This chapter provides an overview of buried suture ligation methods (also known inaccurately in Asian languages as ‘non-incisional’ or ‘no-cut’ methods). Historical perspective and variances in technique are covered.
Evolution of Double-Eyelid Cosmetic Surgery in the Japanese Literature
Publications in the early Japanese medical literature favored the suture ligation methods. The first description of the suture ligation method, by Mikamo, was published in 1896. Mikamo performed the procedure on a Japanese woman who did not have a crease in one of her upper eyelids. The crease was designed to be 6–8 mm from the ciliary margin. Three 4-0 braided silk sutures were used; they passed through the full thickness of the lid from the conjunctiva to the outer layer of skin. The depth of the crease was adjusted by the number of days the sutures were left in, the range being 2–6 days.
As early as 1926, Uchida described his suture ligation method for the double-eyelid operation. He performed the procedure on 1523 eyelids in 396 male and 444 female patients. Uchida described the crease configuration as a fan shape, that is, a somewhat rounded crease. The crease was designed to be 7–8 mm from the ciliary margin. Three buried catgut sutures were used on each lid, encompassing approximately 2 mm of eyelid tissue horizontally. The sutures were removed 4 days after placement.
The first mention of an external incision method dates to 1929, when Maruo reported on both his suturing technique and his incision technique. Maruo’s incision technique required a lid crease incision across the lid, designed to be 7 mm from the ciliary margin. The wound closure technique was a translid passage from the conjunctival side just above the superior tarsal border to the anterior skin surface. One 5-0 catgut suture was used to imbricate four throws along the superior tarsal border, attaching skin edges to the underlying tarsal plate. The spacing between each throw of the stitch was about 5–6 mm. Maruo also discussed subcutaneous dissection 5 mm superior and inferior to the incision line.
In 1933, preference for a higher placement of crease became evident when Hata reported his suture ligation method. The crease line was placed 10 mm from the ciliary margin. Hata used three double-armed 5-0 braided silk sutures, passing them from tarsus to skin, fixing them to the skin surface using small beads. Each arm of the suture required 1 mm spacing for the bead to be tied. Stitches were removed after 8–10 days.
In a comprehensive and scholarly article in 1938, Hayashi described the two methods of crease formation. His suture ligation technique was modeled after Mikamo’s method but was novel in that it was designed for a nasally tapered crease. Three sutures were used on each lid. The central and lateral sutures were applied superior to the crease line or tarsal plate, whereas the medial suture was deliberately applied below the crease line or tarsal plate. Hayashi’s incision method was also revolutionary in that he advocated excision of pretarsal orbicularis oculi muscle at the area of the incision. He also advocated the use of interrupted skin–tarsus–skin sutures and in between skin–skin stitches consisting of 4-0 silk for wound closure. The crease was designed so that medially it was 5 mm from the ciliary margin, centrally 6 mm from the margin and laterally 7 mm from the margin; in essence it was a nasally tapered crease. The sutures were removed after 4 days.
Inoue in 1947 proposed dissecting the ‘connective tissues’ in the subcutaneous plane between the incision line and the ciliary margin. Sutures of 5-0 braided silk were used for skin–tarsus–skin closure; sutures were removed after only 2–3 days.
In 1950, Mitsui continued the evolution of the double-eyelid crease procedure when he described the dissection and removal of pretarsal connective tissue, including pretarsal orbicularis muscle and pretarsal fat pads. Wound closure was carried out in two steps. First, five separate nylon sutures were used to stitch the inferior skin border to the anterior surface of the superior tarsal border and were tied individually. Second, 5-0 braided silk was used to close the incision site skin to skin. The nylon sutures were removed after 2–3 days, the silk sutures after 7–8 days.
Ohashi described a double eyelid crease operation using an electric coagulator. The cautery needle was applied vertically to the skin surface along the crease line until the skin blistered; two more rows of cauterization below the crease line followed. Hirose and Ikegami in 1951 briefly discussed incision methods but did not offer any new information.
