COSMETIC

New Technique Combined with Suture and Incision Method for Creating a More Physiologically Natural Double-Eyelid
Byung Chae Cho, M.D. Jin Suk Byun, M.D.
Daegu, Korea

Background: A combination of incision and nonincision surgical approaches is necessary to create a more physiologically natural double-eyelid. Methods: The location of the partial incision and the burying location are determined. Through a partial incision, the levator aponeurosis is isolated and fixed to the tarsal plate. A single-knot continuous suture is performed. The location of the continuous suture passing through the tarsal plate is at a level that is slightly lower than that at which the levator aponeurosis is fixed to the tarsal plate. Results: A total of 562 patients were operated on from November of 2006 through October of 2008. The double-eyelid operation was performed on 386 patients, the upper blepharoplasty with skin excision was performed in 91 patients, and a secondary operation was performed in 85 patients. Combined mild to moderate blepharoptosis was corrected simultaneously in all cases. The follow-up period ranged from 6 months to 2 years. Individual patient recovery time varied from 2 weeks to 2 months. Conclusions: The advantages of the authors technique are as follows: (1) the process of forming a double-eyelid is natural; (2) the power of the levator palpebrae muscle regarding the eye-opening process is transmitted to pull up the entire lid margin, allowing the eyes to be easily opened with minimal effort; and (3) there is minimal surgical scarring when the eyes are closed. (Plast. Reconstr. Surg. 125: 324, 2010.)

ouble-eyelid surgery, including epicanthoplasty, is the most common aesthetic surgical procedure in Korea.114 Many procedures regarding the Asian double-eyelid operation described in research studies can be classified as incision and nonincision techniques. In the early surgical procedures, a complete incision was considered to be the main surgical technique. However, because of patient demands in which surgical marks should be minimized and postsurgical recovery should be swift, the trends are changing from a complete incision to a partial incision, and from partial incision to the buried suture (nonincision) method. Generally, a buried suture (nonincision) method leaves no visible scar and has a shorter operative time, less morbidity, and faster recovery.
From the Department of Plastic and Reconstructive Surgery, Kyungpook National University Hospital, and BS Aesthetic Clinic. Received for publication February 6, 2009; accepted July 20, 2009. Copyright 2009 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3181c496c5

However, this method is not suitable in every case.17 This method is difficult to apply in cases with a weak function of the levator palpebrae muscle. In contrast, a complete or partial incision method may result in a strengthening of the levator palpebral muscle, in which patients will have a sense of a wide-open feeling of the eyes. However, the levator-to-dermal suture technique and the tarsodermal fixation method both leave a scar, have long-lasting edema, and require a long recovery time. The authors believe that an appropriate combination of these two surgical approaches is necessary to create a more physiologically natural double-eyelid. The strength of eye opening may be achieved and at the same time surgical scarring may be minimized. In addition, when the eyes are open, the double-eyelid line would not be deep

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

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but rather gently and gradually formed. The process of forming a double-eyelid is natural and spontaneous. There are no procedures that describe the combination suture and incision technique regarding double-eyelid operations. The authors introduce a new technique and report on the surgical results. layer. First, one side is separated and the levator aponeurosis is fixed to the tarsal plate. Local anesthesia is allowed to infiltrate into the area below the muscle layer by injecting it into the surgical incision site contralaterally. Incision The orbicularis oculi muscle is dissected in a perpendicular direction through a partial incision. While lifting the skin margin, using a skin hook, the tarsal plates upper border is exposed by separating the internal and external aspects deeply and perpendicularly, in small steps, one at a time (Fig. 2). The anterior septum is opened and then separated from the levator aponeurosis. If there is herniated orbital fat, the fat is removed. Tarsal Fixation The levator aponeurosis is disinserted after isolating it by opening the anterior septum. In the case of a normal or mild ptosis, the levator aponeurosis is disinserted between partial incision line b-c. In the case of moderate or severe ptosis, the disinsertion is slightly extended medially and laterally from the partial incision line b c. The levator aponeurosis is fixed to the tarsal plate by adjusting the position of the levator aponeurosis. The fixation sutures between the levator aponeurosis and the tarsal plate are performed at incision points b and c (Fig. 3). In certain cases, when the levator function is weak, the levator sheath is affixed to the tarsal plate to provide more strength. The location of the tarsal fixation is determined by either the position of the lid margin before the

