Editor: Prof. A Hart Journal Pre-proof Orbicularis-levator-tarsus fixation suturing in buried suture double-eyelid blepharoplasty Jing Shi M.D , Jiaqi Zhang M.D , Congmin Gu M.D , Wen Chen M.D , Mingyong Yang M.D PII: S1748-6815(21)00557-X DOI: https://doi.org/10.1016/j.bjps.2021.11.012 Reference: PRAS 7436 To appear in: Journal of Plastic, Reconstructive & Aesthetic Surgery Received date: 20 December 2020 Accepted date: 3 November 2021 Please cite this article as: Jing Shi M.D , Jiaqi Zhang M.D , Congmin Gu M.D , Wen Chen M.D , Mingyong Yang M.D , Orbicularis-levator-tarsus fixation suturing in buried suture double- eyelid blepharoplasty, Journal of Plastic, Reconstructive & Aesthetic Surgery (2021), doi: https://doi.org/10.1016/j.bjps.2021.11.012 This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2021 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. “Orbicularis-levator-tarsus fixation suturing in buried suture double-eyelid blepharoplasty” Author list: Jing Shi, M.D 1, Jiaqi Zhang, M.D 1, Congmin Gu, M.D 1, Wen Chen, M.D 1, Mingyong Yang, M.D 1. 1. Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100141 China. Corresponding author: W.C. MD. Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Ba-Da-Chu Street, Shi-Jing-Shan District Beijing, 100141, China. email@example.com Financial Disclosure Statement: None of the authors had a financial interest in any of the products, devices, or drugs mentioned in this manuscript. The authors had nothing to disclose. No funding was received for this article. Presented at (if applicable): No Short Running Head (no more than 40 characters in length): No Ethical approval This study was a retrospective review of patients who underwent surgery after review in our outpatient clinic. We obtained institutional review approval and patients’ consent prior to their inclusion in this study. Data were only collected from the patient case notes that were accessible to the authors. All data collected were made anonymous to preserve patient confidentiality. The collection of the data and the results of this study did not impact any aspect of patient management. Patient consent was obtained for the publishing of their medical photographs. Author contributions J.S, J.Z, C.G, W.C, M.Y, designed/planned the study and wrote the paper. J.S. and W.C. performed imaging analysis. Abstract Background: In buried suture methods, the levator aponeurosis is fixed to the subcutaneous tissue in the pretarsal region using a suture. However, loosening of the suture occurs frequently and causes regression or disappearance of the double-eyelid folds. To avoid potential loosening of the suture after surgery, we modified the horizontal suture technique commonly used in buried suture double-eyelid blepharoplasty. Methods: In our procedure, the levator aponeurosis was sutured horizontally, and then the subcutaneous tissue in the pretarsal region was sutured vertically by the same suture. After the two ends of the suture were tied, three tissue layers, namely, the levator aponeurosis, pretarsal fascia, and orbicularis oculi muscle, were fixed together in the pretarsal region. Results: A total of 873 Asian patients underwent double-eyelid blepharoplasty during the past eight years. No loss of the double-eyelid folds occurred in 563 patients who were followed up for more than six months, and 531 patients, accounting for 94% of the sample, were satisfied with the postoperative results. Conclusion: Since the suture was perpendicular to both the levator aponeurosis and the pretarsal orbicularis oculi muscle, pulling on the suture fixation site during blinking was effectively reduced. As a result, regression or disappearance of the double-eyelid folds due to loosening of the suture along the orientation of the muscle fibers was avoided, and the long-term stability of the double-eyelid folds was ensured. Level of Evidence: Level IV, therapeutic study Keywords: Buried suture method; Double-eyelid blepharoplasty; Upper eyelid fixator Introduction With an increasing number of Asians wishing to acquire double eyelids through surgery, double-eyelid blepharoplasty has become the most commonly performed aesthetic procedure among Asians1,2. Many procedures are available for creating double eyelids, which are generally categorized into buried suture and incision methods3. Buried suture methods are preferred due to the natural look of the new double eyelids, as these methods will not damage the tissue structure of the upper eyelid 4,5. However, in these methods, the suture that fixes the levator aponeurosis to the subcutaneous tissue in the pretarsal region is prone to loosening after surgery, resulting in gradual regression or disappearance