INTRODUCTION
Double-eyelid surgery is one of the most commonly performed aesthetic procedures worldwide, especially among Asian populations. As a minimally invasive technique, it offers significant aesthetic enhancement while requiring minimal downtime. Its increasing prevalence has been driven by advancements in surgical techniques, evolving aesthetic ideals, and sociocultural influences. However, despite its widespread adoption, the choice of surgical technique still largely relies on individual surgeon preferences rather than robust evidence-based guidelines, highlighting a significant gap in the literature.
The historical evolution of double-eyelid surgery reflects a paradigm shift from high-crease fixation techniques, historically associated with “Westernization,” toward contemporary approaches prioritizing the preservation of ethnic identity and natural aesthetic outcomes. Lam emphasized that a lower crease height and fuller eyelid configuration align more closely with current Asian aesthetic preferences [1]. Understanding the distinctive anatomical characteristics of Asian eyelids is essential for achieving stable and culturally appropriate outcomes. McCurdy [2] identified the absence or reduced adhesion between the levator aponeurosis and the skin as a defining feature of the Asian eyelid, necessitating meticulous surgical execution to ensure long-term crease retention.
Despite decades of clinical experience, comparative data on the long-term efficacy of different buried suture techniques remain insufficient, limiting the development of standardized best practices. The continuous buried suture method is theoretically advantageous because it distributes tension evenly along the eyelid crease, potentially enhancing stability. In contrast, the two-point buried suture method relies on discrete fixation points, which may result in localized stress and increased suture loosening. A relatively newer approach, the transconjunctival buried suture method, eliminates external skin penetration by anchoring the crease solely through conjunctival fixation, thereby theoretically minimizing visible scarring while maintaining long-term stability.
This study represents the first comprehensive, large-scale comparative analysis of these three techniques, systematically evaluating reoperation rates, time to reoperation, and the primary reasons for revision surgery over a 4-year follow-up period. By providing robust clinical data, this study aims to establish evidence-based guidelines for optimizing outcomes in double-eyelid surgery.
METHODS
Ethical considerations
This study was approved by the local ethics committee of Tokyo Chuo Beauty Clinic (approval number: UMEDAERB-2024Dec002). Anonymized data were used throughout the research, and all data were securely stored and managed according to the guidelines of the research institution to ensure patient confidentiality. The requirement for informed consent was waived because of the retrospective nature of the study. This research adhered to the ethical standards outlined in the 1964 Declaration of Helsinki (Fortaleza Revision, October 2013).
Data collection
Data for this study were obtained from a single, large-scale, nationwide cosmetic surgery network comprising over 100 affiliated clinics across Japan. All participating clinics utilize a unified electronic medical record system, with standardized protocols for both surgical procedures and data entry. Centralized management of patient data ensures consistency and reliability across clinics, facilitating robust multicenter retrospective analyses. Patients who underwent double-eyelid surgery between October 18, 2020, and November 28, 2020, were included, with a follow-up duration of 4 years, concluding on November 28, 2024. A total of 1,500 cases (500 two-point, 500 continuous, and 500 transconjunctival) were randomly selected by an independent researcher who was not involved in the statistical analysis. Collected data included patient demographics, surgical technique, operation date, occurrence of and reasons for reoperation, and time to reoperation.
Surgical procedures
Continuous buried suture method
Markings were placed at four points (a, b, c, and d). A 7-0 Prolene suture was inserted subcutaneously from point a to c and then passed transconjunctivally to point d. The other end of the suture was inserted subcutaneously from point b to point d and then tied at point d (Fig. 1A). The procedure concluded after careful adjustment and confirmation of the shape, height, and symmetry of the double eyelids.
Two-point buried suture method
Markings were created using an 11-blade Bard-Parker scalpel. Shallow incisions were made at four points: two medial points (a’ and b’) and two lateral points (c’ and d’) (Fig. 1B). A 6-0 nylon suture was passed transconjunctivally through the tarsal plate at point a’, exited through point b’, and was tied subcutaneously at point b’. The process was repeated from points c’ to d’, with knots buried subcutaneously at points b’ and d’.
Transconjunctival buried suture method
The suture was placed entirely through the conjunctival side without penetrating the external skin surface. A 7-0 Prolene suture was passed through the dermal layer to ensure secure fixation while avoiding external skin puncture (Fig. 1C).
Statistical analysis
Kaplan-Meier survival curves were used to compare reoperation rates. Cox proportional hazards models were utilized to identify risk factors associated with reoperation. Statistical analyses were conducted using Stata (version 18.5), with statistical significance defined as a P-value of less than 0.05.
RESULTS
Patient demographics
A total of 1,500 patients who underwent double-eyelid surgery were included in this study, with 500 patients allocated to each of the three surgical technique groups: continuous buried suture, two-point buried suture, and transconjunctival buried suture.
The mean patient age was 26.12 years (standard deviation±8.41), and the median age was 24.0 years (interquartile range, 21.0–28.5 years). Most patients (86.7%) were younger than 35 years, and only 13.3% were aged 35 or older. Age distribution did not differ significantly among the three groups (P=0.71). However, the continuous method group had a significantly higher proportion of female patients compared with the two-point and transconjunctival method groups (P<0.001). The overall reoperation rate across all groups was 19.7% (295/1,500 cases), with the majority (80.3%) not requiring revision surgery (Table 1).
