523020

research-article2014
AESXXX10.1177/1090820X14523020Aesthetic Surgery JournalHwang and Spiegel

Oculoplastic Surgery

The Effect of “Single” vs “Double” Eyelids Aesthetic Surgery Journal

2014, Vol. 34(3) 374­–382
© 2014 The American Society for
on the Perceived Attractiveness of Chinese Aesthetic Plastic Surgery, Inc.
Reprints and permission:

Women http://www​.sagepub.com/
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DOI: 10.1177/1090820X14523020
www.aestheticsurgeryjournal.com

Harry S. Hwang, MD; and Jeffrey H. Spiegel, MD, FACS

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Abstract
Background: A well-defined supratarsal crease has often been considered attractive, representing a significant component in a beautiful upper eyelid.
Approximately 50% of East and Southeast Asian women are born with either a minimal or absent supratarsal eyelid crease. Among people of Chinese
descent, the creation of a supratarsal crease (“double” eyelid blepharoplasty) is the most common cosmetic surgical procedure, but no comparative study
has assessed the height by which an upper eyelid crease is deemed most attractive and depending on cultural background.
Objectives: The authors assess how attractiveness is interpreted by different cultural groups to determine whether double-eyelid blepharoplasty
enhances attractiveness according to both Chinese and non-Chinese observers.
Methods: Facial photographs were taken of 19 women of Chinese descent. The photographs were enhanced with computer imaging software
to generate 3 additional pictures, depicting low, medium, and high upper eyelid creases on each model. Via an Internet-based survey tool, Chinese
and non-Chinese observers were asked to rate the attractiveness of the faces with each potential eyelid position. (Surveys are available online at
www.aestheticsurgeryjournal.com, as Appendix 1 and Appendix 2.)
Results: Both Chinese and non-Chinese observers considered the medium-height upper eyelid crease most attractive (P < .00001). An absent upper
eyelid crease was deemed the least attractive (P < .00001).
Conclusions: These preference data for eyelid height can be used to better counsel patients on perceived attractiveness and expectations for surgical
results, since these results further elucidate which facial features are universally considered attractive.

Keywords
oculoplastics, blepharoplasty, Asian eyelid, double eyelid, upper eyelid, attractiveness, supratarsal crease

Accepted for publication June 20, 2013.

