Introduction

Only about 50% of Asians are born with a double eyelid, and double-eyelid blepharoplasty is one of the most commonly performed and most popular surgical procedures in Asia [1]. From an aesthetic point of view, a person with a double eyelid appears to have larger and brighter eyes and be full of energy. Currently, the two types of blepharoplastic procedures are the incision and buried suture methods [2]. The buried suture method was first introduced in 1896 [3]. This method is more popular among the younger population because it results in less scarring, is more likely to be reversible, and is associated with a speedy recovery in comparison with the incision method. Additionally, it has the advantages of easy adjustment and a short procedural time. A large number of buried suture methods have been reported [3,4,5,6,7,8,9,10,11,12]; however, limitations still exist with regard to the application of the various methods, including redundant skin, postsurgical swelling of the eyelid, extra skin tags, and blepharoptosis. Thus, the incisional method is the primary choice for many surgeons. In recent years, the noninvasive buried suture method [13, 14] and minor incision method [15] have been proposed. These methods allow adjustments for desired cosmetic effects and the simultaneous correction of blepharoptosis.

The traditional buried suture blepharoplasty mainly involves the tarsal conjunctiva areas and eyelid skin. Here, we propose a technique that extends the operation area to the aponeurosis–Müller’s muscle complex and eyelid by using the continuous single-knot buried suture method. Additionally, we assessed the effectiveness of this method. This method has the added advantage of the simultaneous correction of mild blepharoptosis along with a short procedural time.

Materials and Methods

We performed a retrospective study based on medical records; therefore, ethical approval was not required. Pre-operatively, we classified the degree of blepharoptosis as mild (1–2 mm), moderate (3–4 mm), or severe (> 4 mm) [16].

The medical records of 42 patients (80 eyes) who underwent double-eyelid blepharoplasty between January 2014 and March 2016 were carefully reviewed. All patients were informed of the study, and written consent was obtained for the use of their results for academic research. The post-operative follow-up period was at least 1 year. Photographs of the patients from different angles were obtained before and after surgery and were used for measurements. Pre- and post-operative photographs at 2 weeks, 1, 3, 6 months, and 1 year were taken by the surgeon (Figs. 1, 2, 3, 4, 5) using a Nikon D3100 camera (Nikon, Tokyo, Japan) positioned 1.5 m in front of the patient. All pre-operative and post-operative data were analyzed by SPSS software (IBM version 1.0.0.903). The statistical methodology we adopted was the Wilcoxon signed rank test for nonparametric paired comparison. A p value < 0.05 was considered statistically significant.

Fig. 1
figure 1

A 36-year-old woman. Follow-up at 6 months. a Pre-operative MRD1 measurements: right eye, 1.75 mm; left eye, 2.03 mm. b Post-operative MRD1 measurements: right eye, 3.22 mm; left eye, 3.45 mm

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Fig. 2
figure 2

A 38-year-old women. Follow-up at 2 years. a Pre-operative MRD1 measurements: right eye, 2.33 mm; left eye, 2.15 mm. b Post-operative MRD1 measurements: right eye, 4.05 mm; left eye, 4.20 mm

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Fig. 3
figure 3

A 19-year-old woman. Follow-up at 7 months. a Pre-operative MRD1 measurements: right eye, 1.47 mm; left eye, 1.56 mm. b Post-operative MRD1 measurements: right eye, 3.31 mm; left eye, 3.58 mm

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Fig. 4
figure 4

A 21-year-old woman. Operation was performed only on the right eye to solve issues of asymmetry. Follow-up at 3 months. a Pre-operative MRD1 measurement: right eye, 2.97 mm. b Post-operative MRD1 measurement: right eye, 4.33 mm

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Fig. 5
figure 5

A 26-year-old woman. Follow-up at 3 months. a Pre-operative MRD1 measurements: right eye, 3.06 mm; left eye, 3.35 mm. b Post-operative MRD1 measurements: right eye, 4.29 mm; left eye, 4.47 mm

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All surgeries were performed by the same surgeon. Based on the patient’s preference and the operating surgeon’s experience, the double eyelid crease line was set between 7 and 9 mm above the eyelid margin.

