Functional and Aesthetic Double Eyelid Surgery: Challenges and the First Clinical Outcome Study in Myanmar

Objective : Upper blepharoplasty surgery includes both esthetic and functional considerations. Double eyelid surgery is one of the most commonly performed facial plastic and esthetic surgical procedures in Asia. Although correctly performed procedures are esthetically pleasing for patients, there are many potential complications and complaints that need to be avoided. Myanmar is a country where there are many ethnic groups and people of different cultures, appearance, and preferences. The purpose of this study is to evaluate the surgical techniques and the outcome in a limited medical environment in Myanmar. Methods : Three hundred and four patients ( 37 men, 267 women ) who underwent double eyelid surgery were enrolled in the study. The double eyelid fold was created by placing and attaching three points between the dermis and levator aponeurosis. The directions of eyelash lines were then adjusted to be inverted approximately 100° upwards on both sides. Satisfactory outcomes were assessed by contacting and surveying the patients’ feedback via telephone whereas functional outcomes were assessed by measuring marginal reflex distance ( MRD1 ) who could visit back to the clinic. Results : The incisional technique healed very rapidly and looked natural within 1 month in young patients but only looked natural after 2 to 6 months in the elders. The MRD1 was increased on postoperative measurement of all patients ( p<0.05 ) . Nearly all the patients were aesthetically satisfied with the result by 6 months postoperatively. Conclusions : The outcomes were esthetically satisfying with functional improvement. This is the first retrospective clinical outcome study of double eyelid surgery in Myanmar.


Introduction
The anatomy of the Asian or single eyelid is characterized by the absence of a supratarsal fold because of the presence of an extensive preaponeurotic fat pad that is enclosed by the orbital septum and ends inferior to the tarsus, covering the attachment of the levator aponeurosis to the dermis. In contrast, a double eyelid has a supratarsal fold that is formed such that the orbital septum ends superior to the tarsus, allowing attachment of the levator aponeurosis to the dermis 1) (Figure 1).
Double eyelid surgery is one of the most commonly performed esthetic surgical procedures in Asian populations [2][3][4] . Various classifications, measurements, and concepts of double eyelid surgery have been described [5][6][7] . Different methods and several forms of double eyelid surgery have been proposed in reports from many countries [8][9][10][11][12][13][14] . Young people prefer a naturally prominent lid fold with less puffiness of the upper eyelids, widened vertical palpebral fissures, and everted eyelashes 15) whereas middle-aged and older patients seek upper blepharoplasty to achieve a youthful eyelid appearance with conservative excision of excess skin, muscle, and periorbital fat to restore the fullness of the eyelid 16) . However, the perception of esthetically attractive eyes is variable. Moreover, the characteristics of an attractive eyelid differ not only according to age, gender, and individual preference but also according to racial background 17,18) . Nevertheless, depending on the individual's desired appearance and functional improvement, an appropriate technique should be chosen and applied for upper blepharoplasty.
In Myanmar, there are several ethnic groups with different cultures and appearance as well as different facial contours 19) . Some people have the characteristic Asian single eyelid while others have an obvious double eyelid with a large suprapalpebral fold. However, most people in Myanmar have a preference for double eyelids with large, symmetric, and obvious folds, which are considered youthful and attractive.
Although Myanmar is a developing country that is mainly based on agriculture, the country's economic growth has progressed despite the 2008 financial crisis 20) . Since 2011, there has been a rapid growth of the concept of socioeconomic status in Myanmar 21) whereby economic changes and the influence of films, advertising, and social media have encouraged people to seek esthetic procedures 22) . Before 2011, there were few private aesthetic dermatology clinics in Myanmar. Nowa-days, there are many such cosmetic dermatology clinics throughout the country but still very few aesthetic plastic surgery clinics exist in Yangon.
The aim of this study was to identify the techniques used and the outcomes of double eyelid surgery at a specialist clinic in Yangon, Myanmar. This study also described clinical challenges, difficulties in follow-up and patient care after double eyelid surgery in a limited environment in a developing country.

Patient demographics
From December 2016 to November 2019, a total of 606 outpatients underwent double eyelid surgery at our clinic in Yangon. Data for 302 patients who did not attend the clinic for follow-up, those who did not wish to make their photographs available, those were not contactable, and those for whom clinical information was incomplete after removal of stitches were excluded. Finally, data for 304 patients (37 men, 267 women) aged 17-82 years were included in the study. Incisional double eyelid procedure was performed to all patients. Extent of redundant eyelid skin was removed to some patients with moderate or large extent of redundant eyelid skin that covered one third to half of the iris area above the pupil.
Information on esthetic outcome, functional improvement and patient satisfaction was retro- spectively collected from the patients' medical records. Written informed consent was obtained from all patients for use of their images for academic research purposes. The study protocol was approved by the ethical committee of Defense Service Medical Research Center (DSMRC) with the approval no. IRB/2020/B2, Nay Pyi Taw, Myanmar.

