include Beauty as one of his famous forms: those transcendent, invisible archetypes of which this reality is nothing but a set of blurry ramshackle imitations. Beauty was not in the eye of the beholder. On the contrary, to borrow Plato’s legendary cave metaphor, the beholder had his back to Beauty, able to see only its flickering shadows on the grimy cave wall of reality.

In short, the Science of Beauty was inaugurated by the two classical thinkers upon whose shoulders the science of pretty much everything else would eventually come to rest. Among historians of science, that’s what is known as a rollicking and auspicious start. 

Imagine the surprise, therefore, of one Dr. Stephen Marquardt, a plastic surgeon working in Southern California at the tail end of the 20th century, who checked in on the progress of the Science of Beauty since Pythagoras and found that very little had been made.

As Los Angeles plastic surgeons go, Marquardt (now retired from clinical practice) was the serious, unsleazy sort. His patients weren’t the standard Valley girls and divorcées whose breasts a doctor could breezily augment to the tinkle of a Japanese water feature before checking his teeth in the shine of his scalpel and heading off for cocktails at Skybar. His patients were deformed. They were people who were born without chins or who had taken a speedboat turbine to the face. And they came to him with dreams not of gorgeousness or superstardom but of one day being able to ingest food orally. 

Yet herein lay a paradox. The fact that aesthetic perfection was the last thing on his patients’ minds meant that Marquardt had to think about it all the time, far more than if he’d been just another surgeon slinging collagen up in Beverly Hills. People didn’t come to him wanting a cleft in their chin; they came to him wanting a chin, and they generally left it up to Marquardt to decide what the thing was actually going to look like. 

Which was harder than it sounds. Often Marquardt would walk out of surgery thinking he’d gotten someone’s chin exactly right, only to find weeks later, when the bandages came off, that the thing just didn’t work on an aesthetic level. 

The solution, Marquardt decided, was to ramp up the degree of proportional precision. But he could find nothing useful in the literature. After Pythagoras with his golden ratio and Plato with his forms, the mathematics of Beauty went largely untouched until Leonardo da Vinci. Da Vinci’s Vitruvian Man, that famous sepia sketch of a nude, spread-eagled person touching a square and a circle with his extremities, asserted the eerie proportional coincidences of the ideal human form (arm span = height; height = hand length x 10) but said nothing about the face.

So Marquardt went it alone. He collected photographs of faces the world deemed beautiful and began measuring their dimensions. Whereupon something peculiar and thrilling presented itself: the golden ratio. Beautiful people’s mouths were 1.618 times wider than their noses, it seemed, their noses 1.618 times wider than the tip of their noses. As his data set expanded, Marquardt found indeed that the perfect face was lousy with golden ratios. Even the triangle formed by the nose and the mouth was a perfect acute golden triangle. 

Marquardt went public, making a splash with his unveiling of the Golden Mask, his understandably grandiose name for what was, if he was right, nothing less than a blueprint for the perfect face—and more than enough reason, you would think, for this reporter, passing through Los Angeles, to check in with Marquardt to see where his work has gone from there.

So I did, and I have to say I left Marquardt’s comfortable home in Huntington Beach not entirely convinced. Gunning my rented Ford Escape back to Los Angeles, I couldn’t help but think that the good doctor was overreaching—perhaps quite a lot—with this whole Golden Mask thing. 

society and culture may call us ugly, but that’s only because society hasn’t yet gone to the trouble of comparing our faces to the golden mask.

The iris, in particular, gave me pause. Marquardt contends that the golden ratio can be detected in the iris, the colored part of the eye. Take 10 golden triangles, arrange them with their sharp points touching, and you have a golden decagon, fitting perfectly within the iris of the eye, vertices neatly touching the rim. But surely, so would a square, if you sized it right. Or an equilateral triangle. Or a bull’s-eye. 