The nature of human facial beauty and attractiveness has
been pondered for thousands of years. Attempts to define
beauty either by neoclassical standards, facial proportion,
or mathematical models lack scientific validity,1 and char-
acteristics of attractiveness may be influenced by cultural
and ethnic differences. However, more recent thinking sug-
gests aesthetic judgment may be both more universal and
similar across different cultural backgrounds than previ-
ously understood.2
Facial averageness and symmetry are 2 characteristics
demonstrated to be standards of beauty in both Western
and non-Western cultures. Rhodes and colleagues3 showed
that an averaged facial-shape composite of the same race
and sex increased perceived attractiveness of both Chinese
and Japanese faces; decreasing averageness by moving the
faces away from the average facial shape decreased per-
ceived attractiveness. The authors concluded that facial
shape averageness influenced attractiveness and, further,
was a characteristic not restricted to Western cultures.
However, averageness and symmetry do not help us to
Dr Hwang is a Staff Physician with the The Permanente Medical
Group, Inc in the Department of Head & Neck Surgery, Kaiser
Permanente Santa Clara Medical Center, Santa Clara, California, and
is a Clinical Instructor in the Department of Otolaryngology–Head
& Neck Surgery, Stanford University School of Medicine, Stanford,
California. Dr Spiegel is Professor and Chief of the Division of Facial
Plastic and Reconstructive Surgery, Department of Otolaryngology-
Head & Neck Surgery, Boston University School of Medicine, Boston,
Massachusetts.
Corresponding Author:
Dr Jeffrey H. Spiegel, Facial Plastic and Reconstructive Surgery,
Boston University School of Medicine, 1200 Boylston Street,
Chestnut Hill, MA 02467, USA.
E-mail: jeffrey.spiegel@bmc.org
Hwang and Spiegel
understand what specific anatomic areas, shapes, and
positions are particularly desirable.
The eyes represent a potential defining factor for facial
attractiveness. Enhancement of the eyes in the quest for
personal beauty has been well documented.4 Not only do
the eyes determine an individual’s ability to see the
world, but they also play a powerful role in nonverbal
communication. An individual’s emotions, interest, and
responsiveness can be communicated by nonverbal cues
generated by the eye and periorbital structures. The peri-
orbital areas also have been shown to be of paramount
importance in determining sex; hence, it may be hypoth-
esized that they are important in determining attractive-
ness as well.5 Further, a well-defined supratarsal crease is
often considered a significant component in the represen-
tation of a beautiful upper eyelid. Blepharoplasty is a
common surgical procedure performed to remove excess
skin or pseudoherniated fat obstructing the defined
supratarsal crease.
Approximately 50% of East and Southeast Asian women
are born with a minimal or absent supratarsal eyelid
crease.6 Creation of a supratarsal crease (“double eyelid”)
is the most common cosmetic surgical procedure among
people of Chinese descent.7 Cosmetic blepharoplasty also
continues to be the most popular facial cosmetic procedure
in Asian Americans.8 In a 2012 American Academy of
Facial Plastic and Reconstructive Surgery (AAFPRS) mem-
bership study, 44% of member surgeons responded that
blepharoplasty was the most common facial plastic sur-
gery procedure for Asian Americans, with rhinoplasty
being the second most common, at 41% in that specific
ethnic group. Double eyelid surgery is based on Mikamo’s
original description in 1896.9 As the supratarsal eyelid
crease is deemed attractive in Western cultures, desire for
this surgery has been considered largely cultural.10
However, we should be cautious about assuming this to be
the motivation of Chinese patients requesting a double
eyelid. The desire may not be for Westernization per se;
instead, the patient may be seeking a conservative natural
Chinese eyelid crease observable among his or her friends
and family. Kaw11 suggests that Asian individuals pursue
cosmetic eyelid surgery not so much to “Westernize” their
eyes but rather to appear more open-minded, energetic,
and youthful.
As a general rule, when performing blepharoplasty, the
superior palpebral crease should not be placed higher than
one-third the distance between the eye’s pupil and the
brow.12 The classic white—or Western—eyelid crease lies
about 7 to 10 mm above the eyelid margin. Alternatively,
the upper eyelid crease can be set at multiple heights, com-
monly designated as low, medium, and high. Liu13 further
stratified the appearance of the upper eyelid into 4 groups.
For Chinese women desiring double eyelid surgery, a
375
crease between 5 and 8 mm above the eyelid margin has
been suggested; for men, a lower eyelid crease has been
suggested as more appropriate.14 However, in our review of
the literature, we did not find a comparative study assess-
ing the height at which an upper eyelid crease is deemed
most attractive, as determined by cultural background.
Prior to undertaking this study, we posited that Chinese
and non-Chinese observers would consider the presence of
an eyelid crease to be more attractive; additionally, we