of the double-eyelid folds, a result that affects the adoption of the buried suture methods6. To avoid potential loosening of the suture after surgery, surgeons have come up with many successful modified suture techniques7. In this study, we will introduce a new orbicularis-levator-tarsus fixation suturing used in buried suture double-eyelid blepharoplasty to form a stable eyelid. Patients and methods Patients From July 2011 to November 2019, 873 Asian patients underwent double-eyelid blepharoplasty using the procedure proposed in this study, including 814 females and 59 males aged 17-32 years, with an average age of 26 years. A total of 716 patients had bilateral single eyelids, 92 patients had single eyelids on one side, and 65 patients had narrow double eyelids and wanted wider double eyelids. The blepharoplasty procedure was performed on both sides in all patients, 416 of whom also underwent epicanthoplasty at the same time. Methods During the procedure, each patient was placed in the supine position. First, the proposed double-eyelid lines were simulated using sterile toothpicks and marked with methylene blue. On the marked line, point A was the intersection with the line perpendicular to the medial margin of the pupil, point B was its intersection with the line perpendicular to the outer margin of the iris, point C was the midpoint of the line connecting point A and the inner canthus, and point D was on the lateral side of point B, with the distance between B and D equal to the distance between A and B (Figure 1A). Patients were anesthetized with a mixture of 0.5% lidocaine and 1:200,000 epinephrine. After one milliliter of anesthetic was injected into the eyelid subcutaneously along the marked line, a 2-mm incision was made along the marked point using a #11-blade knife. The incision reached a depth beneath the orbicularis oculi muscle. The upper eyelid was everted to expose the conjunctiva, and 0.5 ml of anesthetic was injected into the conjunctiva along the upper edge of the tarsus. If the patient had epicanthus, the epicanthus could be corrected before the next step. To ensure a precise suture, we designed a special upper eyelid fixator for fixation and support of the upper eyelid during the operation (Figure 1B). First, the operation was performed at point A. The fixator was inserted into the superior fornix to lift, fix, and support the upper eyelid. A triangular needle with a 7-0 nylon suture was used. The needle tip penetrated perpendicularly into the conjunctiva at the upper edge of the tarsus from point A, was turned horizontally, passed under the levator aponeurosis, and vertically passed through the levator aponeurosis (Figure 2). The needle tip turned from a horizontal direction to a vertical direction to pass through the pretarsal fascia and orbicularis oculi muscle (Figure 3 A), and eventually brought out at point E from the upper eyelid skin. After removing the tip, the needle tail remained in the orbicularis oculi muscle (Figure 3 B). Lifted the tip so that the tail passed through the orbicularis oculi muscle and kept under the skin (Figure 4 A). We treated the tail as the "tip" and put it through the skin subcutaneously to point A (Figure 4 B), and removed the tail, the suture, and the tip at point A (Figure 5 A). The two ends of suture were stretched and tied (Figure 5 B). The same operation was performed at point A on the other eyelid. After the suture was completed, the shape and width of the double-eyelid fold on each eyelid were observed to make sure they were appropriate. After satisfactory results were achieved, the same operation was repeated at points B, C, and D. Finally, the incisions were not sutured, and the preserved suture at each point was cut short at the knot and buried in the incision (Figure 6)(See Video, Supplemental Digital Content 1). To better understanding fixation of tissue levels and direction of internal suture in the operation process, schematic diagrams of the surgical procedure was provided (Figure 7). Results Among the 873 patients in this study, 563 patients were followed up for more than six months. Among these 563 patients, the maximum follow-up was seven years, and the average follow-up was 11 months. Double eyelid width differences are the most common problem after double eyelid surgery. We used each patient's self-perception as the basis for our judgment standard. Among the 563 patients followed up for more than six months, 29 patients considered the widths of the double-eyelid folds to be significantly different, 22 of whom were treated again with the method proposed in this study to widen the narrower fold. Thirteen patients considered the widths of the double-eyelid