Double eyelid surgery: incisional or non-incisional?

Ask ten people who have had double eyelid surgery in Seoul which method they chose and you will hear two words again and again: maemol (buried suture) and jeolgae (incision). The choice is usually presented as a trade between a quick recovery and a lasting result. That is roughly right, but the published evidence is messier than the brochure version, and it is worth knowing where the mess is before you sit down in a consultation room.

What is the surgery actually changing?

An upper eyelid creases when fibres from the muscle that lifts the lid reach forward and attach to the skin. When the eye opens, the muscle pulls, the skin is tugged inward along that line, and a fold appears. In an eyelid without a crease, that connection is absent or sits very low, and there is often more fat lying in front of the muscle.

Every double eyelid operation, whatever it is called, builds that missing connection. Research summaries describe the surgical crease the same way: skin and the thin muscle beneath it are linked to the deeper lifting layer so the lid folds on opening. The two families of technique differ only in how they make the link and how much else they do while they are there.

How does the non-incisional method work?

The surgeon passes fine stitches through the eyelid at several points along the planned crease and buries the knots. Nothing is cut away. The stitches hold the skin against the deeper layer, and the fold forms along the line they trace.

The appeal is obvious. There is no long wound to heal, swelling settles quickly, and there is next to nothing in the way of a visible scar. The research literature gives the method credit for exactly this: faster recovery and minimal scarring.

The weakness is just as consistent across sources. The fold is held by thread and by whatever light scarring forms around it, while the lifting muscle works against those stitches every time you blink. Reviews describe suture creases as carrying less long-term definition, and one paper puts it bluntly: the known disadvantage of the non-incisional method is loosening of the fold compared with an incision.

Surgeons have spent years trying to engineer that weakness away. One example is a “natural adhesion” variation reported in 99 patients treated in 2018, in which no loosening was seen at one year. That is encouraging, but notice what it is: one team, one technique, twelve months. A fold that holds for a year has not yet shown what it does at ten.

How does the incisional method work?

Here the surgeon cuts along the planned crease line. With the eyelid open, they can remove a strip of skin if there is excess, thin out muscle or fat if the lid is heavy, and then stitch the skin edge down to the deeper layer under direct vision. When the wound heals, the scar itself becomes the attachment.

That scar is why the incision method is treated as the durable option, and why it suits eyelids that sutures handle poorly: thick skin, a lot of fat, or loose skin that needs trimming. The price is a longer recovery and a fine line in the crease, which is normally hidden when the eye is open.

It is not a guarantee, though. A study of 193 patients who had incisional surgery between 2018 and 2021 with a modified fixation technique still recorded crease asymmetry in 3.6% and partial loss of the fold in 4.1%, with a smaller number losing the fold completely. The authors were presenting a technique they considered reliable. Those are the figures from a good day.

What about the small-incision option in between?

Many clinics now offer a middle route: one to three short cuts of a few millimetres rather than a full-length incision. Fat can be removed through the openings and the fixation is done under vision, but the wound is far smaller.

A 2022 systematic review pooled the published studies on these techniques. Across both single-incision and three-incision studies it found a total complication rate of 5% and a fold-loss rate of 2%, with no significant difference between the two. The reviewers judged those rates acceptable when set beside both the suture-only and the full-incision methods.

How do the three compare?

	Suture only	Small incision	Full incision
What holds the fold	Buried stitches	Stitches plus small scars	A full-length scar
Can remove skin	No	No	Yes
Can remove fat	Very little	Yes, through the openings	Yes
Recovery	Shortest	Short	Longest
Visible scar	Almost none	Small marks	A line in the crease
What the literature says about durability	More likely to loosen	Pooled fold loss of 2%	Treated as the most durable, though fold loss still occurs

Why can’t the numbers settle it?

Because they were never collected to be compared. Almost every figure above comes from surgeons reporting their own patients, operated on with their own preferred technique, and followed for a period they chose. Patients who lose a fold three years later and go to a different clinic never appear in the first surgeon’s paper. The systematic review itself is graded as level III evidence, which is a polite way of saying it is built from this kind of study.

There is also a selection effect. Surgeons steer thin, light eyelids toward sutures and heavy ones toward incisions. A method that looks durable may simply have been given the easier eyelids.

What should you ask at the consultation?

The useful questions are about your eyelid, not about the method in general.

• Is my skin thick or thin, and is there excess that would need trimming?
• How much fat is there, and would you remove any?
• If you recommend sutures, what do you do if the fold loosens, and what does that cost?
• If you recommend an incision, where will the scar sit when my eyes are closed?
• Who will perform the operation, and will they be the person I am speaking to now?

That last question matters more than the method. You can check whether a clinic’s registered name carries the plastic surgery specialty in our clinic directory.

Asymmetry, a fold that sits too high, and visible scarring are all reported complications, and a crease that is set too high is harder to correct than one that has merely faded. If you are unsure between two heights, that asymmetry of regret is worth saying out loud to the surgeon.