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Stitch Double Eyelid Plasty - the Science

This is the reprint of the paper that was published by Dr Peter Kim in the Journal of Cosmetic Surgery & Medicine on the topic of stitch double eyelid plasty.

A Simple Technique in Creating the Double Eyelid in Asians Using Buried Suture Technique and Chung’s Forcep 


Kim P, Ahn JT


Kim P MBBS FACCS 
Simply Beautiful Cosmetic Surgery & Laser Clinic, Sydney, Australia

Ahn JT MD FKCCS FACCS
Lee & Ahn Cosmetic Surgery Clinic, Seoul, Korea
Past President of the Korean College of Cosmetic Surgery



Acknowledgement:
we would like to thank Dr Chung (Chung Il Bong Simple Plastic Surgery, Seoul, Korea) for his advice and assistance in composing this article.

Sixty percent of Eastern Asians (Korea, Japan, and China) lack in visible supratarsal fold, better known as double eyelid or double fold. Double fold makes one’s eye appear more open and alert, and this is a desirable characteristic in this culture (1).According to Millard (2), “the flat nose and the oriental eye were the features which seemed to lend themselves to the most striking changes with the least radical surgery”. For this reason, Double Eyelid-Plasty (DEP) is the single most popular cosmetic procedure in Asians (3) and a numerous successful Incisional and Non-incisional approaches have been reported

Non-incisionalDEP refers to a method of creating a supratarsal fold (“double fold”) with no skin incisions. Desired double fold is produced by creating fixation between the dermis and either levator or tarsus (fold fixation) using only suturesand its knotsare buried (4).For this reason, Non-incisional DEP is commonly referred to as Buried Suture Technique (BST).  It is not applicable in all DEP candidates, but this approach is very effective in suitable candidates who have thinner eyelid skin and minimal preaponeurotic fat protrusion (5)One of the major fears of using this technique is the disappearance rate of the created double fold (6) but these rates has been proven to be low and are acceptable (5,7).

Any cosmetic surgeon serious in DEP would have considered using BST. Considering that the Asians have a greater tendency towards unsightly scars and an unfavourable post-operative recovery (8), this approach appears to be more attractive as it is much less invasive, there is no associated scar, minimal downtime and the complications rates are lower. In some countries, this form of DEP is marketed as a “lunchtime procedure”, and colloquially it has even been referred to as a “beauty-therapy” procedure rather than a “cosmetic surgery” procedure. For these reasons, it is especially popular with younger Asians (1, 9).

BST sounds easy & simple in theory but in practicefor a surgeon new to this procedure,the learning curve can be rather steep (8). Biggest hurdle is “where do you place the “entry & exit points” for the suture placement to create the double fold on both skin and on the conjunctival surface. A slight miscalculation can lead to alterations in the upper eyelid soft tissue configuration and this canproduce an unattractive double foldshape and an asymmetry of both the height and the shape of the “to be created”  double fold, which are in fact the two most frequent post operative complaints (7). In an attempt to overcome this problem and to simplify the procedure, we have used a marking instrument called “Chung’s Forcep(Figure 1)which facilitates the accuracy and repeatability of the BST in the creation of double fold (9). This article is describing our retrospective experience of Non-incisional DEP with BST using Chung’s Forcep.

Figure 1. Chung’s Forcep – marking the entry and exit points on the skin and the corresponding conjunctival surface to facilitate the suture dermo-tarsal fixation of supratarsal fold.

Method 

Patient Selection: Patients with these features were selected as a candidate for this BST; thin upper eyelid skin, minimal excess skin, minimal pre-aponeurotic fat protrusion, single fold, not had previous surgery and with no levator ptosis. 

Design: All preoperative designs were performed in sitting position at a horizontal gaze. Desired height of the double fold and the desired shape of the fold were marked according to the patient’s preference (Figure 2a). The height of the double fold was kept to less than 8mm from the ciliary margin and on average 6mm. 4 dots representing the suture points were marked. The first mark was placed at the mid papillary line and the subsequent 3 dots were placed, one nasally and two dots laterally, 4mm apart (as the teeth of Chung’s Forcep were 4 mm apart) (Figure 2b)

Figure 2. The Design. (A) Ascertain the patient’s desired shape and height of double fold in sitting position. (B) Marked Suture points and measuring the height of the double fold.

Preparation.

Patients were placed in a supine position and the local anaesthesia (2% Lignocaine with 1:100 000 Epinephrine) was administered to both skin and the conjunctiva (Figure 3A,B). Corneal cap was inserted following application of Amethocaine eye drops. After few minutes, Chung’s Forcep was used to mark the suture points guided by the pre-marked suture points on the eyelid skin (Figure 3C). Suture points on both the skin and the conjunctiva are now clearly visible (Figure 3D), and this maneuver takes away the guess work.

Figure 3. (A) Using the 10 Smile Marking Clamp, (B) Clearly marked entry points on the skin. (C) Clearly marked exit points on the conjunctival surface. 