hypothesized that the lower eyelid crease position would
be considered both more natural and more attractive, given
that the lower crease yields the double eyelid without look-
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ing too “Westernized.” It is our hope that the results of this
study can be used to better counsel patients on realistic
surgical expectations and perceived attractiveness of cer-
tain lid heights.
Methods
After obtaining institutional board review approval at the
Boston University School of Medicine (Boston, Massachu­
setts), 19 women of Chinese descent were recruited as mod-
els and frontal photographs were taken of their faces. This
study was conducted from November 2010 to May 2011. The
participating models were selected from a group of student
volunteers from Boston University. The criterion for being a
model was to be of Asian descent and between 18 and 23
years of age. Consent was obtained from each model. Using
computer imaging software (Photoshop; Adobe, San Jose,
California), the photographs were digitally altered to gener-
ate 3 additional frontal-view pictures corresponding to each
model. Each element of any particular photo set differed
only in the height of the model’s upper eyelid crease. The
upper eyelid creases were categorized as being absent, low,
medium, and high in height, as per Liu’s delineations.14 The
absent crease and high-level creases were first determined,
and then the low and middle crease levels were marked by
separating the distance between the 2 levels. The same
crease width was drawn using the pen-mode of the com-
puter imaging software.
An Internet-based survey tool was created, with an
English version as well as a Chinese version, translated by
a native Chinese speaker. The Chinese version was trans-
lated into the standard traditional (complex) Chinese char-
acters suitable for both Chinese and Taiwanese participants.
Demographic data were collected for all survey partici-
pants, which included adult men and women 18 years of
age or older, of all ethnic backgrounds. (There were no
geographic exclusion criteria.) The study participants were
recruited on a voluntary basis from various social media
websites, including both English-based and Chinese-based
websites. The survey was open for 6 months. Reminders to
complete the survey were sent out 3 months prior to the
376
Figure 1. A 22-year-old Chinese woman. Four upper eyelid crease variations: (A) absent upper eyelid crease, (B) low upper
eyelid crease, (C) medium upper eyelid crease, and (D) high upper eyelid crease.
completion of the study. The non-Chinese group was
defined as all participants who did not self-identify as
being either Chinese or Taiwanese in ethnicity. These
Chinese and non-Chinese participants were then asked to
look at and compare the 4 photos of each model, rating
each version from the most attractive to the least attractive
(Figures 1-5). Faces were scored from 1 to 4, with a score
of 1 denoting the most attractive face and 4 indicating the
least attractive in the set. In this way, higher scores would
correlate with lower perceived attractiveness.
For all 19 models, the 4 photographic versions of each
face were randomly ordered. All images were presented
as half-screen (half a tablet screen) in size, with all image
sizes standardized for viewing. The fact that the upper
eyelid creases were digitally manipulated was not dis-
closed to the survey participants, nor was any informa-
tion regarding the differences between the 4 faces
provided.
At the end of the survey, we asked the participants
various questions regarding double eyelid surgery. We
used a 1-way analysis of variance (ANOVA), assuming
equal variances, to compare the mean attractiveness
scores for each eyelid position with statistical signifi-
cance set at α = 0.05.
Aesthetic Surgery Journal 34(3)
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Subgroup analysis was also performed for responses
based on different ethnic groups. Chinese Americans
and Taiwanese Americans were respondents who self-
identified as either ethnically Chinese or Taiwanese, were
not born in China, had not lived in China, had not worked
in China, or had not visited China frequently. These
respondents primarily used the English survey. Chinese
and Taiwanese nationals were respondents who self-iden-
tified on the Chinese-based survey as either ethnically
Chinese or Taiwanese, or those who spent significant parts
of their lives in China or Taiwan. We defined having spent
significant parts of their lives in China as the respondents
answering “yes” when asked if they were currently in
China, if they were born in China, if they worked in China,
if they were raised in China, or if they visited China often.
The basis for this subgroup classification was to identify
cultural influences, on the assumption that both Taiwanese
and Chinese Americans are more significantly exposed to
Western ideals of beauty. With the globalization of busi-
ness and media, Chinese nationals were anticipated to
have had at least some exposure to Western ideas of
beauty. However, it was expected that the much more cul-
turally homogeneous environments of China or Taiwan
would mitigate the influence of Western cultural norms.
Hwang and Spiegel 377