Surgical Technique

The operation site (7–9 mm from the edge of the eyelash) is marked and anesthetized using 2% lidocaine containing 1:50,000 epinephrine (LIDOPHRINE, Oriental, Taiwan). The conjunctiva is pulled-up using two 4–0 nylon traction sutures (NC194L, UNIK, Taiwan) placed at a site above the eyelash on the lid side and at the middle of the superior edge of the tarsal plate on the conjunctiva side to the target surgical area. Three minor incisions are made using a #11 blade (FEATHER, Japan) at the designated suture sites (3 mm on both ends and 5 mm in the middle). Toothed forceps are used to lift the orbicularis oculi muscle from the three incision sites made by the #11 blade and a small portion of the muscle is subsequently excised. A 7–0 blue double-hook nylon suture (NB 7024DN, Ailee, Korea) is used in our buried suture procedure. The surgical procedure is illustrated in the following steps. We define the penetration points at 1.3.5 for the medial canthus side and 2.4.6 for the lateral side. The figure does not represent the order in which the procedure is conducted on the right eye (see Electronic Supplementary Material: Video 1 displays three partial incisions on the intended double fold line, removal of a small portion of orbicularis oculi muscle, and arrangement of two traction sutures).

Step 1:

The tarsal plate is lifted by pulling on the medial traction suture to clearly expose the surgical field. Then, needle A is pulled (7–0 nylon double-hook suture) through the conjunctiva and aponeurosis–Müller’s muscle complex in a parallel direction and the needle exits the conjunctiva at points 1 and 2. Needles A and A’ are vertically pierced into the conjunctiva and tarsal plate from points 1 and 2 and then exit at points 3 and 4, respectively (Fig. 6a–c).

Fig. 6
figure 6

Illustration of step 1. a Pulling on the medial traction suture on the tarsal plate to expose the conjunctiva. b A 7–0 nylon suture is pierced through the conjunctive in a parallel fashion. c It is penetrated through the tarsal plate at the same exit point via the aponeurosis–Müller’s muscle complex

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Step 2:

Next, the second traction suture placed at the superior border of the eyelashes is pulled. Needle A is then pierced into the tarsal plate from point 4, and it exits from the lateral incision site at point 6. Needle A’ is sutured in a similar fashion, entering at point 3 and exiting at the medial incision site at point 5 (Fig. 7a–c).

Fig. 7
figure 7

Illustration of step 2. a The second traction suture located at the superior border of the eyelashes is pulled to expose the tarsal plate. b After piercing the tarsal plate, the nylon suture is again pierced into the tarsal plate at the same site. c It is pulled out from the upper eyelid incision

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Step 3:

After needle A’ exits the incision site of the medial canthus at point 5, it is reinserted into the same site at point 5 at the subcutaneous level. This suture then exits at the middle incision site at point 7. A Jaeger Lid Plate is placed inside the tarsal plate to protect the eyeball. Needle A’ is then reinserted at point 7, is hooked to the levator aponeurosis, and exits at point 7 close to the lateral incision site. Finally, needle A’ is reinserted at point 7 close to the lateral incision site at the subcutaneous level, and it exits at point 6. The suture lines from needles A and A’ are tightened with a surgical knot and buried subcutaneously (Fig. 8a, b). Stitching is not needed for the incision sites. The traction threads are removed.

Fig. 8
figure 8

Illustration of step 3. a The continuous buried suture method is demonstrated, and hooking of the middle of the incision to the levator aponeurosis is shown. b Needle pass subcutaneous level from the medial to the middle incision site

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Results

Forty-two patients (37 females and 5 males; age range and mean, 18–36 years and 25.3 [SD = 4.50] years, respectively) were treated using the described surgical method between January 2014 and March 2016 by a single surgeon. Forty patients had not undergone a similar procedure before, and two had previously undergone buried suture blepharoplasty, but a loss of the double eyelid fold occurred or the double eyelid became unnoticeable.

Thirty-two patients had a single eyelid, and four of these also had mild blepharoptosis; ten had an indistinct or unsatisfactory double eyelid. The majority of the patients had mild to moderate blepharoptosis with good levator function (> 8 mm). The follow-up period ranged from 2 to 30 months (mean, 11.2 [SD = 4.02] months). Operating times ranged from 15 to 35 min per eye (mean, 21 [SD = 4.38] (minutes). Figure 1 shows pre-operative and seven-month follow-up photographs of a patient with moderate blepharoptosis affecting one eye and mild blepharoptosis affecting the other. Figure 2 compares pre-operative and 3-month follow-up photographs of a patient who underwent single eye surgery.

