5 Techniques for Mini-Incisional Blepharoplasty with Septum–Orbicularis Fixation for Double Eyelid Formation

Introduction The creation of a supratarsal crease remains one of the most frequently performed aesthetic procedures in East Asian patients. Conventional approaches broadly fall into two categories: non-incisional suture techniques and full-incision blepharoplasty. While suture methods offer minimal invasiveness and rapid recovery, they are limited by higher rates of fold attenuation and long-term instability. In contrast, full-incision techniques provide durable crease formation but at the cost of increased tissue trauma, prolonged edema, and visible scarring in selected cases.

Contemporary surgical evolution has focused on bridging this gap through mini-incisional (partial-incision) techniques, which aim to preserve the advantages of both approaches. Central to many of these methods is septum–orbicularis fixation (SOF)—a strategy that anchors the anterior orbital septum (or its derivatives) to the orbicularis oculi muscle to recreate the physiologic adhesion responsible for a natural double eyelid.

This article reviews five established mini-incisional techniques incorporating SOF principles, with emphasis on their anatomical rationale, operative workflow, and reported clinical outcomes. These techniques provide a structured framework for tailoring surgical strategy to individual eyelid morphology.

The height of the supratarsal crease influences the shape of the palpebral fissure (the eye opening).

The levator aponeurosis and the anterior orbital septum conjoined at the superior border of tarsal plate

---

Core Techniques in Mini-Incisional Septum–Orbicularis Fixation 1. Single Mini-Incision Orbicularis–Orbital Septum Fixation (SOF)

The single mini-incision technique represents the most streamlined implementation of SOF. A solitary incision (8–12 mm) is placed along the designed crease, typically corresponding to the superior border of the tarsal plate. The defining maneuver involves inferior turnover of the distal anterior orbital septum, which is then anchored to the inferior orbicularis oculi muscle using three buried sutures (central, medial, and lateral). This configuration recreates the layered adhesion seen in naturally occurring double eyelids. Closure is performed with an intradermal suture, avoiding external knot visibility.

Surgical Workflow

• Preoperative crease marking from the lid margin in the sitting position

• Local anesthesia followed by a single midline mini-incision

• Dissection to expose orbital septum and levator aponeurosis junction

• Selective debulking of orbicularis and fat as indicated

• Inferior rotation of distal septum and three-point fixation to inferior orbicularis

• Intradermal skin closure

Outcomes

• Mean operative time: 27 minutes

• Rapid edema resolution (≈5 days; near complete by 2 weeks)

• High satisfaction (99.4%)

• Low complication rates (asymmetry 1.2%, crease loss 0.6%)

2. Triple Mini-Incision Technique with Distributed Fixation

The three-incision method expands fixation across the eyelid by utilizing three discrete portals (medial, central, lateral), each measuring 3–5 mm. This configuration improves crease continuity and is advantageous in patients with thicker soft tissue or prominent pre-aponeurotic fat.

Through each incision, selective debulking of pretarsal orbicularis and fat is performed. Fixation sutures engage the septum or levator complex and are anchored to the lower flap dermis or orbicularis.

Surgical Workflow

• Three incision points marked along the crease line

• Portal-based dissection to pre-aponeurotic plane

• Targeted fat and orbicularis reduction per region

• Placement of fixation sutures at each portal

• Closure with fine sutures or adhesive support

Outcomes

• Consistent crease formation

• Improved symmetry across the lid

• Reliable long-term retention
  

3. Four-Portal Mini-Incisional Technique with Pretarsal Fascia Fixation

The four-incision approach further refines crease precision by distributing fixation across four equidistant 2 mm portals. This method is especially useful in patients with long palpebral fissures, where fewer fixation points may result in segmental instability.

Following orbicularis excision over the levator plane, fat removal is performed—typically more aggressively laterally. Each portal is then used to anchor skin to the pretarsal fascia.

Surgical Workflow

• Design of four evenly spaced incision sites

• Blunt dissection to levator aponeurosis level

• Removal of overlying orbicularis

• Lateral (and selective medial) fat excision

• Four-point fixation to pretarsal fascia

• Skin closure

Outcomes

• Satisfaction rate: approximately 92%

• Mean follow-up duration: 9 months

• Consistent supratarsal crease formation observed

• High degree of symmetry across the eyelid

• Stable aesthetic outcomes maintained over follow-up period

4.Modified Partial-Incision Technique (SIMDI)

The SIMDI (Small-Incision, Minimal Dissection) technique diverges from traditional methods by preserving the orbicularis oculi muscle rather than excising it. Instead of debulking, the intact orbicularis serves as a fixation interface.

Sutures are placed between the orbicularis and levator aponeurosis, allowing crease formation through dynamic tissue coupling rather than structural reduction.

Surgical Workflow

• Small incision (6–10 mm) at crease level

• Minimal subcutaneous dissection

• Conservative fat removal only when necessary

• Identification of levator aponeurosis

• Orbicularis-to-levator fixation (1–2 sutures)

• Skin closure with optional short-term taping

Outcomes

• Preservation of anterior lamellar volume

• Formation of softer, more natural-appearing supratarsal folds

• Dynamic crease behavior with eyelid movement

• Reduced risk of postoperative hollowing

• Lower likelihood of over-deepened or overly rigid crease formation

5.Tarsus–Orbicularis–Septum (TOS) Triple-Layer Fixation

The TOS technique represents the most structurally comprehensive mini-incisional approach, utilizing a three-layer anchoring system involving the pretarsal tissue/tarsus, orbicularis oculi, and distal orbital septum flap. By incorporating the tarsus as a deep anchor, this method addresses a key mechanism of long-term failure—insufficient deep fixation.

