Minimally Invasive Double Eyelid Surgery: 6 Suture Ligation Methods for Lasting Results
Suture ligation techniques have played a significant role in the evolution of double-eyelid surgery, offering a less invasive alternative to traditional incisional methods. Various approaches have been developed over the past century, each with distinct advantages and limitations. Drawing from William P.D. Chen’s research in Asian Blepharoplasty and the Eyelid Crease, this article explores six of the most prominent suture ligation techniques, detailing their surgical execution, expected outcomes, and insights from key pioneers in the field, including Dr. Khoo Boo-Chai.
The Evolution of Suture Ligation Techniques
Originally described in Japanese literature before being introduced to Western surgical communities, suture ligation (often referred to as "buried sutures" or "non-incisional" techniques) has undergone continuous refinement. The method primarily involves creating an upper eyelid crease by using sutures to connect the levator aponeurosis to the subdermal tissue, avoiding large external incisions.
6 Key Variations of Suture Ligation Techniques
Several modifications of the suture ligation method exist, classified based on the entry and exit points of the sutures:
1. Full-Thickness Suture Technique
This method involves passing sutures from the conjunctival side of the eyelid through the entire thickness of the lid to emerge on the skin surface. The ends of the suture are then tied subcutaneously, forming a secure fixation between the levator aponeurosis and the dermis.
Execution: The upper eyelid is everted, and three double-armed sutures are passed transconjunctivally 3mm above the superior tarsal border. The sutures are tied beneath the skin to avoid exposure. Proper positioning is crucial to prevent crease asymmetry.
Outcome: A strong and well-defined eyelid crease with minimal external scarring. The buried nature of the suture prevents direct contact with the skin, reducing irritation.
Best for: Patients with thin eyelid skin and minimal fat who want a subtle yet well-defined crease.
Drawback: Risk of crease regression if suture tension is inadequate.
2. Full-Thickness Suture Technique with Stab Incisions
Similar to the full-thickness method, but with the addition of small stab incisions at the crease line, this technique allows for a more precise placement of the sutures and better tissue integration.
Execution: The stab incisions are placed at predetermined crease positions. The suture is passed through the conjunctiva, exits through the stab incision, and is then tied subcutaneously.
Outcome: Reduced risk of suture extrusion and improved crease stability.
Best for: Patients with moderate fat deposits in the upper lid, as the additional stab incisions aid in creating stronger adhesions.
Drawback: Stab incisions introduce a minor risk of visible scarring.
3. Transconjunctival Intramuscular Suture Technique
Unlike the full-thickness approach, this technique involves inserting sutures through the conjunctiva and embedding them within the levator aponeurosis and Müller muscle without emerging on the skin.
Execution: A double-armed suture is inserted from the conjunctival side, remains intramuscular without reaching the skin, and is tied subconjunctivally.
Outcome: Completely hidden sutures with a natural crease formation, though the risk of regression may be slightly higher due to the lack of dermal fixation.
Best for: Patients who prefer a completely non-visible approach and have minimal subcutaneous fat.
Drawback: May require additional reinforcement in patients with thick skin.
4. Transcutaneous Intramuscular Suture Technique
Small stab incisions are made on the skin surface, and the suture is passed through the levator aponeurosis and Müller muscle without entering the conjunctival space.
Execution: Using 6-0 nylon, the suture is passed from the stab incision, traverses the levator aponeurosis, and is tied subcutaneously.
Outcome: Strong crease fixation with a slightly longer healing time compared to transconjunctival techniques.
Best for: Patients who want a durable crease but are prone to conjunctival irritation.
Drawback: Risk of mild swelling due to small incisions.
5. Twisted Needle and Compression Method
This method uses a screw-threaded needle to create controlled scarring, followed by the application of a rubber catheter for compression. The compression enhances tissue adhesion over time.
Execution: A specialized twisted needle is passed through the upper lid’s pretarsal region. A rubber catheter is temporarily sutured in place to reinforce crease formation.
Outcome: Quick healing with effective scar formation ensuring a durable crease.
Best for: Patients with thin skin requiring a more permanent crease.
Drawback: Not suitable for patients with excessive fat or thick skin.
6. Transcutaneous Intradermal and Intratarsal Suturing
In this method, sutures are passed through small stab incisions, traversing both the dermal and tarsal layers for increased stability.
Execution: A 7-0 nylon suture is passed in a figure-of-eight pattern through the superior tarsal border, ensuring long-term crease stability.
Outcome: A strong, natural-looking crease that integrates well with the eyelid’s anatomy.
Best for: Patients with mild to moderate fat deposits requiring long-term results.
Drawback: If improperly placed, can lead to asymmetry or crease failure.
Advantages of Suture Ligation Techniques
Suture ligation techniques provide several benefits over traditional full-incision methods:
Minimally Invasive: Reduced trauma to the eyelid tissue, leading to faster recovery times.
Less Swelling and Downtime: Minimal dissection results in decreased postoperative swelling.
Reversibility: Unlike incisional techniques, most suture methods allow for crease reversal if the patient is dissatisfied.
No Visible Scarring: The absence of large external incisions makes the procedure appealing for patients concerned about scars.
Khoo Boo-Chai’s Contribution to Suture Ligation Methods
Dr. Khoo Boo-Chai was a pioneer in the field of Asian eyelid surgery. His extensive work in the 1960s laid the foundation for modern suture ligation techniques. He developed a conjunctival suture method, which is still referenced in contemporary practice.
Khoo Boo-Chai’s Technique
He used exogenous monofilament nylon slings to connect the levator palpebrae superioris to the eyelid skin at a desired level, creating a long-lasting yet flexible crease. His method involved careful placement of three sutures, ensuring symmetry and minimal trauma.
Execution: The upper eyelid was everted, and a 4-0 nylon suture was passed subconjunctivally. The suture was looped and anchored at three points, forming a robust crease.
Outcomes: Khoo’s approach was praised for its low risk of complications, minimal postoperative swelling, and strong adherence between skin and levator structures.
Conclusion
Suture ligation remains a valuable option for double-eyelid surgery, particularly for patients seeking a less invasive procedure with faster recovery. By understanding the nuances of each technique and selecting the right candidates, surgeons can achieve optimal, long-lasting results. Insights from pioneers like Khoo Boo-Chai continue to shape modern eyelid surgery, offering a blend of tradition and innovation in aesthetic procedures.
Reference:
Chen, William. (2015). Suture Ligation Methods. 10.1016/B978-0-7506-7574-1.50011-6.
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