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71
Copyright © 2014 The Korean Society of Plastic and Reconstructive Surgeons
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
www.e-aps.org
INTRODUCTION
Double eyelid surgery is now the most common cosmetic surgi-
cal procedure performed amongst East Asians and is synony-
mous with blepharoplasty in this patient population [1]. East
Asians, in contrast to their Caucasian counterparts, typically
have smaller eyes that oen lack supratarsal creases, also known
as double eyelid folds. Moreover, the lack of a supratarsal crease
that causes hooding of the upper eyelid and the relative weak-
ness of the upper eyelid elevators that reduces the vertical pal-
pebral ssure height both produce the illusion of smaller eyes in
Asians. By creating a supratarsal crease, either by an incisional
or non-incisional method, the hooding of the skin is corrected
by increasing the surface area of the skin as the skin invaginates
inward. In addition, previously unrecognized blepharoptosis is
frequently revealed in patients presenting for double eyelid sur-
gery. Moreover, the creation of a supratarsal crease can unmask
latent mild blepharoptosis or create it through iatrogenic injury
Mild Ptosis Correction with the Stitch Method
During Incisional Double Fold Formation
Edward Ilho Lee1, Tae Joo Ahn2
1Department of Plastic Surgery, Baylor College of Medicine, Houston, TX, USA; 2Gyalumhan Plastic Surgery, Seoul, Korea
Correspondence: Tae-Joo Ahn
Gyalumhan Plastic Surgery, 21th,
Mijinplaza, 390 Gangnam-daero,
Gangnam-gu, Seoul 135-934, Korea
Tel: +82-2-535-6688
Fax: +82-2-535-8580
E-mail: cmcanti@hanmail.net
Background Numerous methods exist for simultaneous correction of mild blepharoptosis
during double eyelid surgery. These methods are generally categorized into either incisional
(open) or non-incisional (suture) methods. The incisional method is commonly used for the
creation of the double eyelid crease in patients with excessive or thick skin. However, concurrent
open ptosis correction is often marred by the lengthy period of intraoperative adjustment,
causing more swelling, a longer recovery time, and an increased risk of postoperative compli-
cations.
Methods The authors have devised a new, minimally invasive technique to alleviate mild
ptosis during incisional double eyelid surgery. The anterior lamella is approached through the
incisional technique for the creation of a double eyelid while the posterior lamella, including
Muller’s and levator muscles, is approached with the suture method for Muller’s plication and
ptosis correction.
Results The procedure described was utilized in 28 patients from June 2012 to August 2012.
Postoperative asymmetry was noted in one patient who had severe preoperative conjunctival
scarring. Otherwise, ptosis was corrected as planned in the rest of the cases and all of the
patients were satisfied with their postoperative appearance and experienced no complications.
Conclusions Our hybrid technique combines the benefits of both the incisional and suture
methods, allowing for a predictable and easily reproducible correction of blepharoptosis with
an aesthetically pleasing double eyelid.
Keywords Blepharoptosis / Muscles / Conjunctiva
Received: 2 Apr 2013 • Revised: 29 May 2013 • Accepted: 7 Jun 2013
pISSN: 2234-6163 • eISSN: 2234-6171 • http://dx.doi.org/10.5999/aps.2014.41.1.71 • Arch Plast Surg 2014;41:71-76
No potential conflict of interest relevant
to this article was reported.
Original Article
72
Lee EI. et al. Mild ptosis correction with stitch method
to the levator complex. erefore, concurrent ptosis correction
is oen needed, either through an incisional or a non-incisional
method.