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Figure 2. A 23-year-old Chinese woman: (A) absent upper eyelid crease, (B) low upper eyelid crease, (C) medium upper
eyelid crease, and (D) high upper eyelid crease.

Figure 3. A 22-year-old Chinese woman: (A) absent upper eyelid crease, (B) low upper eyelid crease, (C) medium upper
eyelid crease, and (D) high upper eyelid crease.
378 Aesthetic Surgery Journal 34(3)

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Figure 4. A 21-year-old Chinese woman: (A) absent upper eyelid crease, (B) low upper eyelid crease, (C) medium upper
eyelid crease, and (D) high upper eyelid crease.

Figure 5. A 21-year-old Chinese woman: (A) absent upper eyelid crease, (B) low upper eyelid crease, (C) medium upper
eyelid crease, and (D) high upper eyelid crease.
Hwang and Spiegel 379

Table 1. Demographic Dataa When the results were analyzed by respondent sub-
Characteristic No. (%)
groups divided by ethnic backgrounds, self-identified
white respondents rated the middle-height crease variation
Sex as the most attractive (average score, 1.96). An absent
Male 59 (22.3) upper eyelid crease was rated as least attractive (average
score, 3.29). This subgroup’s overall results comparing the
Female 205 (77.7)
mean scores between the 4 variations (the difference
Age, y between each score) within the subgroup were statistically
significant (P < .00001). Furthermore, when comparing
18-24 36 (13.6)
the lowest score, middle-height crease variation (average
25-34 116 (43.9) score, 1.96), with the highest score, absent-height crease
35-44 80 (30.3)
variation (average score, 3.29), there was a statistically sig-

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45-54
55-64
Older than 65
Ethnicity
White
Black
Chinese
Taiwanese
Korean
Japanese
Filipino
Vietnamese
Other
a
In total, 409 respondents participated in the survey; 264 total surveys, in both English and
Chinese languages, were completed in entirety (response rate, 64.5%).
Results
A total of 409 participants responded to the survey request;
264 (64.5%) surveys were completed in entirety. For the
English-based survey, 147 (59.8%) of 246 surveys were
completed. For the Chinese-language survey, 117 (72.8%)
of 163 surveys were completed. The demographic charac-
teristics of all participants are provided in Table 1.
Table 2 highlights the mean attractiveness scores for
each of the 4 upper eyelid crease versions. Among all
grouped survey respondents, the most attractive of the 4
upper eyelid crease variations was the middle height (aver-
age score, 1.91; P < .00001). This was confirmed by com-
paring the 2 lowest mean attractiveness scores of the 4
variations (P < .00005). The least attractive was the absent
upper eyelid crease version (average score, 3.19; P <
.00001). This was confirmed by comparing the 2 highest
mean attractiveness scores of the 4 variations (P < .00001).
nificant (P < .00001) difference between these 2 mean
24 (9.1) scores.
8 (3.1) For the combined Chinese and Taiwanese American
subgroup, the middle-height crease variation was also
0
deemed the most attractive (average score, 2.00) overall;
however, when compared with the second most-attractive
52 (19.7)
variation (the low-height crease, at an average score of
2.15), the difference between the two was not significant
3 (1.1) (P = .11). An absent upper eyelid crease was deemed least
97 (36.7) attractive (average score, 2.96), but again, this result was
not statistically significant compared with the second least-
69 (26.1)
attractive crease (the highest crease, with an average
16 (6.1) score of 2.90; P = .60). When comparing the lowest score,
middle-height crease variation (average score, 2.00), with
5 (1.9)
the highest score, absent-height crease variation (average
5 (1.9) score, 2.96), there was a statistically significant (P <
6 (2.3)
.00001) difference between these 2 mean scores.
For the combined Chinese and Taiwanese national sub-
11 (4.2) group, responses were similar to those from the self-
identified white subgroup. The middle-height crease varia-
tion was deemed most attractive (average score, 1.89), and
the absent upper eyelid crease variation was deemed least
attractive (average score, 3.26). The results overall com-
paring mean scores between the 4 variations (the differ-
ence between each score) within this subgroup were
significant (P < .00001).
When the results were analyzed by subgroup based
on sex, both men and women deemed the middle eyelid
height variation as the most attractive of the 4 upper eyelid
creases (men: average score, 2.00, P < .00001; women:
average score, 1.93, P < .00001). Both groups also deemed
the absent crease as the least attractive (men: average score,
3.16, P < .00001; women: average score, 3.24, P < .00001).
Table 3 shows the participants’ responses to 3 questions
regarding their thoughts on double eyelid surgery. Most
respondents stated they were familiar with double eyelid
surgery (78.8%). The percentage of respondents who
stated they knew of a person having double eyelid surgery
performed was higher in the Chinese-based survey com-
pared with the English-based survey (68.4% vs 40.1%).
Most respondents in both groups neither liked nor disliked
double eyelid surgery (63.3% English-based survey vs
380 Aesthetic Surgery Journal 34(3)