Preoperative evaluation
Levator function on each side of the eyelid was assessed by careful inspection on the eyeball movement followed by examination of the total upper eyelid and eyeball movement from down gaze to up gaze, while pressing over the patient's eyebrow. During the consultation, the appearance desired by the patient was taken into consideration before surgical planning. Surgeon should aware the preference of desired size of eyelid (i.e., small; 7-8 mm and large; 8-10 mm size of eyelid) that varies among each ethnic group. The height and shape of the desired double eyelid was demonstrated while the patient was in the sitting position. A probe was used to push the upper eyelid upward to form a crease in front of a mirror. When the patient was satisfied with the simulated crease, a point position was confirmed that was approximately 7-10 mm above the ciliary margin depending on the desired lid fold size of patients. A precise line for the incision was then drawn on both sides of the eyelids symmetrically using a marker pen with the patient in the supine position. The marking for the incision varies depending on age, thickness of skin, extent of redundant skin, amount of excess orbital fat, desired size and appearance of the patients ( Figure 2). Photographs were taken by the same surgeon at the same distance from the patient's face in all cases using a Nikon COOLPIX B700 digital camera (Nikon, Tokyo, Japan). Photographs were obtained for all patients who could return to the clinic before surgery and 7 days to 6 months after surgery depending on whether or not the patient made a follow-up visit. All surgeries were performed by one surgeon (KCK).

Surgical techniques
A supratarsal fold was created by attaching the dermis to the levator aponeurosis (levator-dermal attachment) after exposing the orbital septum 23,24) . Incisional technique with or without removing eyelid skin and orbital fat was performed. After the final markings had been drawn on both eyelids, 1-2 ml of 1% lidocaine with epinephrine 1:100,000 was injected for anesthesia on both sides of the marked area via a 29-gauge needle. The injected area was gently pressed manually for 5 minutes to minimize bleeding. The incision was made using a #11 blade to the skin and subcutaneous tissue. The orbital septum was incised and the preaponeurotic orbital fat was exposed. Excessive orbital fat was then removed and cauterized. Hemostasis was achieved with the aid of unipolar electrocoagulation. Once the levator aponeurosis was exposed, three 6/0 nylon sutures were placed and anchored through the levator aponeurosis to the dermis. The size of the lid fold on both eyelids was checked for symmetry by measuring the distance between the ciliary margin and the fold. To ensure the symmetry of the lid fold, the directions of eyelash lines were then confirmed to be inverting approximately 100° upwards on both sides while the patient was asked to open the eyes in the supine position ( Figure 3). Skin closure was carried out by placement of interrupted 6/0 nylon sutures.

Postoperative assessment
Postoperatively, all patients were asked to attend for follow-up within 1 week to 6 months to evaluate the esthetic outcome and functional improvement. The criteria used to define an esthetically successful outcome were as follows: an obvious crease without multiple eyelids; no disappearance of the fold; and a bilaterally symmetric eyelid.
Functional improvement was assessed using the marginal reflex distance (MRD1) 25) , i.e., the distance between the center of the pupil and the upper eyelid margin (Figure 4). The real (white-towhite) corneal diameter was assumed to be 11.77 mm, which is the normal value in a healthy human 26) . The MRD1 was calculated using the following formula in Microsoft Excel 2018: Real MRD1 = Real corneal diameter (11.77 mm) x Measured MRD1 / Measured corneal diameter The MRD1 was measured and calculated only in patients who attended a follow-up visit in the clinic 1 month after double eyelid surgery.
Complications and any complaints were recorded to assist further modification of our techniques or undergo revisional surgery.

Statistical analysis
Adobe Photoshop 6.0 was used to analyze the preoperative and postoperative images. The statistical analyses were performed using Prism 8 software (GraphPadSoftware, La Jolla, CA, USA). MRD1 was analyzed by paired t-test and expressed as mean ± S.D. (standard deviation). The differences in preference between small and large lid fold size among ethnic groups were analyzed by The distances between a, b, and c and a1, b1, and c1 must be equal to achieve symmetric lid folds. The distances between x, y, and z and x1, y1, and z1 must be equal to achieve symmetric brow heights. (f) Pre-operative measurement of an old patient with large extent of sagging eyelid skin.
chi-squared test. A p-value < 0.05 was considered statistically significant.