PATIENTS AND METHODS

Design Careful review of the current state of both eyes is necessary before the operation. A decision must be reached regarding the location of the doubleeyelid line and an appropriate dimension of it. Once the line for the double-eyelid has been determined, the location of the partial incision and the burying location are decided on (Fig. 1). A minor incision may be applicable to individuals who have thin skin and a protruding eyelid (Fig. 1, b and c). A half incision may be applicable to patients with thick skin, sunken-type eyelids, or blepharoptosis, and in cases in which the doubleeyelid line should be changed because of a recessed double-eyelid or scar (Fig. 1, a, b, and c). A full incision may be applicable to patients with (1) redundant skin with droopy eyelids, (2) severely scarred secondary upper lid blepharoplasty, and (3) high fold correction procedures (Fig. 1, a through e). Infiltration A small amount of 1% lidocaine containing 1:100,000 epinephrine is infiltrated into the skin at the surgical site. The side with a stronger levator function is selected preferentially, a skin incision is made, and then a slightly higher amount of anesthesia is injected to the area below the muscle

Fig. 1. Drawing demonstrating the preoperative design. a, Medial limbus; b, medial pupil; c, lateral limbus; b and c, partial incision; a, d, and e, stab incisions.

Fig. 2. Drawing demonstrating the operative procedure. Through a partial incision, the upper border of the tarsal plate is exposed by separating the internal and external aspects deeply and perpendicularly.

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Fig. 3. Drawings demonstrating the operative procedure. The levator aponeurosis is fixed to the tarsal plate by adjusting the position of the levator aponeurosis. If the levator function is weak in certain cases, the strength of the levator sheath is used to fix it to the tarsal plate. L, levator aponeurosis; T, tarsal plate.

operation or by the extent of the levator function. By observing the condition of the right and left eyes, a tarsal fixation is performed first on the side in which the levator function is somewhat better. Thus, tarsal fixation regarding the side with a weaker levator function is conducted in as close a proximity as possible to the normal side, based on the principle that this induces a good result. The side with weaker levator function may be more sensitive to lidocaine. Thus, there is a possibility of a wrong decision being made if it is fixed to a weaker area rather than the actual fixation height. Therefore, in adjusting the actual strength of the opened eyes, one should pay attention to the fact that the tarsal plate should not be fixed too strongly, as opposed to that of the normal side. The immediate postoperative height of the lid margin should be verified by opening the eyes without the function of the frontalis muscle. Suture Technique Once the site of the tarsal fixation is verified bilaterally, a single-knot continuous suture is performed (Fig. 4, above). The medial (Fig. 4, a b) and lateral (Fig. 4, d e) locations of the continuous suture pass through the tarsal plate (Fig. 4, above and center). The location of the continuous suture should be at a slightly lower level than that at which the levator aponeurosis is fixed to the tarsal plate (Fig. 4, below). The location of the knot

Fig. 4. Drawings demonstrating the procedure of a single-knot continuous suture. (Above) Cross-sectional view of a single-knot continuous suture. The location of the knot should be at the central part of the partial incision, and the knot should not be tight at all. (Center) The location of the continuous suture passing through the tarsal plate should be at a level slightly lower than the level at which the levator aponeurosis is fixed to the tarsal plate. (Below) Final view. The knot loosely fitting to the distal end of the levator aponeurosis is located at a level that is below the orbicularis oculi muscle and the levator aponeurosis. a, Medial limbus; b, medial pupil; c, lateral limbus; a, d, and e, stab incisions; L, levator aponeurosis; T, tarsal plate.

should be at the central part of the partial incision, with the knot fitted loosely to the distal end of the levator aponeurosis. The knot is located beneath the orbicularis oculi muscle and the levator aponeurosis (Fig. 4, center and below).

