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   OZ (2015-12-03 15:44:29, Hit : 1133, Vote : 83)
   Everything about scar from double fold surgery
Everything about scar from double fold surgery

When I started my carrier as a plastic surgeon, I thought double fold surgery is the easiest one.
But now, I think double fold surgery is one of the most delicate and hardest one.
Making double fold is easy but making perfect and natural double fold is not easy.
To make the best results, we need much information about anatomy, physics, wound healing, and surgery.
in addition, we need good surgical skills, much experiences and knowhows.

Among them, let's think about scar from double fold surgery today.
Can the scar be minimized by excellent suture ?
Is the scar better when doctor close the wound under microscope ?
(One of the funniest advertisement by one silly doctor)
The answer is definitely 'No'.
Let's find the causes of ugly scar.

Eyelid is the thinnest skin in our body.
So, the wound in eyelid can be healed fast and leaves minimal faint scar.
Then, why do some people have ugly and noticeable double fold scar ?

Fixation method is the biggest cause of ugly scar.
There are two ways of fixation in double fold surgery; static and dynamic.
Static fixation is the most common cause of deep, irregular scar and unnatural movement of eyelid on opening and closing.

In static fixation, the double crease is fixed to deep and hard tarsus of eyelid.
The skin in crease is fixed to deep tarsus and the scar looks deep when people close their eyes.
Because there is no soft and elastic material between the scar and tarsus, the scar becomes irregular and doesn't move at all.
During opening and closing of eyelids, the movement also may look artificial.

In dynamic fixation, the double fold crease is fixed to extended aponeurosis of levator muscle (eye opening muscle).
Because this aponeurosis of levator muscle is shallow, soft, and flexible, the scar becomes flat and faint and crease looks clean.
When people open their eyes, the levator muscle contract and pulls double fold crease in natural way.
All people who have original double fold crease have this kind of fixation, which means god also use dynamic fixation in double fold creation.

Then, why do some doctors don't use dynamic fixation in double fold surgery and make ugly scar ?
Because dynamic fixation is more difficult, cumbersome, time consuming, and needs a lot of experience.
Exact cutting hard material like wood as 1 cm is easy, but exact cutting elastic material like rubber bands as 1 cm is difficult.
In dynamic fixation, not only the height of fixation but also the tension in fixation can make differences easily and resulting asymmetry.

Besides of fixation methods, many other factors affect scar from double fold surgery.

1. Design of double fold crease
When the scar follows natural skin crease, it can be minimized.
If the incision and fixation follows the natural skin crease which is created by pressing against eyelid with a toothpick in one spot, the scar can be minimized, the shape of double fold looks natural, and the crease looks natural in opening and closing also.
Excessive use of double fold tape and glue can make eyelid skin thick and disrupt this natural skin crease and resulting ugly scar.
Too high double fold crease is made in thicker skin and can make more noticeable scar.

2. Anesthesia
Double fold surgery is usually done under local anesthesia because I should watch the movement of eyelids during the procedure.
Sometimes, I ask my patients to sit up to compare both sides exactly because the movement of eyelid can be changed in upright position.
This is critical in dynamic fixation especially.
IV and general anesthesia makes doctors to compare both sides exactly difficutl.

3. Incision and tissue handling
Incision made with a sharp knife in exact angle and appropriate pressure can make the edge cleaner and thus make the scar minimized.
Gentle handling of tissue and minimizing tissue damage around the operation field during the procedure can make less scarring under skin and resultant faster recovery, less swelling, and clenaer line.
The is the same principle as the cutting wound with a kife heals better than the dirty and shattered wound.
In revision eyelid surgery, I can frequently find excessive and irregular scarring under skin and can presume how bad and rough the previous surgery did the surgery.

4. Fixation method
See above for the difference in fixation methods.

5. Suture
Scar can be minimized by exact approximation of both edge of incision.
Because too long placement of suture can make stitch marks and milia, the stitches in eyelid should be removed as soon as possible.
Many people presume suture is the most important thing in minimizing scar.
But that is not true.
Other factors like designing, incision, tissue handling, fixation methods are much more important factors in scarring.

Like this, all the process in double fold surgery affect scarring.
That the reason why basic skills, craftsmanship, medical knowledge of doctors are so important in any plastic surgery.
Doctors should try to be perfect and try their best in any procedures instead of advertising and fantasizing patients.

Simple scar from double fold surgery alone can tell the previous doctors basic skills, intelligence, medical knowledge, and attitude to their patients.
Devil is in detail.

This is the photos of my patient which were taken after 6 months of double fold surgery and medial epicanthoplasty.
As you can see, the scar is faint, not depressed and the crease looks clean and crisp.
The movement of eyelids also looks so natural.
Most people can't notice whether she underwent eyelid surgery.


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