Results
Patients' demographics and post-operative measures including esthetical outcome, MRD1 and satisfactory outcomes were shown ( Table 1).
In terms of esthetic outcomes, all patients had an obvious crease without multiple folds, no disappearance of the fold and a bilateral symmetric eyelid except 1 patient presented with disappearance of fold by 1 month postoperatively, 6 patients presented with bilateral asymmetrical lid folds by 2 months postoperatively. The patients who presented with disappearance of fold and bilateral asymmetrical lid folds were performed for revisional surgery by the end of 6 months.
In terms of functional outcomes, the MRD1 was measured and calculated only for the 60 patients who attended a follow-up visit in the clinic after 1 month of surgery. Among them (n=60; 7 men, 53 women), the mean preoperative MRD1 was 3.34 ± 0.66 mm and the mean postoperative MRD1 was 4.40 ± 0.77 mm, indicating an increase of 1.05 ± 0.57 mm significantly (p<0.0001). A representative case was shown ( Figure 5).
Patient satisfaction was evaluated after postoperative months 1, 2, 3, and 6 in all patients. Patients' satisfaction changed with the passage of time. After 1 month, 149 patients (49 %) were very satisfied with the result, 197 patients (65 %) were very satisfied with the result at 2 month, 218 patients (72 %) were very satisfied with the result at 3 month and 259 patients (85 %) at 6 months. Two patients out of 304 patients (0.66 %) were not satisfied with the result by the end of 6 months ( Figure 6).
It was found that the differences in preference between small and large lid fold size among the ethnic groups were significantly different by the end of 6 months ( Table 2). Among the different ethnic groups in Myanmar, most Kachin and Shan   ethnic people desired for a small lid fold whereas Bamar and other ethnic people desired a large lid fold. The detail different preference of desired lid fold with very satisfied outcomes by the end of 6 months among the different ethnic groups were shown (Figure 7). There were no complaints, with the exception of 1 patient who requested repeat surgery to create a larger and wider lid fold and 1 patient with disappearance of fold. Complications occurred in 2 patients who experienced delayed wound healing and 1 patient developed an infection after 2 months and 1 month of surgery, respectively.

