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Treatment of Suture-related Complications of Buried-suture Double-eyelid Blepharoplasty in Asians

Double-eyelid blepharoplasty is a popular aesthetic surgery in Asian countries and is performed using one of the 2 alternative approaches: the incisional method or the buried-suture method. The incisional method is advised in cases of secondary surgery or patients with excessive amounts of fat or redundant skin in the upper eyelid because this technique is associated with a lower rate of double-eyelid loss. The buried-suture method is most often indicated as primary surgery if the patient wants to avoid visible surgical scars. Additionally, the buried-suture method is more easily revised. Ease of suture removal must be taken into account when performing double-eyelid blepharoplasty because some patients casually decide to undergo surgery, but later change their minds and request to return to their original eyelid.

However, buried-suture double-eyelid blepharoplasty involves implantation of the suture thread as a foreign material. Therefore, potential complications caused by foreign material should be considered. Most affected patients have long-term mild pain or an uncomfortable pulling sensation that has been considered negligible subclinical symptoms by surgeons.


This retrospective study included 210 upper eyelids of 116 consecutive Japanese patients who had undergone buried suture double-eyelid blepharoplasty at other clinics. All patients underwent suture removal surgery at the author's institution for treatment of suture-related complications. Although 12 patients (10.3%) underwent suture removal surgery alone, 104 (89.7%) underwent secondary double-eyelid blepharoplasty. The outcomes of 3 techniques were evaluated: the small skin incision method, the full skin incision method, and the conjunctival method.

1) Small Skin Incision

The small skin incision method was indicated if the number of buried threads was small or at the patient’s request. Using small forceps, the knot of the buried thread was picked up outside the skin incision after dissection of the buried thread from the surrounding scar tissue (Fig. ​(Fig.1A).1A). If only the knot of the buried suture was erroneously removed during suture-removal surgery, the remnant of the buried suture was iatrogenically left in the tarsal plate (Fig. ​(Fig.1B).1B). In such cases, the remnant of the buried suture in the tarsal plate could move toward the conjunctival surface and cause corneal irritation, which should be avoided. After confirmation of continuity of the buried suture, the suture ring was cut and the suture was completely removed.

2) Full Skin Incision Method Combined with Secondary Double-Eyelid Blepharoplasty

Double-prong sharp retractors were used to stretch the incision, and this helped to reveal the buried sutures under the skin and remove them. The strip of the orbicularis oculi muscle was excised immediately above the lower skin edge. The buried sutures were also removed if they were located under the orbicularis oculi muscle. The upper and lower skin edges were both fixed with 7-0 nylon stitches to the levator aponeurosis along the superior tarsal border to create new double eyelids. These stitches were removed after 5 to 7 days. No buried sutures of any kind were used for this method.

3) Conjunctival Method

The conjunctival method was mainly indicated for late-onset suture extrusion. Sudden severe corneal irritation occurred in some patients with late-onset suture extrusion several years after undergoing the buried-suture double-eyelid blepharoplasty. The buried thread in the conjunctiva was easily removed using small forceps because the thread was often broken and free. However, if the buried thread was not removed because the knot was undissolved, the small skin incision method was required.


The small skin incision method was performed in 46 patients, the full skin incision method in 63, and the conjunctival method in 7. The success rate of the full skin incision method was significantly higher than that of the small skin incision method (4.8% vs 37.0%, respectively; p < 0.0001). Patients with an uncomfortable pulling sensation exhibited a linear scar or depressive deformity without inflammation of the tarsal plate and impingement on the subconjunctival capillary vessels of the tarsal plate or a depressive deformity of the levator muscle. Patients with corneal irritation exhibited chronic inflammation of the conjunctival surface of the tarsal plate.


Suture-related complications of buried suture double-eyelid blepharoplasty in Asians must be treated with suture removal surgery. The full skin incision method is more reliable than the small incision method for such patients.


Learn more about Upper & Lower Blepharoplasty: Suture & Incisional Techniques in Academia, Singapore General Hospital on Dec 11-12, 2020.

IFAAS Hands-On Master Class

Upper & Lower Blepharoplasty: Suture & Incisional Techniques

Date: December 11-12, 2020


Moon Seop Choi, M.D., South Korea

Matthew Yeo, M.D., Singapore

Venue: Academia, Singapore General Hospital, Singapore


More Upcoming Aesthetic Trainings happening globally:

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