Several methods for non-incisional ptosis correction have
been published. Shimizu et al. [2] utilized two to four separate
threads to narrow the gap between the tarsus and levator muscle,
which, in effect, plicates the Muller’s muscle for ptosis correc-
tion. Around the same time, we introduced our method of non-
incisional ptosis correction by tucking Muller’s muscle through
the triangular stitch method [3]. This method is composed
of a single, running suture that locks soft tissue between the
conjunctiva and Muller’s muscle in a triangular configuration,
which allows the thread to work as a loop or a sling in pulling
up as much soft tissue as possible to correct ptosis. We, along
with many others, believe that a single, running suture is prefer-
able over multiple knots because it is able to distribute tension
between thread points better, thus reducing the risk of suture
loosening and allowing for more predictable results [2]. In cases
of asymmetric ptosis correction, if there is a 1 mm difference
in the eye opening strength between the eyes, then 2-loops are
used for the weaker eye and 1-loop for the stronger eye to take
into account the eect of Herring’s law. If there is a 2 mm dier-
ence, then 2-loops are used for the weaker eye only.
e advantages of our technique include minimal to no scar-
ring, quick recovery time, and minimal trauma to the eyelid tis-
sue. Moreover, this technique is predictable and easily reproduc-
ible with low complication rates. Unfortunately, this technique
should not be used in patients with loose or excess upper eyelid
skin requiring skin excision or in patients with thick skin where
the placement and eectiveness of the suture is unpredictable.
In order to overcome limitations of the suture method in these
patients, we have devised a hybrid technique whereby a double
eyelid fold is created through an incisional method but ptosis is
corrected through a non-incisional (suture) method.
METHODS
Patient selection
ere are two steps to our method for patient selection. First, we
determine whether the patient is a candidate for double eyelid
surgery. If so, then we examine the upper eyelid skin for thick-
ness and elasticity to determine whether the suture method is
suitable. When patients present with excess or thick upper eye-
lid skin, the ecacy of the suture method is limited. erefore,
these types of patients require incisional double eyelid surgery.
Second, we determine whether the patient needs ptosis cor-
rection. We use marginal reex distance 1 (MRD1) as a proxy to
determine whether the patient has ptosis. ose with a MRD1
of 1 to 3 mm, which we dene as mild ptosis, are favorable can-
didates for correction with our suture method. Notably, we do
not recommend the suture method for patients with severe pto-
sis, as they will require a more extensive procedure to achieve
desirable correction.
Once it is determined that the patient needs an open approach
for the skin and has mild ptosis, the following steps are followed.
Surgical technique
With the patient in a seated position, a line for the location of
the double eyelid crease is identified and marked. Next, the
amount of excess upper eyelid skin is determined and the area
of skin excision is marked. At this point, the degree of ptosis on
the two sides is compared, and the amount of ptosis correction
needed is established. e patient is then brought to the operat-
ing room, where she is laid in a supine position. All procedures
are performed under conscious sedation and local anesthetics.
After confirming all markings and injecting local anesthetic,
an incision is made along the line demarcating the excess skin
excision. e incision is carried down to the orbital septum and
the excess skin and orbicularis muscle is excised. If necessary,
the orbital septum is accessed to tease out and excise any excess
orbital fat. en, ptosis correction is performed with either the
1-loop or the 2-loop suture technique as described below.
1-Loop technique
First, three points are marked on the conjoint tendon perpendicu-
lar to the upper margin of the tarsal plate as follows: 1) medial lim-
bus; 2) midpupillary line; and 3) lateral limbus (Fig. 1). A 7-0
nylon suture on a 24-mm long needle is inserted from directly
above the upper margin of the tarsal plate and passed through
point 3 and out through the conjunctiva. Next, Muller’s muscle
tucking is performed by passing this suture approximately 8 to
10 mm cephalad and then passing it back caudally to the upper
border of the tarsal plate. At this point the upper border of the
tarsal plate should be directly above the midpupillary line. e
suture is next passed anteriorly from the upper border of the
tarsal plate through point 2, then towards point 3 while securing
a portion of the conjoint tendon and nally tied there.
2-Loop technique
e steps as described above are followed up to the completion
of the rst Muller’s tucking procedure. Aer passing the suture
anteriorly from the upper border of the tarsal plate through point
2, the suture is routed towards point 1 while securing a portion
of the conjoint tendon. At point 1, the suture is inserted through
the upper margin of the tarsal plate and passed out through the
conjunctiva directly below the point. Next, Muller’s muscle
Vol. 41 / No. 1 / January 2014
73
tucking is performed again and the needle is passed through
point 2. e suture is then passed toward point 3 while securing
a portion of the conjoint tendon and then tied here.