Table 2. Mean Attractiveness Scoresa

Upper Eyelid Crease Height

Absent Low Middle High P Value

All respondents (N = 264) 3.19 2.28 1.91 2.62 <.00001

White (n = 52) 3.29 2.42 1.96 2.32 <.00001

Chinese and Taiwanese 2.96 2.15 2.00 2.90 <.00001

Americans (n = 33)

Chinese and Taiwanese 3.26 2.30 1.89 2.56 <.00001

nationals (n = 119)

Male (n = 59) 3.16 2.41 2.00 2.44 <.00001

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Women (n = 205) 3.24 2.33 1.93 2.50 <.00001

a
Mean attractiveness scores range from 1 to 4: 1 equals the most attractive, while 4 is the least attractive.

Table 3. Double Eyelid Surgery Questions and Responses

English Survey, No. (%) Chinese Survey, No. (%) All, No. (%)

Have you heard of double eyelid surgery?

Yes 113 (76.9) 95 (81.2) 208 (78.8)

No 34 (23.1) 22 (18.8) 56 (21.2)

Has anyone you know ever gotten double eyelid surgery?

Yes 59 (40.1) 80 (68.4) 139 (52.7)

No 88 (59.5) 37 (31.6) 125 (47.3)

How do you feel about double eyelid surgery?

Like 26 (17.7) 30 (25.6) 56 (21.2)

Dislike 28 (19.0) 15 (12.8) 43 (16.2)

No opinion 93 (63.3) 72 (61.5) 165 (63.6)