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After the completion of a continuous suture, the skin is closed after verifying that the eyelid levels are symmetrical bilaterally in a sitting position (Fig. 5). If the eyelid levels are not aligned, the eyelid level is adjusted to either a weak or strong side by means of levator plication or levator loosening or the eyelid levels are corrected by an additional fixation procedure.

RESULTS
A total of 562 patients were operated on from November of 2006 to October of 2008. The double-eyelid operation alone was performed in 386 patients, an upper blepharoplasty with skin excision was performed in 91 patients, and a secondary operation was performed in 85 patients, using the authors technique. Mild to moderate cases of blepharoptosis were corrected in conjunction with the double-eyelid operation and upper blepharoplasty. In particular, 21 patients presented with moderate to severe blepharoptosis. The follow-up period ranged from 6 months to 2 years. The length of the operation was 40 minutes. Total stitch-out was performed on the third day after the operation. The patients general recovery time to achieve a more naturally physiologic double-eyelid was within approximately 2 weeks to 2 months (Figs. 6 through 10). Four hundred thirtysix patients were able to be followed-up between 6 months and 2 years. The final results were evaluated on the basis of the degree of symmetry and

Fig. 6. Photographs of a 23-year-old woman with a single-eyelid (above) preoperatively and (below) 20 months postoperatively.

Fig. 5. Final view of skin closure.

the shape of the double-eyelid and the degree of patient satisfaction. Excellent results were achieved in 395 patients (90.6 percent), with symmetry of both double-eyelids and excellent levels of satisfaction; 32 patients (7.3 percent) showed good results, nine patients (2.1 percent) achieved fair results, and no patients achieved poor results. Postoperative complications included doubleeyelid asymmetry in 25 cases, loosening of the double-eyelid in three cases, and exposure of suture material in one case. In 23 cases, in which the heights of lid margins differed bilaterally, the eyelid levels were corrected by adjusting the levator tension 1 week after the operation. The main cause of the postoperative difference of lid levels is supposed to be preoperative anatomical structural differences of the levator palpebrae muscle and unreflected levator palpebrae muscle function in both eyes. It is not appropriate to inject the lidocaine mixed with epinephrine solution into the deep and wide operative field during the operative procedure because of the nature of the postoperative difference regarding both lid levels, which was shown in cases with an overinfiltration of lidocaine with an epinephrine solution in one

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Fig. 7. Photographs of a 25-year-old woman with a high double-eyelid and moderate ptosis. In this patient, a double-eyelid operation and ptosis correction were performed at another clinic. However, high double-eyelid and uncorrected ptosis were presented. (Above, left). Preoperative view with uncorrected ptosis. (Above, right). Preoperative eye closing view showing a deep intense previous double-eyelid operation line. (Below, left) Four-month postoperative view. (Below, right) Four-month postoperative eye closing view shows no intense double-eyelid line.

eye. The three cases with weakening or loosening of the double-eyelid fold were corrected with an additional buried technique. One case exhibited exposure of the suture material at 4 months after the operation. The double-eyelid was maintained after removal of the suture material. To avoid exposure of suture material, it is important to take care not to make a superficial passage of the suture material in the patient with very thin skin of the upper eyelid.

DISCUSSION
The mechanism of creating a natural-appearing double-eyelid is known as following the process. In observing inherently natural double-eyelids, they begin to form slightly in the process of eye opening as the levator palpebrae muscle contracts and the double-eyelid lines become distinctive when the eyes open widely. However, as the eyes are closed, the distinctive fold disappears and even the buried line cannot be seen. The pro-

cesses of creating a double-eyelid after the operation may be different, depending on the fixation position and strength of connections from the levator aponeurosis to the tarsal plate and the levator aponeurosis to the skin (Fig. 11). Therefore, there are differences regarding the strength required to open the eyes and the depth of a double-eyelid. A double-eyelid created by a buried method has a loose connection between the levator palpebrae muscle and the skin. Thus, this exhibits a similar process in creating an inherent doubleeyelid. However, creating a double-eyelid using a buried technique to an eye with a weak levator function would lead to the patient having a lid margin level that is lower than that of a normal position. Application of the buried technique is limited to situations in which the sizes of both eyes are different or in cases where the size of the double-eyelid should be changed. In cases in which the buried nonincision method is used, the

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Fig. 8. Photographs of a 26-year-old woman with single-eyelid and mild ptosis (above) preoperatively and (below) 6 months postoperatively.

