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Why is One Eye Lower than the Other and How Asian Double Eyelid Surgery Can Improve It

Thank you for your question. You submitted your question with a close-up view of your eyes. And you ask in your question about your perception that your right eye appears to be considerably smaller than your left. And that you notice it in particular when you take photos and you’re asking what are your options. Well, I can certainly share with you what my impression is in the absence of a full physical examination but I think I can give you some guidance as to how I approach this type of situation in my practice. A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. Helping people with their eyelids especially when it comes to more advanced eyelid procedures such as Asian eyelid surgery has been a very big part of my practice. And I think that when I look at your photos, I can just give you some basic principles that are applicable that can help guide you as to what is probably the option that will fit best for you. So to begin with, this situation, what I see is in the left eye you have a crease and the fold of skin is actually above the crease. When you look at the right eye, you don’t see a crease. You see a fold overlying the eyelid margin. And this is actually a very common situation. You see, there is a certain anatomic variation that is specific of Asian descent and it has to do with the absence of a crease or a presence of a crease. And it is due to an attachment between the muscle called the levator muscle, the muscle that can also sound like the word “elevator” or look like the word elevator without the letter “e”. It’s the muscle that lifts the eyelid. Well, from the front of that muscle are these fibers that attach to the skin. And when they’re attached very firmly, you get a crease. When they’re not attached, you don’t have a crease and the skin folds over. When the skin folds over, it creates the perception of the eye being smaller. And essentially what it is, is that the fold is defining the shape of the eye and so generally speaking, a relatively straightforward issue. What the key is to try to create that connection between the skin and the muscle, the levator muscle and that is the entire basis of Asian eyelid surgery. Now when you learn more about Asian eyelid surgery, you learn that there are non-incisional procedures and incisional procedures. A non-incisional procedure is basically defined by essentially making small openings in the skin and attaching the skin to the muscle underlying the levator muscle and creating that fold. I would say that it is more than likely that in your situation that you would probably benefit from that procedure again, in the absence of a physical exam and seeing how much overlap of skin there is. But when I make this decision, I basically look between the choice of doing a non-incisional and incisional procedure. In an incisional procedure, I’m either removing some skin or addressing a certain amount of fat in order to create that crease and fold. And so in a situation like yours, where all I see is a little bit of folding over the skin, I can actually visualize the placement of the sutures that would result in a crease that would create some balance. Now of course there are pluses and minuses to every surgery and risks etc, but I think that when you get down to why your eye is looking smaller, the right eye than the left, it is because of the fold of the skin. It is very straightforward. In fact in our practice, what I routinely do is use something like a Q-tip just to create a crease and push the skin in a way that mimics what would happen if I were to attach the skin to the muscle with the surgery. And basically, you can then see what it would look like. Like I said, the procedure itself is fairly straightforward. In our practice, we do this procedure under local anesthesia with LITE™ sedation. Especially if it’s a non-incisional procedure, it’s actually fairly straightforward. It’s done pretty quickly. It’s done with local anesthesia. It’s just a matter of allowing the time for the skin to heal over the course of several weeks. But most people go back to work in about a week. And as far as swelling, with Asian eyelid surgery, the area between the crease and the eyelid margin, is an area that can linger for several months but does progressively get better. And it is usually a little bit less swelling in my experience with non-incisional compared to incisional. So I think it’s probably the next appropriate step for you is to meet with qualified, experienced eyelid surgeons who have a lot of experience with Asian eyelid surgery and learn about what your options are based on this particular issue of the absence of a fold resulting in overlapping skin. And of course a proper examination would reveal any other issues that would potentially be useful to address at the time. But again, as I said, my impression is this is basically a matter of getting that skin to fold in so that it matches as closely as possible with the other eye. So I hope that was helpful, I wish you the best of luck and thank you for your question.

Asymmetrical eyes, uneven eyes, or one eye lower than the other are common situations among people of Asian descent. There is a certain anatomic variation that is specific to Asian descent and it has to do with the absence of a crease or the presence of a crease. And it is due to an attachment between the muscle that lifts the eyelid called the levator muscle.

Droopy eyelid-levator muscle illustration

In front of the levator muscle are fibers that attach to the skin. When they’re attached very firmly, you get a crease; when they’re not attached firmly, there’s no crease, or a shallow crease, and the skin folds over.

When the eyelid skin folds over, it creates the perception of the eye being smaller. Essentially, it is the fold that is defining the shape of the eye, so generally, a relatively straightforward issue. The key to this is to try to create that connection between the eyelid skin and the levator muscle which is the entire basis of Asian double eyelid surgery.

Asian Eyelid Surgery Procedures

Asian eyelid surgery has two types of procedures: non-incisional surgery, and incisional surgery. A non-incisional procedure is basically defined as making small openings in the skin and attaching the skin to the muscle underlying the levator muscle and creating that fold.

Asian double eyelid surgery before and after - non incisional procedure
Asian double eyelid surgery before and after - non incisional procedure

In an incisional procedure, Dr. Prasad would either remove some skin, and address a certain amount of fat in order to create the crease and fold.

Asian eyelid surgery before and after - incisional
Before and after double eyelid surgery on male patient using incisional method
There are advantages, disadvantages, and risks to every surgery, but when you get down to why the eye is looking smaller, such as the right eye smaller than the left, it can be because of the fold of skin.
Asian eyelid - one eye smaller than the other photo

At Prasad Cosmetic Surgery, Dr. Prasad routinely uses a Q-tip or instrument to simulate a crease and push the skin in a way that mimics what would happen if he were to attach the skin to the muscle with the surgery. Basically, you can then see what the crease would look like before surgery.

Asian eyelid surgery is a cosmetic procedure that Dr. Amiya Prasad does under local anesthesia with LITE™ IV sedation. When it’s done with local anesthesia, it’s just a matter of allowing the time for the skin to heal over the course of several weeks, but most patients can get back to work in about a week after the procedure.

asian eyelid surgery recovery
asian eyelid surgery recovery after 10 days

As far as swelling, with upper eyelid surgery the area between the crease and the eyelid margin, is an area where swelling can linger for several months, but does progressively get better. There is usually a little less swelling with non-incisional compared to incisional eyelid surgery.

One Eye Smaller than the Other Treatment (Asian Eyelid)

A proper examination would reveal any other issues that would be potentially useful to address your uneven eyelids. Your next appropriate step is to meet with a qualified, experienced eyelid surgeon with considerable experience with Asian eyelid surgery, and learn about your options based on the particular issue of an absence of a fold, or shallow folds resulting in overlapping skin.

Asian Blepharoplasty in New York

Dr. Amiya Prasad is a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. He has been in practice in Manhattan, NYC and Long Island for over 20 years. Helping people with their eyelids especially when it comes to more advanced eyelid procedures such as Asian eyelid surgery has been a very big part of his practice. Follow the link to view the upper eye lift surgery before and after photos of his patients.

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