Discussion
The eyes are recognized as a prominent and important facial esthetic characteristic that defines one's overall appearance and facial attractiveness. Structural differences in the eyelids as a result of ethnicity have been described in the literature. Asian eyes are characterized by a single eyelid with puffiness of the upper eyelid, the presence of medial epicanthal folds, laxity of the supratarsal skin and a vertically narrowed palpebral fissure 17,27) . In contrast, Caucasian are characterized by a double eyelid crease and wider palpebral fissures. Because  of the environmental and cultural ideal of beauty, a double eyelid is a desired facial characteristic among Asians 17,28) . As Myanmar is a country where many ethnic groups with different environmental and cultural backgrounds 19) , individuals' satisfaction upon size and shape of desired eyelid are different. Although the outcome of blepharoplasty itself was reported to be favorable and satisfied in previous study 29) , our incisional technique in most patients could result in a more satisfying and pleasing outcome by attaining not only a bilateral symmetric lid fold but also a favorable eyelash line direction.
It is important to evaluate not only the esthetic outcomes but also the functional improvement after double eyelid surgery. Previous studies have shown that measurement of the MRD1 is an objective functional evaluation method after this surgery 23,25) . Our study confirmed that the incisional techniques achieved functional improvement by increasing the MRD1 measurement after surgery to the patients of all ages (17-82 years old). It can also be thought that as the younger has stronger function of levator aponeurosis than the older, shortening the stronger levator aponeurosis can more effectively pull up the dermal-levator attachment and increase MRD1. On the other hand, weaker levator aponeurosis in the elder may additionally be needed to be removed the excessive sagging skin to be able to increase MRD1 in addition to dermal-levator fixation to achieve both effective aesthetical and functional outcomes.
In this study, we performed double eyelid surgery and evaluated patient satisfaction at months 1, 2, 3, and 6 after surgery. Questionnaire survey for satisfactory were taken by telephone interview as there were some patients who were uncooperative to fill the survey form and send it back by air mail, unfamiliar or unavailable to fill the survey form by internet in some rural areas and inconvenient to  visit back to the clinic after surgery. Surgeons should be aware that patient satisfaction changes depending on duration after surgery and environmental factors. In the author's experience, some patients are very happy and satisfied with the appearance even though they become acceptable and satisfied with the passing of time. However, proof was required that the results of our incisional technique were considered satisfactory by the patient at 6 months after surgery. The results of this study may help other surgeons to understand more about patient satisfaction, which improves over time and is the most important outcome measure after double eyelid surgery. Although Myanmar is a country where 135 ethnic groups exit, there are eight major ethnic groups named Kachin, Kayah, Karen, Chin, Mon, Bamar, Rakhine and Shan 19) . The locations of eight major ethnic groups with their different traditional costume and facial contour are shown (Figure 8). The different locations (plain, hilly, delta, coastal and dry zone) lead them into different professions, economics, educations, culture, life style, complexion and preference to beauty. Therefore, people preferences to the shape of double eyelid may also be differed. Among the Shan ethnic people, 44 patients out of 53 patients (83 %) desired for a small or narrow lid fold whereas 87 % of the Bamar people (58 patients out of 67 patients) preferred a large and wide lid fold (Figure 9). The different double eyelid shapes 14) should be discussed in detail with the patient to achieve the desired result. It is important not only for the surgeon but also for the patient that the incisional wound must be cared to achieve primary healing. Personal hygiene, environmental sanitation, educational background, socioeconomic status, and availability of transport should be taken into consideration for an ideal outcome in a developing country. In addition, surgeon should awe that blood glucose level, blood pressure and bleeding tendency are prone to be increased due to some traditional medicines, local herbal supplements and local foods taken in some ethnic groups and people in rural area 30) . Such patients must be given brief health education about the incisional wound healing, frequent followed-up and checked for condition after operation. Special measures are needed to persuade some patients to take the medication prescribed by the surgeon because there are some local people who believe that medicinal plants, traditional medicines, fortune tellers' advices and meditation are more effective than Western medicines 31,32) . Surgeon should awe and check the condition of wound healing frequently to some patients who have religious attitudes toward foods such as being vegetarian, avoiding some meats and avoiding meals in the night time in some ethnic groups. Repeated follow-up at short intervals may be helpful for prevention of an infected wound and scarring. Furthermore, antibiotic resistance can occur because of poor personal and environmental hygiene and ready access to antibiotics over the counter without a prescription 33) . Consequently, antibiotic resistance is one of the health problems in Myanmar 34) . Therefore, different types of antibiotic were given to some patients who were not sensitive to the previously given antibiotic. To date, health insurance has not been available in Myanmar and is not well understood by most of its inhabitants. However, the country has the opportunity to establish a health insurance system in the future 21) .
This study has some limitations that stem mainly from its retrospective design. The recovery time varies from patient to patient according to the individual's natural healing process and general condition, ranging from 2 to 6 months or more to achieve the final outcome. It is difficult for patients who live outside Yangon to return to the clinic at the time when their final outcome is evident. Some patients who live outside Yangon received surgery but could not stay 7 days or come back Yangon for the removal of their stitches were referred to remove their stitches to the local doctors in their cities or villages. The condition of such patients was monitored and followed up by telephone only. Some patients did not return to the clinic after removal of their stitches (7 days after surgery) either because they kept their operation confidential or because of the inconvenient transport system outside Yangon. Therefore, the MRD1 was not able to measure in these patients. Some patients may need more time to recover, and a further study of the changes in the eyelid and the stages of recovery at 1 month to 6 months postoperatively may be needed. Some patients were incorporative to the questionnaire and some patients were half incomplete. Such patients were excluded. Therefore, the contact details or the final results could not be obtained for 302 of 606 patients, i.e., 49.8 % of the samples were dropped out in this study. Lacking the data for MRD1, the esthetical and satisfactory outcome from these dropped-out patients may be affected to the result. Therefore, the present results should be interpreted cautiously. In the future, studies that follow more patients will be necessary. Finally, the study was performed at a single center and all surgeries were performed by the same surgeon, which limits the generalizability of its findings. More advanced techniques with a certain period of recovery time and follow-up care are essential for the stability of lid fold and to prevent dropping of redundant eyelid skin that may cover the lid fold with better functional and esthetic benefit.

Conclusions
This study demonstrates the techniques used to perform double eyelid surgery in Myanmar that are effective in terms of both functional improvement and satisfactory cosmetic outcome. In addition, our technique by adjusting the directions of eyelash lines could prevent eyelash ptosis and bilateral asymmetric lid folds. It is important to understand the individual patient's esthetic desires and eyelid structure among different ethnic people in Myanmar. This report has also outlined the evolution of plastic esthetic surgery in Myanmar and the challenges faced. This is the first retrospective study of double eyelid surgery in Myanmar and may help other clinicians and researchers to achieve better functional and esthetic outcomes.