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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, antibi-otic resistance can occur because of poor personal and environmental hygiene and ready access to antibiotics over the counter without a prescrip-tion33). Consequently, antibiotic resistance is one of the health problems in Myanmar34). 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 under-stood by most of its inhabitants. However, the country has the opportunity to establish a health insurance system in the future21).This study has some limitations that stem mainly from its retrospective design. The recovery time varies from patient to patient according to the indi-vidual’s natural healing process and general condi-tion, 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 moni-tored 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. This study demonstrates the techniques used to perform double eyelid surgery in Myanmar that are effective in terms of both functional improve-ment and satisfactory cosmetic outcome. In addi-tion, our technique by adjusting the directions of eyelash lines could prevent eyelash ptosis and bilat-eral asymmetric lid folds. It is important to under-stand the individual patient’s esthetic desires and eyelid structure among different ethnic people in Myanmar. This report has also outlined the evolu-tion 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. The authors thank Dr. Choladhis Sinrachtanant, Teeraporn Clinic, Facial Cosmetic Surgery Insti-tute, Bangkok and Dr. Gordon Soo, Department of Othorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong for giving advices. The authors also thank staffs of the clinic for assisting in contacting the patients to complete the questionnaire. The authors received no financial support for the research, authorship, and publication of this article. Study conception and design: KCK, HM Drafting of the article: KCKAnalysis and interpretation of data: HM Data acquisition: KCKThe authors have no conflict of interest to disclose. 461Conclusions AcknowledgementsFundingAuthor contributions Conflicts of interest