More than thirty techniques have been described that involve placement of one or more permanent sutures into the eyelid from small incisions made on the back and/or front surfaces of the eyelid (while sometimes called "non-incisional," the designation is incorrect). The internal sutures essentially compress an indentation into place. The procedure was first described in the late 1890s.
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Simplified suture techniques are practiced widely in some Asian countries and by less experienced eyelid surgeons. In Japan, the technique remains popular, where the so-called "quick double eyelid surgery" (fifteen minutes) is used commonly. In Korea and the United States, most experienced surgeons favor the full incisional technique for a number of reasons.
One major objection is that since the suture technique does not allow for an orderly removal and realignment of internal eyelid tissues, the major anatomical impediments to true crease formation are not addressed. The technique is non-physiological with no ability to replicate the natural crease formation mechanism found in people born with a crease.
Duration is a major shortcoming. While the full inicisional approach creates a long-lasting result, the indentation formed after a suture approach may disappear within a few years as the suture weakens (or even months if the suture unties or breaks). If one crease weakens before the other, the eyes can appear noticeably imbalanced.
Essentially a "stock" operation, individual customization is limited. Typically, no tissue is removed, which imposes a major limitation in patients showing signs of skin aging. Even in the young, there is little ability to vary the crease shape and height. The final crease is not dynamic (that is, it is not dependent upon eyelid opening) and is thus visible even when the eyes are closed.
One variation known as DST (double sutures with twisting, double stranded twist, or durable suture technique, all of which indicate the same operation) employs two sutures that are tied in three places and twisted around each other four or five times at the central tie. While promoted as yielding a more stable or even permanent result, we have seen many patients who have undergone this operation elsewhere only to have their creases fade as early as one to eight months following surgery.
Another variation (sometimes called "semi-open") incorporates between one to five small skin incisions and allows for removal of fat. A series of small scars then extends across the eyelid.
Compared to incisional surgery, suture methods are much faster and easier to perform, recovery time is significantly shorter, and costs are less. While less invasive, however, the risks are far from negligible.
Surgery may be complicated by irritation from sutures rubbing against the cornea of the eye. Since the lid is entered through multiple small cuts without full visualization of the internal eyelid anatomy, suture placement and surgical manipulation may cause tissue injury as well as uneven skin scars. Crease loss is common.
If a patient who has undergone suture treatment later elects to undergo an incisional technique, internal scarring and retained suture fragments may limit the precision of the second surgery.