For both the 1-loop and 2-loop techniques, the protrusion in
the conjunctiva and Muller’s muscle evens out and aens over
time so that it does not irritate the eye. Aer completion of pto-
sis correction, the supratarsal fold is created and the incisional
double eyelid surgery is completed in a standard manner.
RESULTS
e procedure described was utilized in 28 patients from June
2012 to August 2012. Postoperative asymmetry was noted in
one patient who had severe preoperative conjunctival scarring.
Otherwise, no other complications were noted over a minimum
follow-up period of 3 months.
Case 1
A 19-year-old female presented with 2 mm MRD1 on both eyes,
which appeared to be worse due to hooding of excess skin caus-
ing eacement of the lid margin. Excess skin and muscle were
excised through the incisional method, which also resulted in
adhesion-like septated tissue around the septum being freed up.
e MRD1 measurements at 3 months postoperatively were 5
mm on both eyes (Fig. 2).
Case 2
A 28-year-old female presented complaining of sunken eyes and
discomfort when opening her eyes. e skin and muscle excision
was kept at a minimum and the 2-loop technique as described
above was used for ptosis correction. MRD1 was increased from
3.5 mm preoperatively to 5.5 mm at 8 months postoperatively.
Resolution of discomfort with eye opening and the correction
of sunken eyes was maintained at 8 months postoperatively
(Fig. 3).
Case 3
A 31-year-old female, with a history of double eyelid surgery 4
years earlier through a partial incision technique, presented com-
plaining that her eyes still appeared small and tired. e double
eyelid was revised and ptosis was corrected with our technique as
described above. e MRD1 was increased from 2.5 mm preop-
A B C
Fig. 1. Schematic diagram of 2-loop suture
(A) Schematic diagram of the 2-loop suture technique to tuck Muller’s muscle for ptosis correction. Design of the 2-loop technique during incisional
double eyelid surgery, as viewed from (B) the anterior lamella and from (C) conjunctiva.
A B C
Fig. 2. Case 1: preoperative and postoperative appearance
A 19-year-old female. Incisional double eyelid surgery combined with the 2-loop suture technique for ptosis correction. (A) Preoperative appearance
with 2 mm marginal reflex distance 1 (MRD1) on both eyes, which appeared to be worse due to hooding of excess skin causing effacement of the lid
margin. (B) Appearance 3 months postoperatively with an MRD1 of 5 mm on both eyes. (C) Intraoperative view of the conjunctiva after completion
of the 2-loop suture technique to tuck Muller’s muscle.
74
Lee EI. et al. Mild ptosis correction with stitch method
eratively to 5 mm at 3 months postoperatively (Fig. 4).
Case 4
A 46-year-old female, with a history of bilateral upper and lower
blepharoplasty 10 years earlier, presented for revision. e MRD1
on the right was 2 mm and on the le was 1.5 mm. e asymme-
try became more pronounced when the frontalis muscle action
was blocked, with an MRD1 of 2 mm on the right and 1 mm on
the le. Incisional double eyelid surgery was performed on both
eyes, with 1-loop on the right and 2-loops on the le for ptosis
correction. At 3 months postoperatively, an MRD1 of 3 mm was
maintained bilaterally with improvements in the lower scleral
show phenomenon (Fig. 5).
DISCUSSION
The method for correcting blepharoptosis varies depending
upon its severity and cause. Numerous operative methods have
been reported; however, variables such as local anesthetics,
hematoma, swelling, and elasticity of the muscle make verifying
A B C
Fig. 3. Case 2: preoperative and postoperative appearance
A 28-year-old female. Incisional double eyelid surgery combined with the 2-loop suture technique for ptosis correction. (A,B) Preoperative appearance
with sunken eyes and a 3.5 mm marginal reflex distance 1 (MRD1) on both eyes. (C) Appearance 8 months postoperatively with an MRD1 of 5.5 mm
on both eyes.
A B C
Fig. 5. Case 4: preoperative and postoperative appearance
A 46-year-old female. Incisional double eyelid surgery combined with a 1-loop (right) and 2-loop (left) suture technique for ptosis correction. (A) Preo-
perative appearance. The marginal reflex distance 1 (MRD1) on the left was 0.5 mm smaller. (B) Preoperatively, the asymmetry was more pronounced
when frontalis muscle action was blocked, with an MRD1 difference of 1 mm. (C) Appearance 3 months postoperatively with an MRD1 of 3 mm on
both eyes.