Fig. 9. Photographs of a 25-year-old woman with ptosis and asymmetry of the double-eyelid by suture technique (above) preoperatively and (below) 17 months postoperatively, with simultaneous correction of ptosis and asymmetry of the double-eyelid.

process of strengthening the levator function is absent, and the levator function becomes distinctively weaker after the operation (Fig. 11, above). The mechanism of creating a double-eyelid using an incision method involves a technique by which the dermis or muscle layer of the lower flap is fixed directly to the levator aponeurosis. In this way, the degree of strength regarding eye opening is transmitted from the levator aponeurosis to the tarsal plate, thereby lifting the lid margin. However, in the process of transmitting this strength, because the power is dispersed and redistributed to the lower flap that is connected to the central part, the power of eye opening would not be transmitted efficiently. The higher the height of fixation of the lower flap, the greater the loss of the strength of the eye opening, because significant dispersion of the strength before the eye while opening is transmitted to the lid margin at the early stage (Fig. 11, below). Furthermore, the lower flap that retains tension after the operation contains edema, acting as another hindering factor that further limits the power of the eye while opening. If double-eyelid folds are created by means of using an incision method along the incision line

by fixing the muscle layer or dermis portion of the lower flap to the levator aponeurosis or the levator sheath, the strong force of the eye opening is applied, especially to the fixed area in the line of the double-eyelid. As a result, a depression frequently develops in the fixed area as opposed to that of the unfixed area. When reviewing the mechanism of opening the eyes after an operation using the authors method, the levator palpebrae muscle strength, exhibited when the eyes are open immediately after closure, is not affected by the skin and is transmitted directly to the tarsal plate. As a result, the lid margin is preferentially lifted and the strength of the levator palpebrae muscle that opens the eye is totally transmitted to pull the lid margin. Thus, the eyes are opened easily with minimal effort, because the strength of the levator palpebrae muscle in the early stage of the eye-opening process is first transmitted to the tarsal plate. In the mechanism proposed in this article, unlike the incision method, the lower flap is connected loosely with suture material to the distal end of the levator aponeurosis to a level that is

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Fig. 10. Photographs of a 50-year-old woman with single-eyelid and moderate ptosis (above) preoperatively and (below) 3 months postoperatively,withsimultaneousskinexcisionoftheuppereyelid and elevation of the eyebrow using endoscopic surgery.

lower than that of the fixation position of the levator aponeurosis. In such a structure, the power of eye opening is efficiently transmitted without diminishing its strength in the early phase of the eye-opening process. In addition, postoperative swelling on the lower flap is minimal, without loss of the power of eye opening, which allows for effective correction of ptosis in the event of weak levator function. This allows for easy lifting of the lid margin as a dynamic lid crease (Fig. 11, below). With the eyes open somewhat (if the lid margin is moved to the upper direction), tension is triggered gradually by the suture material, therefore gently creating the eyelid folds. At this moment, the upper eyelid skin, including the lid margin, has already been moved to the upper direction. Thus, a soft and natural double-eyelid, instead of a deep and intense fold, is created along the suture material. In addition, because only a little tension is required by the lower flap after the operation, the advantages of less edema and a faster recovery process in most cases are evident. The possibility of weakening or loosening of the double-eyelid fold in the

Fig. 11. Comparisonofdifferencesinthestrengthofopeningtheeye and depth of double-eyelid among three techniques. (Above) Nonincision technique; (center) incision technique; (below) the authors technique. The processes of creating a double-eyelid after double-eyelid surgery may be different depending on the fixation position and strengthofconnectionsfromthelevatoraponeurosistothetarsalplate andthelevatoraponeurosistotheskin.Strengthofopeningtheeye,A1 B1 C1;strengthofcreatingthedouble-eyelid,A3 C3 B3;postoperative edema, A2 C2 B2; strength of opening the eye and creatingthedouble-eyelid,A1-A2-A3 B1-B2-B3 C1-C2-C3(A B C).