folds to be overly narrow after the operation, three of whom were treated again using the proposed method, while ten were treated using an incisional method. No loss of double-eyelid folds occurred in 563 patients who were followed up for more than six months, and 531 patients, accounting for 94% of the sample, were satisfied with the postoperative results (Figures 8-9). Discussion Unlike Western populations, only 50% of Asians are born with double eyelids 8. With an increasing number of Asians wishing to acquire double eyelids through surgery, double-eyelid blepharoplasty has become the most commonly performed aesthetic procedure among Asians1,2. There are many procedures available for creating double eyelids, and they are generally categorized into buried suture and incision methods3. In buried suture methods, the levator aponeurosis is fixed to the subcutaneous tissue in the pretarsal region using a suture. Buried suture methods do not damage the normal tissue structure of the upper eyelid and can simulate the natural formation process of a double eyelid; thus, such methods are the first choice for Asians who want to obtain double eyelids through surgery4, 5. Nonetheless, buried suture methods are much less popular than incision methods, mainly because the suture that fixes the levator aponeurosis to the subcutaneous tissue in the pretarsal region is prone to loosening after surgery, resulting in gradual regression or disappearance of the double-eyelid folds, which affects the adoption of these methods6. In addition, the indications of the buried method are relatively limited. For patients with poor eyelid conditions, such as patients with swollen eyelids or ptosis, the postoperative buried method cannot achieve satisfactory results, so a total resection has to be selected. In incision methods, the full-thickness skin of the upper eyelid is cut open, and the subcutaneous tissue in the pretarsal region is removed to form cicatricial adhesion between the levator aponeurosis and the pretarsal skin, resulting in double eyelids that are stable and long lasting9. However, the formation of double eyelids by cicatricial adhesion does not simulate the natural formation of double eyelids, and the resulting double eyelids are overly deep and unnatural looking10. To obtain a more natural-looking double eyelid, increasing numbers of doctors choose to preserve the pretarsal orbicularis oculi muscle and suture it to the levator aponeurosis using incision methods11,12. A stable double eyelid can also be formed by suturing the pretarsal orbicularis oculi muscle and the levator aponeurosis together using incision methods, which caused us to rethink the strategy used to modify the suturing procedure in conventional buried suture methods to avoid regression or disappearance of the double-eyelid folds. In incision methods, multi-layer and multi-direction precise suturing under direct vision of the pretarsal orbicularis oculi muscle and the levator aponeurosis is the key to creating a lasting and stable double eyelid 13,14 . Due to the lack of direct vision, the horizontal suture is often used in the buried method, which has a good immediate effect but easily loosening after frequently blinking. To solve the vision limitation of the buried method and achieve stereo suture, we use the small-incision and special upper eyelid fixator to realize accurate suture without direct vision. Therefore, the concept of multi-layer and multi-angle suture of the incision method can be applied to the suture method, then the indication of buried method can be expanded. In operation procedure, We passed the suture needle horizontally through the levator aponeurosis and then turned the needle tip in a vertical direction to fix the suture to the pretarsal orbicularis oculi muscle. Because the suture ligation was perpendicular to both the levator aponeurosis and the orbicularis oculi muscle, pulling of the suture during blinking could be effectively resisted, and thus the regression or disappearance of the double-eyelid folds due to loosening of the suture along the orientation of the muscle fibers could be avoided (Figure 7A). After suture ligation, three tissue layers—the levator aponeurosis, the pretarsal orbicularis oculi muscle, and the pretarsal fascia—were fixed together, and the tissue adhesion at the suture fixation site was stronger and more stable. At the same time, the pretarsal fixation of the levator aponeurosis produced a mild folding effect, which reinforced the levator aponeurosis and enlarged the palpebral fissure15 (Figure 7B). In summary, buried methods can create a more natural double eyelid fold. Although the loss of folds is a concern for surgeons, many