A B
Fig. 4. Case 3: preoperative and postoperative appearance
A 31-year-old female. Incisional double eyelid
surgery combined with the 2-loop suture
technique for ptosis correction. (A) Preopera-
tive appearance with a history of double
eyelid surgery 4 years earlier through the
partial incision technique, and a complaint
of small and tired eyes. (B) Appearance 3
months postoperatively after double eyelid
revision and ptosis correction. Marginal
reflex distance 1 was increased from 2.5 mm
preoperatively to 5 mm.
Vol. 41 / No. 1 / January 2014
75
and adjusting the degree of ptosis correction challenging with
these methods [2,3].
Capitalizing on our experience with the non-incisional meth-
od for simultaneous double eyelid and ptosis correction, the
current technique was craed to: 1) allow the creation of a dou-
ble eyelid fold in patients with loose or thick skin; 2) minimize
the risk of complications in cases of mild ptosis by simplifying
the procedure and maintaining integrity of the posterior lamella
through the non-incisional method; and 3) minimize asym-
metry in ptosis correction while eliminating the need for the
patient to sit up during the procedure to check for symmetry.
Although an incision is not created in order to correct ptosis
(the posterior lamella is not violated either by incision or detach-
ment), we believe that Muller’s plication technique creates scar
casting by permanently shortening the muscle. In addition, by
using the suture method for concomitant ptosis repair instead
of the traditional open technique, we are able to preserve the
integrity of both the Muller’s and levator muscles. Moreover, the
levator may appear to have had levator complex advancement
because it is likely that the levator complex is being pulled with
our technique (Figs. 1, 6).
According to Hirasawa et al. [4], the eye-elevating muscle
is composed of voluntary fast-twitch muscle fibers and invol-
untary slow-twitch muscle fibers. The initial, voluntary, and
quick muscle contraction leads to the stretching of the Muller’s
muscle. This contraction elicits an involuntary response from
the muscles to strengthen the eye opening reex.
To sum up, the eectiveness of our suture method for ptosis
repair is based on the following: 1) the reex action, as described
above, that is reinforced with tucking of the Muller’s muscle; 2)
posterior lamella shortening; 3) creation of a sling for the con-
joint fascial sheath; and 4) levator advancement.
Although our experience with the current method described
(incisional method for double eyelid creation and suture method
for ptosis correction) is limited, our experience with the non-
incisional method for simultaneous double eyelid creation and
mild ptosis correction is more extensive, and we decided to ana-
lyze these results in order to assess the utility of this technique.
From January 2011 to December 2012, the non-incisional
method for simultaneous double eyelid creation and mild
ptosis correction was utilized in 371 patients with an average
of 6 months of follow-up. In all of the patients, the number of
loops to use, and therefore, the degree of ptosis correction, was
decided preoperatively, which allowed judicious use of local
anesthetics during the procedure for patient comfort, aribut-
ing any small degree of intraoperative asymmetry to the eect of
local anesthetics. ere were 7 revision cases, including 3 cases
of suture failure, 2 of asymmetry, 1 unsatisfactory result due to
what was perceived as an excessively deep supratarsal fold, and
another unsatisfactory result due to lateral hooding created by
eyebrow descent from improvement in eyelid ptosis. Revision
was performed in one patient because she wanted smaller folds.
e case of asymmetry was easily corrected by adding 1-loop to
the more ptotic side under local anesthesia.
Since we have used this method, the utility, safety, and predict-
ability of Muller tucking through the triangular stitch method
(also known as a conjoint fascial sheath sling) was realized and
applied to open double eyelid surgery to address patients with
thick or excessive skin who were previously thought not to be
ideal candidates for the non-incisional method for ptosis correc-
tion. Moreover, in the cases of incisional double eyelid surgery
with symmetric mild ptosis, the 1-loop or 2-loop techniques
were easily added without the need to sit patients up during
surgery to conrm symmetric ptosis correction, thus reducing
operative times.