The foregoing procedures were described only in the Japanese literature and were not readily available to Western readers. As a result, the publication of articles on this procedure in Western medical journals in the 1950s made the procedure seem new (and Western) in concept. Between 1896 and 1950, 11 articles relating to the suture ligation methods and eight articles on external incision methods were published in the Japanese medical literature. Much of the early Western literature on this subject described techniques quite similar to those described in the early Japanese publications.
In 1954, Sayoc wrote the first article published in the English literature on the external incision technique. Millard in 1955 described his Korean Armed Service experience. He mentioned that Koreans at that time desired to look ‘round-eyed’ like Westerners rather than ‘slant-eyed’. Millard believed that the absence of a crease in Koreans was a result of excessive skin and supraorbital fat. One patient Millard described underwent excision of a 3 mm strip of skin, dissection under both upper and lower skin edges, trimming of the orbicularis muscles along the inferior skin incision, and complete excision of the supraorbital (preaponeurotic) fat pads. Although he used crease-enhancing silk sutures from skin to tarsus to skin, Millard believed such sutures were not always necessary. A small Z-plasty was performed selectively to eliminate an epicanthal fold. Millard’s article is an interesting illustration of the interaction between Western surgeons and Asian patients in the 1950s.
In 1961, Pang described his ‘trans-lid’ full-thickness eyelid sutures placement to form an upper lid fold: three double-armed 4-0 black silk sutures were placed from the conjunctival side towards the skin side, they were tied and left in for 10 days.
Fernandez, Uchida and Khoo Boo-Chai also wrote articles on the external incision technique. In 1962, Uchida described the presence of different fat compartments and variations of fat distribution in the upper eyelids of Asians. His incision method involved selective excision of pretarsal subcutaneous tissues, including skin, pretarsal orbicularis muscle and fat, preaponeurotic fat and even some preseptal fat pads.
In 1964, Khoo Boo-Chai advocated the simpler transconjunctival suturing technique for younger patients with a minimum amount of excess fat and skin.
Mutou and Mutou in 1972 also described the suture ligation technique. In this classic paper, Mutou and Mutou detailed their interpretation of their concepts of the double eyelid and their less invasive method for patients with thin eyelid skin and scarce subcutaneous fat. They performed 4805 procedures between 1965 and 1969, of which about 90% were in women. One-quarter preferred the parallel shape and three-quarters preferred the ‘unfolded fan type’ (equivalent to a nasally tapered crease but with gradual widening towards the lateral end of the lid fissure). To make the crease nasally tapered, the authors turned the ligature over the inner canthus downward. They explained that three options in the crease height were available to the patients: the lowest level, at 4–5 mm, was called the ‘deep double eyes’ (the deep here connotes more of the sense of inferior anatomic location), the usual was 6–8 mm crease height, and the highest was 9–12 mm and is available for those with large eyes. The actual technique basically involved passing two double-armed 6-0 sutures from the conjunctival side: each traverses horizontally for 5 mm at a position 3 mm above the superior tarsal border in a subconjunctival fashion (see Faden effect in Chapter 21 ). Each arm is then reinserted through the conjunctiva (within 1 mm of its exit) towards the skin side. One arm of the suture thus exited on the skin side is then passed subcutaneously and tied with the second arm on the skin side. These authors’ placement of the double-armed sutures was such that the medial ligature straddled the junction of the medial one-third and central one-third of the upper lid; the lateral ligature straddled the lateral one-third of the upper eyelid. The sutures were meant to be buried permanently. They stated that mild transient ptosis was seen in almost all cases. Mutou and Mutou had initially reported in 1972 a disappearance rate of 1.3% among their patients who underwent an intradermal double-eyelid procedure with buried sutures. Two sutures were used but subsequently, due to a significant postoperative ptosis (weakness and drooping of eyelid muscle), Mutou modified the technique to using a single stitch in 1973. This observation of postoperative ptosis reflects the Faden effect (impairment of contractile function of levator muscle), which I discuss in Chapter 21 , that is often associated with high placement of sutures, as well as use of permanent buried sutures that bind the anterior and posterior lamellae together.