Surgical Workflow

• Exposure of the orbital septum and levator aponeurosis complex

• Controlled fat debulking with creation of a distal septal flap

• Three-layer fixation sequence:

  • Pretarsal tissue / superficial tarsus (deep anchor)

  • Orbicularis oculi of the lower flap (intermediate layer)

  • Downward-turned distal septal flap (anterior layer)

• Skin closure using a buried knot technique

Outcomes

• High overall improvement rates with durable crease formation

• Enhanced long-term fold stability due to deep tarsal anchoring

• Reduced likelihood of crease loosening compared to superficial fixation methods

• Natural, dynamic eyelid movement preserved through multi-layer coupling

• Consistent aesthetic outcomes maintained over mid- to long-term follow-up

  
  

18-year-old woman underwent bilateral single mini-incisional blepharoplasty with orbicularis–orbital septum fixation and medial epicanthoplasty. Preoperative and 2-week postoperative views of open and closed eyes.

27-year-old woman underwent bilateral single mini-incisional blepharoplasty with orbicularis–orbital septum fixation. Preoperative and postoperative open/closed eye views at 1 week and 5 months.

---

Comparative Analysis: Technique Selection Matrix

Technique	No. of Incisions	Fixation Anchor	Debulking	Operative Time	Ideal Candidate	Crease Stability
Single-Incision SOF	1 (~8–12 mm)	Septum → Orbicularis	Moderate	~27 min	Thin–medium eyelids, younger patients	High (reported satisfaction ~99%)
Triple Mini-Incision	3 (3–5 mm each)	Septum / Levator → Orbicularis	Moderate–high	30–45 min	Medium–thick eyelids, prominent lateral fat	Good (supported by systematic review data)
Four-Portal Pretarsal	4 (≈2 mm each)	Skin → Pretarsal Fascia	Selective (per portal)	35–50 min	Longer palpebral aperture, need for even crease distribution	Good (reported satisfaction ~92%)
SIMDI (Orbicularis-Preservation)	1 (6–10 mm)	Orbicularis → Levator	Minimal (orbicularis preserved)	20–30 min	Younger patients, thin eyelids, preference for soft crease	Moderate (volume-dependent outcomes)
TOS Triple-Layer Fixation	1–3 (variable)	Tarsus + Orbicularis + Septum	Moderate	40–55 min	Revision cases, higher risk of crease loss	High (enhanced structural durability)

Conclusion

Mini-incisional blepharoplasty techniques incorporating septum–orbicularis fixation represent a meaningful evolution in double eyelid surgery, providing a structured intermediate approach between non-incisional suture methods and full-incision procedures. Across the spectrum of techniques, long-term outcomes are primarily influenced by the depth and distribution of fixation, the extent of soft-tissue preservation, and the precision of anatomical layer engagement, rather than incision length alone.

Single-incision approaches offer procedural efficiency and rapid recovery with reliable crease formation in appropriately selected patients. In contrast, multi-portal techniques improve regional control and symmetry, particularly in patients with thicker or anatomically variable eyelids. Preservation-based strategies such as SIMDI prioritize maintenance of soft-tissue volume and dynamic crease behavior, whereas multi-layer fixation systems such as TOS enhance structural stability and long-term fold retention, especially in revision or high-risk cases.

Overall, septum–orbicularis fixation serves as a unifying reconstructive principle that enhances predictability of crease formation by recreating a physiologic adhesion plane. With appropriate technique selection based on eyelid anatomy and surgical objectives, mini-incisional approaches can achieve an optimal balance of natural aesthetic outcome, low morbidity, and durable crease stability.

Read Similar Articles Here

Reference:

• Chen, B., Ma, L., Qi, H., & Luo, L. (2024). Single-incision mini-incisional blepharoplasty with orbital septum–orbicularis fixation: A clinical study of outcomes and technique refinement. Journal of Plastic and Aesthetic Surgery.

• Lin, X., Wang, Y., & Zhang, H. (2022). Small-incision orbicularis-preserving double eyelid surgery (SIMDI): A minimally invasive approach for dynamic crease formation. Journal of Plastic and Reconstructive Surgery.

• Xu, Y., Liu, J., & Chen, W. (2016). Four-portal mini-incisional blepharoplasty with pretarsal fascia fixation: A long-term clinical evaluation. Journal of Plastic, Reconstructive & Aesthetic Surgery.

• Zheng, M., Huang, L., & Gao, Q. (2022). Mini-incisional blepharoplasty techniques: A systematic review of multi-portal fixation methods in double eyelid surgery. Journal of Plastic, Reconstructive & Aesthetic Surgery.

• Wang, J., Li, X., & Sun, R. (2022). Tarsus–orbicularis–septum (TOS) triple-layer fixation in double eyelid surgery: A prospective clinical evaluation. Aesthetic Plastic Surgery.

---

Master principles and techniques of non- and incisional eyelid surgery, including double eyelid creation, ptosis correction, epicanthoplasty, canthoplasty, and lower eyelid approaches:

IFAAS Mini Fellowship (In-OR Observation)​

Korean Advanced Facial Aesthetic Surgeries - Advanced Asian Blepharoplasty

21-22 August, 2026 - Seoul, South Korea  - [Register Now]

---

More Upcoming Global Events

Global Event Calendar