61.5% Chinese-based survey). Interestingly, however,
Chinese-speaking respondents (n = 30) were more likely
to be in favor of the surgery than non-Chinese or English-
speaking Chinese Americans (n = 26); in contrast, both
non-Chinese and Chinese Americans (n = 28) were more
likely to dislike the surgery than were Chinese (n = 15).
Discussion
The results of this study confirm our hypothesis that for
both Chinese and non-Chinese observers, the presence of
an upper eyelid crease is more attractive than an absent
upper eyelid crease. However, the middle-height eyelid
crease variation was found to be most attractive overall, in
contrast to our hypothesis that the low-height eyelid crease
variation would be the most attractive. These findings
were similar in both self-identified non-Chinese partici-
pants, as well as Chinese and Taiwanese national respon-
dents, suggesting that cultural influence may play less of a
role than previously thought in determining attractiveness.
Instead, a sense of attractiveness may be more innate, irre-
spective of ethnic and cultural background. Accordingly,
the impetus to pursue cosmetic eyelid surgery for Chinese
patients may be the desire to look more spirited and
energetic12—not necessarily to look more “Westernized,”
as suggested by Millard.15 Because the upper third of the
face has the most significance overall in determining femi-
ninity and attractiveness,16 it is not surprising the presence
of an upper eyelid crease plays a role in determining attrac-
tiveness, given its location.
The results of this study can allow surgeons to better
understand patients’ expectations of double eyelid surgery,
which may help them provide better counsel to patients on
what may be an acceptable, natural-appearing upper eye-
lid crease. Preoperative analysis is important when a
patient presents for double eyelid surgery. Aesthetic con-
siderations vary; anatomic variations and asymmetry are
common and must be recognized prior to surgery. Eyelid
Hwang and Spiegel
size, eyelid shape, and disposition of epicanthal creases
must be taken into consideration. Furthermore, surgeons
must identify anatomic variants that can lead to facial
asymmetry, such as unilateral brow or upper eyelid ptosis;
variations in globe position due to conditions such as
exophthalmos; variations in intercanthal axis, tilt, or
dimension between the eyes; postural disparities of the
lower eyelid position resulting in scleral show; or variation
in malar prominences.
Further, variations in the upper eyelid crease exist
between ethnicities. Chen5 accordingly subcategorized 7
forms of Asian eyelids: he emphasized that Asian upper
eyelid creases are generally lower compared with white
upper eyelid creases, due to a shorter tarsal width (6.5-8.5
mm). The distance between the eyebrow and the upper
eyelid margin is also narrower in the Asian upper eyelid.
Furthermore, the white upper eyelid crease has a semilu-
nar shape, which rarely occurs in Asians. These anatomic
ethnic differences need to be recognized to best determine
the most natural postoperative appearance of the upper
eyelid creases based on the patient’s ethnicity and desires.
The survey responses to questions concerning double
eyelid surgery in our study were not unexpected. Most par-
ticipants acknowledged they had heard of double eyelid
surgery, at a slightly higher percentage in the Chinese-
based survey (81.2%) compared with the English-based
survey (76.9%). This is not surprising, since blepharo-
plasty is the most common cosmetic procedure performed
in Asia.17 Likewise, a higher percentage of respondents to
the Chinese-based survey (68.4%) acknowledged they
knew of a person who had undergone double eyelid sur-
gery, as compared with English-based survey respondents
(40.1%). Interestingly, when asked about their personal
feelings regarding double eyelid surgery, the majority
of respondents in both groups neither liked nor disliked the
surgery—instead having no opinion. The percentage within
subgroups having no opinion was nearly equal: 63.3% in
the English-based survey and 61.5% in the Chinese-based
survey. However, more respondents to the Chinese-based
survey (25.6%) liked double eyelid surgery compared with
those answering the English-based survey (17.7%). The
majority of respondents having no opinion about the sur-
gery is somewhat surprising, given that more cosmetic pro-
cedures are being performed each year.9
Our study has a few potential weaknesses. First,
although we had a reasonable number of completed sur-
vey responses, the sample size for the combined Chinese
and Taiwanese American subgroup was smaller than that
for the white and Chinese and Taiwanese national sub-
groups. The smaller sample size for this subgroup may not
be adequately powered to signal a difference between the
2 most attractive and 2 least attractive upper eyelid crease
variations. Second, a selection bias may be inherent in our
381
study. Because our survey was conducted via a website,
the survey respondents may have been more technologi-
cally savvy and possibly more greatly influenced by the
media’s portrayal of women. Last, a few respondents com-
mented that they had difficulty determining which varia-
tions of the model faces were more or less attractive. Some
respondents felt there were no obvious differences in the
facial variations. We intentionally did not divulge to poten-
tial participants of our study what changes were made to
the models’ faces; we did not want to bias the decision-
making process of the respondents. Our goal was to deter-
mine whether respondents had an intrinsic perception of
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female attractiveness based on subtle changes in upper
eyelid crease heights.
Conclusions
Both Chinese and non-Chinese observers considered the
presence of a medium upper eyelid crease to be the most
significantly attractive eyelid shape, regardless of exposure
to Western cultures. Absence of an upper eyelid crease was
considered the least attractive. The results of this study can
be used to better counsel patients on realistic expectations
for surgery, as well as perceived attractiveness of certain
upper eyelid heights prior to double eyelid blepharoplasty.
Additionally, we can conclude that an upper eyelid crease
may be an important indicator of attractiveness regardless
of ethnicity.
Acknowledgments
The authors thank Jack Hwang for his assistance in the
Chinese translation of our survey and in recruiting partici-
pants for our study; additionally, Dr Hwang had full access to
all of the study’s data and takes responsibility for both its
integrity and the accuracy of the data analysis. We also thank
Nadia Chan for her assistance as a study coordinator.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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