The buried suture method has the short-term advantage of being relatively non-invasive and usually causes less postoperative swelling (amount and time of resolution). The main disadvantage is that the crease may disappear with time ( Figure 6-1 ). I will discuss further the implications of use of buried sutures in Chapter 21 .
In 1979, Dr Yukio Shirakabe modified the compressive beads method of Hata (1933); his method consisted of making an external skin incision followed by undermining of the pretarsal area, followed by closure and crease fixation using six double-armed 4-0 nylon stitches, with each arm of each pair of the stitches looped and tied down with a small bead (total = 12 beads).
In their paper of 2000, Homma and colleagues reported that Mutou had a crease regression rate of 3.4% out of 1457 patients during a seven-year period from 1986. They indicated that the technique is applicable for those patients with little fat tissue or mild puffiness only. They quoted the advantages as including minimal postoperative swelling, that the crease can be reversed by cutting the stitch and no apparent scar. The procedure involved everting the tarsus and applying 7-0 nylon through the conjunctiva at a point 3 mm above the superior tarsal border. It traverses the conjunctiva for 5 mm. One arm is reinserted through the conjunctiva 1 mm adjacent to where it came out, exiting through the anterior skin surface. This is followed by the second arm of the conjunctival suture exiting the skin in the same fashion. The first suture is then passed subcutaneously to join the second suture, now on the skin side, and the two are tied and cut close to the knot.
Other authors, including Tsurukiri, had reported a regression rate of 10%. Satou and Ichida reported a regression rate of 16.8%. Homma and colleagues postulated that the disappearance rate is higher among those individuals with thicker skin or who possess excess subcutaneous fat. They acknowledged the difficulty in assessing the true rate of disappearance since patients often do not return for follow-up, and that often patients seek other doctors for revision when the first procedure was suboptimal. A significant factor not discussed is the fact that most of the patients who undergo the stitch methods realize that when the crease does disappear they are often then candidates for the incision methods, and therefore may proceed directly to seek consultation with those who practice the open incision methods.
In general, the suture ligation method has always been touted as being a relatively non-invasive procedure that usually results in less postoperative swelling. Its main disadvantage is that the crease may disappear with time. It can be a significant disadvantage when it happens, as time and resources have been invested. (This is a case where little was done, and little can therefore be expected in the long term. See Chapter 21 on the effect of high stitch placement above the tarsus, the hindering ‘Faden effect’ when the levator is tied within loops of sutures, and the effect of the use of buried permanent suture.)
There are other papers published that described the use of small incisional approach with removal of tissues along the superior tarsal area, coupled with passage of buried sutures. For example, Lee, Baek and Chung’s paper described use of 7-0 nylon through small skin incision wounds, applying it as a buried figure-of-eight continuous suture, forming three hexagonal loops spanning the width of the crease; this was combined with removal of tissues (muscle, preseptal fat and septum). They applied it in 327 patients with a mean follow-up of 13 months only.
From the years 1970 to 1990, there were at least a dozen papers describing the external incision methods. Among them, Zubiri’s article in 1981 described the measurement of the vertical dimension of the upper tarsus as a way to guide the placement of the lid crease incision. This is a logical and anatomically correct way of tailoring the incision lines. It approximates a true crease position and is the method I favor. Since 1995 when my Asian Blepharoplasty: A Surgical Atlas was published, there have been at least an additional 40 publications whose range of topics included epicanthoplasty as well as papers describing smaller skin incision or variations of ‘partial’ incision methods, and various forms of crease fixation, including ‘septodermal’ and ‘orbicularis-levator’ fixation.