Buried Suture Technique

Chung’s Forcep marked “suture points” points were used to place the buried sutures that will create the fold fixation. On each eyelid, two interrupted buried sutures were created using Double-Arm 7/0 Nylon (Figure 4). It is essential that the knots are buried. Dimpling of the suture points on both the skin and the conjunctiva is common. Skin dimpling can be smoothened by applying a slight lateral traction of the skin around these points. Conjunctival dimpling will resolve spontaneously within few days as the result of “cheese wiring” effect. Final result should be checked immediately post operatively in sitting position, and the desirable outcome is an Asian Upper Eyelid with a distinct double fold with the shape and the height as planed pre-operatively (Figure 5 A,B).

Figure 4. Diagramatic representation of BST. (A) Double arm needle, 7/0 Nylon, was used to create BST. Two buried sutures were created.  (B) BST after few weeks. Due to the cheese-wiring effect, all entry & exit points as well as the knots are buried. 


Figure 5. Photo of immediately before and after the Non-incisional Asian DEP using DST & Chung’s Forcep  

RESULTS 

Between 2007 - 2009, we have treated 497 patients using the above mentioned technique. 96% were females (between ages of 16-32) and 4% were males (between ages of 16-25). Rates of complications were; undoing of double fold (10 patients – 2% usually within the first 6 months), Asymmetry (3 patients – 0.6%), Suture granuloma (5 patients – 1%), and no infection. An overall reoperation rate was 3% (15 patients) mainly for the above reasons, which is acceptable. Vast majority of the patients were satisfied with the aesthetic outcome (Figure 6-7).



Figure 6. Preop and 3 months post BST using Chung’s Forcep.



Figure 7. Preop and 18 months post BST using Chung’s Forcep.



DISCUSSION

Success rate and complication rates in this study was similar to the other published reports, which further confirms the effectiveness of BST in selected candidates.

The most important determinant of the shape and the symmetry of the double fold to be created depend on the location of the dermo-fixation. And the most important determinant of the precise localization of this fixation depends on the precise entry and exit points of the sutures and a symmetrical distance of dermofixation from the ciliary margin on both the skin and conjunctiva. Imprecise suture entry and exit points can create an unattractive double fold shape and asymmetry. In the past, designation of these points was performed on a “trial and error” basis and this often required numerous re-attempt to create an attractive double fold which leads to unnecessary trauma and frustration. Hence this procedure has been emphasised by some, as over-complex and an inferior alternative to Incisional double eyelid plasty. And those who preserved and succeeded in using this approach had to perhaps endure a steep learning curve.

Chung’s Forcep was invented to facilitate the BST by clearly marking the entry and exit points of the suture dermo-fixation, both on the surface of the upper eyelid skin and on its corresponding location on the conjunctival surface. With a simplicity, repeatability and reliability of marking these points, BST becomes not only a simple and effective procedure, but also reliable and repeatable.

We have used two interrupted single buried sutures as our choice of BST. Single BST can produce a satisfactory double fold but having more than one loop of buried knot and/or a more complex buried sutures appears to reduce the double fold disappearance rate, both in the literature (7,8) and in our experience. There are over 30 reported variations of BSTs (8) and the surgeon should use the one that they are comfortable with. We have found single loop to be the simplest and most reproducible. With a reproducible template of entry and exit suture points using 10 Chung’s Force, the “trial and error” approach of creating a precise buried dermo-fixation loops has been resolved.

 We have found Chung’s Forcep to facilitate the application of BST; it is simple, effective, reproducible and reliable in creating an aesthetically pleasing double fold in Asian upper blepharoplasty.

Conclusion

BST is a simple, effective, and reliable method and effective method of creating Non-incisional DEP in selected Asians, and Chung’s Forcep facilitates this technique by providing a reliable template to guide the suture dermo-fixation. Using such instrument can facilitate learning of this procedure to the surgeons not already familiar with the Non Incisional Double Eyelid-plasty, and in an efficient and timely manner.

References

1. Shirakabe Y, Kinugasa T, Kawata M, et al. The double-eyelid operation in Japan: its evolution as related to cultural changes. Ann Plast Surg 1985;15:224-241.

2. Millard DR Jr. Oriental peregrinations. Plast Reconstruct Sur 1955; 16: 319-36

3. Onizuka T, Iwanami M. Blepharoplasty in Japan. Aesthetic Plast Surg 1984;8:97-101

4. Uchida J. A surgical procedure for blepharoptosis vera and for pseudoblepharoptosis orientalis. Br J Plast Surg 1962;15:271-276.

5. Mutou Y, Mutou H: Intradermal double eyelid operation and its follow-up results. Br J Plast Surg 25:285, 1972

6. Fernandez LR: Double eyelid operation in the Oriental in Hawaii. Plast Reconstr Surg 25:257, 1960

7. Homma K, Mutou Y, Mutou H, et al. Intradermal stitch blepharoplasty for Orientals: does it disappear? Aesthetic Plast Surg 2000;24:289- 291.

8. Kure K, Minami A. A Simple and Durable Way to Createa Supratarsal Fold (Double Eyelid) in Asian Patients. Aesthetic Surg J 2001;21:227-232.)

9. Chung IB. Digital Double-Eyelid Operation. Han-Mi Book. Seoul, Korea. ISBN:978 89892-98-4

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