The pre-operative margin reflex distance (MRD1, the distance between the pupil center and upper eyelid margin) was 2.36 ± 0.61 mm (standard deviation [SD] = 0.608), and the post-operative MRD1 was 3.72 ± 0.63 mm (SD = 0.633) (p < 0.001)). Post-operatively, nearly all patients felt that surgery improved their appearance. Two patients complained of insufficient correction of blepharoptosis, and one was dissatisfied owing to asymmetry. The post-operative swelling was mild and lasted between 1 and 2 weeks. Two patients experienced severe blood stasis and conjunctival hemorrhage, and the swelling lasted for longer than 3 weeks. There was no chronic inflammation at the sites of needle insertion or granuloma formation at the suture-buried sites. No case of the disappearance of the double eyelid crease was reported during the follow-up.

Discussion

The buried suture double eyelid method is one of the most popular aesthetic surgical procedures among young people in Asia. For both physicians and patients, a short operation time, rapid recovery period, and better aesthetic effects are the common goals, but considerable limitations remain in the application. The incision method has better adjustment effects in terms of double eyelid formation and correction of blepharoptosis; however, tissue removal and vascular and lymphatic reflux issues may result in a long recovery period [2]. Furthermore, owing to the possibility of scar formation, the incision method becomes an unfavorable option. On the other hand, the buried suture method has limitations with regard to the creation of a double eyelid width in patients with blepharoptosis. We proposed a novel surgical technique to solve these issues. The ability of the aponeurosis–Müller’s muscle complex to lift the upper eyelid has been anatomically confirmed [17], and this study has reported a less aggressive surgical technique that can reduce the possibility of the double eyelid disappearing after surgical intervention [12, 18]. In the continuous buried suture procedure, the eyelid crease is generated through a continuous subcutaneous single-knotted suture placed through the aponeurosis–Müller’s muscle complex, tarsal plate, and upper eyelid.

Owing to the shortening of the aponeurosis–Müller’s muscle complex distance with this method, we created a brighter and more natural-looking eye than with the tarsal plate buried suture method. In addition, our method is reversible, effective, and has a rapid recovery period.

We proposed a surgical method involving the use of only one double-hook nylon suture per eye, resulting in the reduction of surgical materials required. On the other hand, it is less likely for the double eyelid to disappear after the operation with the continuous method than with the interrupted method [19], and there is less tension and torque [20], which subsequently leads to reduced swelling of the eyes, a short recovery period, ideal symmetry, and an unobtrusive scar. Further, the single-knot method allows relatively easy suture removal and, thus, has high reversibility, and removal of fatty tissue through the minor incision can be accomplished simultaneously. Technically, bidirectional traction of the aponeurosis–Müller’s muscle complex from the medial conjunctiva and upper eyelid also strengthens the fixation after the shortening of the aponeurosis–Müller’s muscle complex. In young patients with a general single eyelid or indistinct double eyelid, the described buried suture method can achieve more satisfactory cosmetic outcomes.

Nonetheless, the method has several limitations. First, attention should be paid to patients who develop severe conjunctival hemorrhage during the procedure. Such patients may complain of abnormal sensation and increased secretion in the eyes, along with a longer recovery time (over 3 weeks). Although conjunctival irritation from the permanent suture was not found in our study, this may be a concern if the surgical method was not precisely performed. Second, this method cannot be used to remove excess skin and is not applicable in patients with poor levator palpebrae superioris muscle function. Patient selection is of extreme importance. If excess skin excision is required or moderate ptosis is present, then the patient’s expectations may not be met. Lastly, suture placement is of extreme importance as injury to the orbit or conjunctiva may be an unwanted effect of improper suture position.

Conclusion

We reported a rapid, effective, and reversible buried suture method for double-eyelid blepharoplasty. This buried suture double eyelid surgical technique involving the aponeurosis–Müller’s muscle complex strengthens the function of the levator palpebrae superioris muscle and subsequently leads to a better cosmetic effect than other methods that simply embed sutures in the tarsal plate.