modified techniques have shown high success rates7. The new fixation suture technique proposed in this paper has also been proved to be a feasible and high success rate buried operation through our years of application and follow-up. The special upper eyelid fixator we designed reduces the difficulty of suture for each tissue level. A doctor who has mastered the traditional suture technique can easily master this technique after a period of practice. Conclusion A new suture method we applied in buried suture double-eyelid blepharoplasty, can provide a solid suture fixation and avoid suture loosening during blinking through multi-layer and multi-direction suture technique, which ensures the long-term stability of the double-eyelid folds and could be used in the clinic. References 1. Kim SS. Effects in the upper face of far east Asians after Oriental blepharoplasty: a scientific perspective on why Oriental blepharoplasty is essential. Aesthetic Plast Surg. 2013;37(5):863‐ 868. 2. Hwang HS, Spiegel JH. The effect of "single" vs "double" eyelids on the perceived attractiveness of Chinese women. Aesthet Surg J. 2014;34(3):374‐ 382. 3. McCurdy JA Jr. Upper blepharoplasty in the Asian patient: the "double eyelid" operation. Facial Plast Surg Clin North Am. 2005;13(1):47‐ 64. 4. Song RY, Song YG. Double eyelid operations. Aesthetic Plast Surg. 1985;9(3):173‐ 180. 5. Baek SM, Kim SS, Tokunaga S, Bindiger A. Oriental blepharoplasty: single-stitch, nonincision technique. Plast Reconstr Surg. 1989;83(2):236‐ 242. 6. Choi AK. Oriental blepharoplasty: nonincisional suture technique versus conventional incisional technique. Facial Plast Surg. 1994;10(1):67‐ 83. 7. Moon KC, Yoon ES, Lee JM. Modified double-eyelid blepharoplasty using the single-knot continuous buried non-incisional technique. Arch Plast Surg. 2013;40(4):409‐ 413. 8. Hiraga Y. The double eyelid operation and augmentation rhinoplasty in the Oriental patient. Clin Plast Surg. 1980;7(4):553‐ 567. 9. Zhang MY, Yang H, Ding SL, et al. Construction of a double eyelid: an uncut strip of orbicularis removed through three mini-incisions. Aesthetic Plast Surg. 2013;37(1):22‐ 28. 10. Choi Y, Eo S. A new crease fixation technique for double eyelidplasty using mini-flaps derived from pretarsal levator tissues. Plast Reconstr Surg. 2010;126(3):1048‐ 1057. 11. Park JI. Orbicularis-levator fixation in double-eyelid operation. Arch Facial Plast Surg. 1999;1(2):90‐ 96. 12. Sun W, Wang Y, Song T, Wu D, Li H, Yin N. Orbicularis-Tarsus Fixation Approach in Double-Eyelid Blepharoplasty: A Modification of Park's Technique. Aesthetic Plast Surg. 2018;42(6):1582‐ 1590. 13. Wu LW, Ye Z, Xu Y, Yu J, Wu Y. Orbicularis-levator-tarsus composite suture technique in double-eyelid operation. J Plast Reconstr Aesthet Surg. 2015;68(8):1079‐ 1084. 14. Yang SY. Oriental double eyelid: a limited-incision technique. Ann Plast Surg. 2001;46(4):364‐ 368. 15. Ma CJ, Lu F, Liu L. A Modified Double Eyelid Plastic Surgery Method: Continuous Buried Suture Method Accompanied by Simultaneous Correction of Mild Blepharoptosis. Aesthetic Plast Surg. 2018;42(6):1565‐ 1570. Figure 1. A. Four incision points (A, B, C, and D) marked along the double-eyelid line. B. A special upper eyelid fixator was designed for fixation and support of the upper eyelid to ensure precise suturing during the operation without direct vision. Figure 2. The needle tip started with stitching horizontally across the conjunctiva at the upper edge of the tarsuse and the levator aponeurosis. Figure 3. A. The tip was turned vertically, passed through the pretarsal fascia and orbicularis oculi muscle. B. After the tip was removed at point E, the needle tail remained in the orbicularis oculi muscle. Figure 4. A. The tip was lifted so that the tail passed through the orbicularis oculi muscle and kept under the skin. B. The tail was treated as the "tip" and put through the skin subcutaneously to point A. Figure 5. A. The needle tail, the suture, and the tip was removed out at point A. B. The two ends of suture were stretched and tied. Figure 6. The preserved suture at points A, B, C, and D was cut short at the knot and buried in the incision. Figure 7. Schematic diagrams of the surgical procedure, A. The suture was perpendicular to both the levator aponeurosis and the orbicularis oculi muscle. B. After suture ligation, three tissue layers—the levator aponeurosis, the pretarsal orbicularis oculi muscle, and the pretarsal fascia—were fixed together. Figure 8. The comparison of a 26-year-old woman before operation and 4 years postoperatively. Figure 9. The comparison of a 19-year-old woman (with mild blepharoptosis) before operation and 2 years and 9 months postoperatively.