Then there was the way the Mask did not quite fit supposedly beautiful faces as well as Marquardt told me it did, while he helpfully talked me through the images on his Web site (beautyanalysis.com). As well as the way it seemed to fit supposedly ugly faces much better than you’d expect. Marquardt conceded this last point and hailed it as proof that the human race has evolved to the point that—hooray!—most of us, in objective terms, are actually rather attractive. Society and culture may call us ugly, but that’s only because society hasn’t yet gone to the trouble of comparing our faces to the Golden Mask, which was derived by studying faces that society deems beautiful . . . which would seem to me to invalidate the whole ball of wax.

It was only later that I changed my mind—a gradual, nay, ineffable process I should probably describe, for the sake of Beauty, as an epiphany at the end of a pier in Santa Monica while watching the sun go down through my Ray-Bans.

So what if Marquardt’s overreaching? I suddenly realized. If he’s right only in his assertion that the most pleasing faces have mouths that relate to the noses above them by the ancient and mysterious golden ratio, that’s not nothing. That’s a lot. And if he’s also right, as he once told The Washington Post, that the width of the front two teeth in a supermodel’s smile is 1.618 times the height of each tooth, then he is actually really onto something.

Maybe Plato was right as well: that nothing in this world is perfect, be it a table, a face, or the life’s work of a California scientist, until you tune out the noise and break through to what is true—and even a whiff of mathematical insight into Beauty gets the job done. For as John Keats once said, frantically overachieving en route to his glamorous early grave, “Beauty is truth, truth beauty—that is all ye know on earth, and all ye need to know.”

Other scholars can debate whether Keats, at 24, dying, working in the anything-goes medium of poetry, actually knew what he was talking about when he wrote those words. But I think perhaps that I, peering through the faux-deep shallows of Southern California to its faux-shallow depths, finally do. 

Discover Magazine - June 2007 Issue

Babies can spot pretty face right from birth

By Mark Henderson, Science Correspondent
Times Online, Sept 6, 2004


BEAUTY is not in the eye of the beholder: British scientists have discovered that human infants are born with an innate concept of what makes an attractive face.

The findings suggest that ideals of facial beauty are not determined by culture alone, but also rely on universal standards that have been hard-wired, or imprinted, in our genes.

“Attractiveness is not simply in the eye of the beholder, it is in the brains of newborn infants, right from the moment of birth,” said Alan Slater, a developmental psychologist who led the study. “This view contradicts views arguing that the newborn infant enters the world as a tabula rasa — a blank slate on which experience will write.”

Dr Slater will present the results this week at the British Assocation Festival of Science at Exeter University.

Though infants cannot tell scientists that they prefer this face or that, a large volume of research has shown that their attention is much more easily captured by images they find pleasing or interesting.

In the new study, Dr Slater’s team used this effect to test whether newborns with little or no experience of the world shared their elders’ assumptions about facial beauty. The researchers took hundreds of pictures of female members of the public, and asked adult volunteers to rate their attractiveness on a scale of one to five.

Dr Slater then paired particularly beautiful faces, with an average score of close to five, with particularly unattractive ones scoring close to one. Care was taken to match qualities such as hair colour and length that might otherwise interfere with the experiment. Almost 100 newborn babies, with an average age of two days, were then shown these paired images.

About 80 per cent of the time the babies looked exclusively or mainly at the face judged “prettier”. The effect was also seen when the experiment was repeated with male faces and faces from many different ethnic groups.

Dr Slater said: “A lot of it is hard-wired, and you can’t get away from that hard-wiring.”

There are two probable evolutionary explanations for the phenomenon. First, facial symmetry — which is strongly linked to beauty across cultures — may be an “honest” signal of good genes, good health and an absence of parasitic diseases.

We may be primed to recognise this as a way of selecting sexual partners with the best breeding prospects. Second, the preference could be a by-product of an evolved mental capacity to recognise faces from birth. It is thought that babies fit faces to some sort of average facial template.