DST or incision surgery – Low crease or medium crease?


I think I have different eye shapes on both of my eyes. Whenever I smile my left eye is noticeably smaller than the right. My eye bags will be raised as well. They aren’t saggy though. Eye bags aren’t my priority, double eyelids are. My questions are, number one. Should I go for DST or incision for double eyelids? Number two, low crease or medium crease for the ideal and most natural look that complements the size of my eye. I smile with my mouth wide open so that the eye bags are more noticeable, thanks.

Answer from Dr Amiya Prasad:

Thank you for your question. By the very wording of your question it is clear that you’ve done a lot of research and with the photos you submitted, with expression and smiling and mouth open, etc. that you really have a very good general understanding of how we make some of our decisions on what type of eyelid surgery would be right for someone like yourself. So you’re asking, should you have DST or incisional surgery. A low crease or a medium crease?

Well with the photos you submitted. It’s difficult to give you an exact answer because the one thing we can’t do is the one thing that we always do is the physical examination.


Just to give you a background, I’m a board-certified cosmetic surgeon and I’m a specialist in ocular facial plastic reconstructive surgery, Asian eyelid surgery is something we do a lot in our practice and certainly I’ve been at this for over twenty years and I can give you my approach to an evaluation so that you would get an understanding of how I would probably do it and what recommendations I’d have for someone like you.

So first, when we decide incisional versus non incisional. Well to decide whether or not an incision is indicated, we look at two factors, is their excess skin, is their excess fat. And whether there would be value in removal of extra skin in order to create an eyelid platform that creates the double fold. In your situation. Although you mentioned DST which is one method of the non-incisional technique.

It is likely that and probably say for me to assume that you’re young and that you don’t appear to have that much extra skin then you would probably have in our practice, a non-incisional surgery, non incisional for clarification means making small entry point in the skin and then creating connections between the eyelid skin and the levator muscle using sutures that are tied effectively into small loops that connect the muscle with the skin. DST basically does it in a way which is kind of a continuous threading of the suture all the way across from one end to the other.
The other question you have is low or medium crease. Well I think that it’s important to understand that when you are doing say nonsurgical procedure. There is certain amount of relaxation that always happens, whether it’s actually incisional on non- incisional and that relaxation can have an effect on the height of the crease. So I would say that the question is more about the way the crease naturally tapers into the epicanthal fold or whether you want to go parallel to the epicanthal fold.

Usually what my approaches is, is I recommend to patients that the goal from my perspective is do to the procedure as if you were born with the crease and I would say that most of the time that means the natural crease would be one that goes naturally into the epicanthal fold.

Now it can only go so high before it looks unnatural and so the difference between low and medium crease is a question of one to two millimeters. And so that’s something that has to be determined by physical exam. Generally I tend to make the crease a little bit higher because I know there’s a certain amount of resolution of swelling and then the crease kind of sits in a way so that when the eyes are open you can see a decently defined crease.

Again it has to do more with what you’re comfortable with and what is realistic in terms of an option. Again the difference between low to medium could be very, very small and it doesn’t matter how you label it as long as it looks good. So this is where physical examination and discussion and details about the height have to be clarified before you do the procedure.

So I think at this point, you have more than enough research-based information. Meet with some doctors, learn about the options, learn about what the potential outcome would be for you and would it be right for you or would you be comfortable with that. This is still not an exact science and there isn’t always one perfect solution for everybody, but in the end it’s all about getting the results that are close to what you imagine those results will be. So I hope that was helpful. I wish you the best of luck and thank you for your question.