When compared to the traditional open ptosis repair technique,
our loop technique has the following advantages: 1) It can be
performed as fast as 5 minutes per eyelid without the need to sit
patients up intra-operatively to conrm ptosis correction, thus
saving time; 2) although the anterior lamella is incised in both
techniques, posterior lamella, which is commonly detached
or incised in open ptosis repair, is preserved, thus reducing re-
covery time; and 3) ample amounts of local anesthetics can be
administered since intra-operative adjustments are not needed,
thus improving patient comfort during the procedure.
From our experience, 1 mm and 2 mm of ptosis correction can
Levator aponeurosis Levator aponeurosis
Tarsus
Conjoint fascial sheath
(Check ligament of
superior fornix)
Muller’s muscle
Fig. 6. Cross-sectional view and intraoperative view
Cross-sectional view of Muller’s muscle tucking with the 2-loop
technique.
76
Lee EI. et al. Mild ptosis correction with stitch method
be achieved predictably using 1-loop and 2-loops, respectively,
in patients with so or thin eyelid skin. However, the degree of
ptosis correction using the suture technique could be reduced
by as much as 50% due to the texture of the thick, scarred skin
in patients with previous trauma. In these patients, the skin’s
added thickness and weight, along with adhesions from previ-
ous trauma, likely contribute to this reduced effectiveness.
Moreover, this technique is least successful in patients who have
severe conjunctival scarring from strabismus surgery during
childhood. Such cases highlight the potential for scars to hinder
a surgery that attempts to augment levator function. The inci-
sional method to approach the anterior lamella allows for lysis
of adhesions and separation of scar tissue. is greatly improves
the quality of the skin and compliments the suture method by
allowing it to be more eective and predictable. In case 4, the
degree of lysis was minimized by going through previous bleph-
aroplasty incision, and ptosis was predictably corrected with
our stitch method by utilizing tracks from the previous suture
method for double eyelid creation. In general, for patients with
symmetric mild ptosis in the seing of thick or scarred skin, the
2-loop technique is recommended over the 1-loop technique
due to its greater ability to overcome so tissue limitations. We
plan on publishing our long-term results of the suture method
for ptosis correction with either the incisional or suture method
for double eyelid surgery in the near future.
Technically, the location of the suture should be at a depth
underneath the conjunctiva and Muller’s muscle so that if the
needle is lied during Muller tucking of the posterior wall, the
suture should be visible. Additionally, it is important to note that
if the plication is performed at a deeper depth, its eect can take
longer to become visible in the postoperative period. erefore,
although the results of this method are predictable, the eyes can
appear to be deceptively asymmetric for two to three months
depending on the depth of plication and the amount of postop-
erative swelling.
Our proposed suture technique further stabilizes the integrity
and function of the stitch by placing the stitch between the up-
per margin of the tarsal plate and the conjoint fascial sheath [5]
above Muller’s muscle for the Muller’s muscle plication, allow-
ing for longer tails on the knot since the knot can be buried at
this interface.
Furthermore, the volume of local anesthetics used is of mini-
mal concern when performing our technique. Therefore, the
pain management of patients occurs more seamlessly. With cur-
rent techniques, local anesthetics are used cautiously because
these techniques require intraoperative adjustments for ptosis
correction and cannot account for post-operative asymmetry
resulting from using a higher volume of local anesthetic. In con-
trast, since the degree of ptosis correction is solely dependent
on the number of loops used, our technique can accommodate
a more liberal usage of local anesthetic for the patient.
The non-incisional suture method technique has gained im-
mense popularity among young Asian females who desire dou-
ble eyelid creases [6,7]. In today’s fast-paced society, a surgically
eective method for correcting blepharoptosis is needed along
with a minimal recovery period. Despite the need for skin inci-
sion for double eyelid creation, there is no additional incision or
detachment of structures for blepharoptosis correction with our
technique.
In conclusion, this article introduces a minimally invasive
technique to conduct double eyelid creation simultaneously
with mild blepharoptosis correction. e advantages of our new,
hybrid technique are predictable results, minimal scarring, quick
recovery time, and reduced trauma to the eyelid tissue. And
nally, this method is technically simple and easily reproducible
with a relatively short operative time.
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