The "type" of buried suture technique changes how long your Double eyelids last by 3 times.
When considering Double eyelid surgery, you might think, "Wouldn't more sutures last longer?" or "Wouldn't 3-point or 4-point fixation be more resistant to coming undone than 2-point fixation?" However, in reality, it's "which surgical technique (type) you choose" rather than "how many sutures" that creates a decisive difference in the longevity and final results of your Double eyelids. Furthermore, the evolution of buried suture techniques has been remarkable, and the latest technologies have produced methods with durability that rivals incisional techniques. This article provides a thorough explanation based on data from the latest medical literature, covering the mechanism of buried suture techniques, the characteristics of each method, and how to choose the optimal buried suture technique for you.
Buried Suture Technique Explained——First, Let's Review How "Suturing" Works
People who are naturally born with Double eyelids have a structural characteristic where the fibers of the levator aponeurosis penetrate through the orbicularis oculi muscle and attach to the subcutaneous tissue of the eyelid skin. This fiber structure pulls the skin inward when opening the eye, forming a clean Double eyelid crease. On the other hand, people with single eyelids, who make up approximately half of East Asians, lack this fiber structure congenitally.
The "Buried Suture Technique (Non-incisional method)" is a surgical method that simulates and artificially recreates this natural Double eyelid formation process. Rather than cutting the skin open with a scalpel, it uses surgical ultra-fine medical sutures to connect the "levator aponeurosis" or "tarsal plate" with the subcutaneous tissue of the eyelid, creating a Double eyelid line. It has the major advantages of not destroying the normal tissue structure of the upper eyelid, having an extremely fast postoperative recovery time, and leaving no visible scars.
However, buried suture techniques also have structural weaknesses. As the eyelid opens and closes tens of thousands of times, the sutures fixed in the subcutaneous tissue gradually tend to loosen. As a result, there is a risk that the Double eyelid line will become thinner or completely disappear after surgery, and this is considered the biggest challenge of buried suture techniques.
Check the Differences Among 3 Main Buried Suture Technique Types in a List
Characteristics of Continuous (Loop) Method
The Continuous (Loop) method is a technique where a single long suture is continuously sewn into the eyelid tissue (Baek et al. 2015) and fixed across a broad area as a surface. Because the suture passes through in a loop shape, the tension during eye opening and closing is easily dispersed throughout the entire suture, making the Double eyelid line more likely to last longer compared to point fixation. Additionally, since knot points are minimized, the risk of knots becoming visible under the skin is also reduced.
Characteristics of Point Fixation (Interrupted) Method
Point fixation (interrupted method) is a technique that uses multiple short sutures to create independent knots at each point (2-point fixation, 3-point fixation, etc.). While the surgical procedure is extremely simple and quick, the force exerted when opening the eyelid becomes locally concentrated on each independent suture. If a specific knot loosens, there is a risk that the line will disappear from that area.
Levator muscle method vs. tarsal plate method——differences in fixation sites
The levator muscle method is a technique that fixes sutures to the "levator aponeurosis," the extension of the muscle that opens the eye. It is closer to the anatomical structure of naturally occurring Double eyelids and allows for the formation of natural and dynamic Double eyelids. The tarsal plate method is a technique that fixes sutures to the hard "tarsal plate" on the back of the eyelid. It has the advantage of creating strong fixation and making the line appear more vivid, but there is a risk that the suture will be exposed on the back side of the eyelid and damage the cornea.
Evidence from research on "outcomes by surgical technique"——results from a 3-technique comparison study
In a large-scale clinical study (Yang et al. 2022) conducted on 852 patients with single eyelids, clear differences in outcomes were demonstrated among three surgical techniques: "3-point buried suture method (point fixation)," "3-point subcutaneous tunnel method with micro-incision," and "incision method."
Simple point fixation results in less swelling but a relatively high reversion rate of approximately 6%. The subcutaneous tunnel method, despite being a buried suture technique, achieves durability (0.58%) that exceeds that of the incision method (Yang et al. 2022).
Durability, swelling, and ease of revision——choose based on 3 axes
- If minimizing swelling is your priority: "Point fixation buried suture method":Downtime is short and revision is relatively easy. However, there is a high risk of reversion.
- If durability is your priority: "Incision method":Semi-permanent Double eyelids can be created, but scarring is likely and revision is difficult.
- If you want the best of both worlds: "Subcutaneous tunnel method and advanced buried suture techniques such as continuous suturing method":Recurrence rate less than 1% (Yang et al. 2022), minimal scarring, and extremely high satisfaction.
Recommended surgical techniques by eyelid thickness
When there is excessive eyelid fat and strong skin sagging (skin laxity), standard buried suture methods may be insufficient in effectiveness. Since the ROOF and orbital fat act as physical barriers, incision methods, partial incision methods, or buried suture with fat removal are recommended. By combining fat removal, thread loosening can be prevented.
For those with thin eyelids and minimal excess fat, standard buried suture methods, continuous suture methods, and subcutaneous tunnel methods are extremely suitable. Since there is minimal physical strain, even non-incisional methods provide sufficient longevity.
OLT technique and next-generation buried suture methods
The "OLT method (Orbicularis-levator-tarsus fixation)" is a multi-layered, multidirectional three-dimensional suturing technique using specialized instruments to pass sutures horizontally through the levator aponeurosis, and then vertically through the preseptal orbicularis oculi muscle and fascia. Because the sutures are positioned perpendicular to the muscle fibers, resistance to tension during blinking is dramatically improved.
In a study of 873 patients (Shi et al. 2022), among 563 patients followed for an average of 11 months (maximum 7 years), there were 0 cases where the double eyelid line disappeared (Shi et al. 2022) (remarkable 0% line disappearance rate). 94% of patients are satisfied with their post-operative results (Shi et al. 2022).
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Summary of this article
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References
- Baek J, Ahn J, Jang S, et al. Comparison Between Continuous Buried Suture and Interrupted Buried Suture Methods for Double Eyelid Blepharoplasty. Journal of Craniofacial Surgery. 2015 DOI
- Ma C, Lu F, Liu L. A Modified Double Eyelid Plastic Surgery Method: Continuous Buried Suture Method Accompanied by Simultaneous Correction of Mild Blepharoptosis. Aesthetic Plastic Surgery. 2018 DOI
- Shi et al. 2022. Orbicularis–levator–tarsus fixation suturing in buried suture double-eyelid blepharoplasty. JPRAS. 2022
- Yang et al. 2022. Clinical comparison of 3 different double eyelid surgeries. Ann Plast Surg. 2022
Author of this article
Hiromitsu NakamuraPhysician
Zetith Beauty Clinic Ginza, Osaka, Fukuoka
He has a track record of research presentations at domestic and international conferences and is involved in technical guidance and education throughout Zetith Beauty Clinic. He specializes in precision aesthetic medicine based on anatomical evidence and pursues natural results tailored to each individual's skeletal structure and tissues.