authors proposed technique is rare compared with the suture method alone over the 2-year follow-up period. The proposed technique allows the strength of the eye opening to be transmitted first and

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the double-eyelid folds are created during the eye-opening process. Thus, the eye-opening strength does not become weakened and the double-eyelid lines are created distinctively at the eye-opening phase. In addition, the levator palpebrae muscle is connected weakly to the lower flap by the suture material. Thus, the folds created by indirect power are gentle but are not easily disconnected or dissolved in the cases studied (Fig. 11, below).
2. Mikamo M. Mikamos double-eyelid operations: The advent of Japanese aesthetic surgery, 1896. Plast Reconstr Surg. 1997; 99:664; discussion 664669. 3. McCord CD, Seify H, Codner MA. Transblepharoplasty ptosis repair: Three-step technique. Plast Reconstr Surg. 2007; 120:10371044. 4. Megumi Y. Double-eyelid procedure by removal of transconjunctival orbital fat and buried sutures combined with sling technique to avoid wounding the eyelid. Aesthetic Plast Surg. 1997;21:254257. 5. Shiao IS. Oriental double-eyelid: A simplified nonincisional technique using the twin-needle suturer. Plast Reconstr Surg. 1995;96:179182. 6. Shirakabe Y, Kinugasa T, Kawata M, Kishimoto T, Shirakabe T. The double-eyelid operation in Japan: Its evolution as related to cultural changes. Ann Plast Surg. 1985;15:224241. 7. Baek SM, Kim SS, Tokunaga S, Bindiger A. Oriental blepharoplasty: Single-stitch, nonincision technique. Plast Reconstr Surg. 1989;83:236242. 8. Sayoc BT. Plastic construction of the superior palpebral fold. Am J Ophthalmol. 1954;38:556559. 9. Boo-Chai K. Plastic construction of the superior palpebral fold. Plast Reconstr Surg. 1963;31:7478. 10. Fernandes LR. The double-eyelid operation in the Oriental in Hawaii. Plast Reconstr Surg. 1960;25:257264. 11. Flowers RS. Upper blepharoplasty by eyelid invagination: Anchor blepharoplasty. Clin Plast Surg. 1993;20:193207. 12. Lee JS, Park WJ, Shin MS, Song IC. Simplified anatomic method of double-eyelid operation: Septodermal fixation technique. Plast Reconstr Surg. 1997;100:170178; discussion 179181. 13. Kim SJ, Song IG, Choi JH, Lee JH, You YJ, Koh IS. Epicanthoplasty using Y-V advancement flap method. J Korean Soc Plast Reconstr Surg. 2009;36:200. 14. Baik BS, Suhk JH, Choi WS, Yang WS. Treatment of blepharoptosis by the advancement procedure of the Mullers muscle-Levator aponeurosis composite flap. J Korean Soc Plast Reconstr Surg. 2009;36:211.

CONCLUSIONS
In conclusion, the advantages of the authors technique are as follows. First, the power of the levator palpebrae muscle regarding the eye-opening process is transmitted to pull up the entire lid margin, allowing the eyes to be easily opened with minimal effort. Second, there is minimal surgical scarring when the eyes are closed. When the eyes are open, the double-eyelid line would not be deep, and is gently and gradually formed. Third, the difference between the left and right eyelid levels can be easily adjusted.
Jin Suk Byun, M.D. BS Aesthetic Clinic 59 Sa-il dong Jung-gu, Daegu 700-040, Korea byunjs55@hanmail.net

REFERENCES
1. Liao WC, Tung TC, Tsai TR, Wang CY, Lin CH. Celebrity arcade suture blepharoplasty for double-eyelid. Aesthetic Plast Surg. 2005;29:540545.

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