Reoperation rates
Reoperation rates varied significantly among the three groups (P<0.001). The continuous method showed the lowest reoperation rate, whereas the transconjunctival method demonstrated better stability compared with the two-point method. No significant differences were found in the time to reoperation among the three groups (P=0.65) (Table 2). Kaplan-Meier analysis confirmed that the continuous method had the highest long-term stability, followed by the transconjunctival method, with the two-point method exhibiting the lowest durability (log-rank test, P<0.001).
Kaplan-Meier analysis
The double-eyelid crease retention rates at 500 days postoperatively differed among the three methods. The continuous method had the highest retention rate (85%), followed by the transconjunctival (78%) and two-point methods (72%). At 1,000 days, retention rates declined across all methods. The continuous method maintained the highest rate at 81%, whereas the transconjunctival method decreased to 72%, and the two-point method declined further to 65% (Fig. 2). Overall, the continuous method demonstrated the most stable long-term retention. The transconjunctival method exhibited moderate stability, still superior to that of the two-point method, which consistently showed the lowest retention rates at both measured time points.
Multivariate analysis
A Cox proportional hazards model was employed to assess the reoperation risks associated with different surgical techniques. The analysis revealed that the continuous buried suture method significantly reduced the risk of reoperation by 54% compared with the two-point method (hazard ratio [HR], 0.46; 95% confidence interval [CI], 0.34–0.62; P<0.001). Likewise, the transconjunctival method reduced the reoperation risk by 28% compared with the two-point method (HR, 0.72; 95% CI, 0.55–0.94; P=0.014).
In contrast, patient age (HR, 0.99; P=0.339) and sex (HR, 0.87; P=0.531) were not significant predictors of reoperation risk (Fig. 3). These findings confirmed that the continuous buried suture method offers superior long-term stability, and the transconjunctival approach represents a viable alternative, significantly outperforming the two-point method regarding reoperation risk (Fig. 3).
Analysis of reoperation causes and frequency
A total of 283 revision operations were performed across the three groups. The most frequent reason for revision surgery was suture loosening, with significant differences among the groups. The highest incidence of suture loosening occurred in the two-point method (117/500 cases), followed by the transconjunctival buried method (50/500 cases), with the lowest observed in the continuous method (41/500 cases).
Suture exposure was another cause of revision, occurring in the two-point method (4/500 cases) and the continuous method (5/500 cases). No instances of suture exposure occurred in the transconjunctival buried method.
Other reasons for reoperation included asymmetry, which was reported in 32 cases, with the highest frequency in the transconjunctival buried method (21/500 cases). Crease width adjustment was required in 23 cases, again most commonly seen in the transconjunctival buried method (15/500 cases). Infection was uncommon, occurring in only seven patients across all groups. Patient-requested revisions were extremely rare, with only one case recorded in the transconjunctival buried method group.
Overall, the continuous method had the lowest complication rate. While the transconjunctival buried method had a lower incidence of suture loosening than the two-point method, it exhibited a slightly higher occurrence of asymmetry.
DISCUSSION
This study provides a comprehensive comparative analysis of the continuous, two-point, and transconjunctival buried suture methods for double-eyelid surgery, delivering robust evidence to guide surgical decision-making. By evaluating reoperation rates, time to reoperation, and reasons for revision surgery over a 4-year follow-up period, we identified key factors influencing long-term stability and clinical outcomes across these widely utilized techniques.
Comparison of reoperation rates and advantages of the continuous method
Our findings showed that the continuous buried suture method had the lowest reoperation rate (13.4%), followed by the transconjunctival buried suture method (19.4%), with the two-point buried suture method exhibiting the highest rate (26.2%) (P<0.001). These results indicate that the continuity of the suture and fixation technique substantially affects the long-term stability of the eyelid.
The superior outcomes observed with the continuous method align with previous research [3,4], emphasizing its structural and mechanical advantages in maintaining crease integrity over time. However, our study uniquely included the transconjunctival method in the comparison, demonstrating that while it is less stable than the continuous method, it provides significantly improved stability compared to the two-point method. The Cox proportional hazards model further validated these results, confirming that fixation techniques significantly influence reoperation likelihood. Specifically, compared to the two-point method, the continuous method reduced reoperation risk by 54% (HR, 0.46; P<0.001), and the transconjunctival method reduced risk by 28% (HR, 0.72; P=0.014). These findings reinforce the importance of selecting appropriate fixation techniques and suture placement to enhance the long-term success of double-eyelid surgery.
Mechanical properties and their influence on surgical stability
The mechanical distribution of suture tension and tissue adhesion greatly influences the structural integrity of the double-eyelid fold. The anatomical complexity of the Asian upper eyelid—especially the presence of preaponeurotic fat and variations in levator attachment—requires a tailored surgical approach to achieve optimal long-term stability, as highlighted by Lee et al. [5]. Among the evaluated methods, the continuous technique ensures uniform distribution of suture tension, enhancing crease formation while reducing localized stress along the suture line. This even tension distribution decreases suture loosening, identified as the primary reason for reoperation in our study.
In contrast, the two-point method relies on discrete fixation points, leading to localized stress concentrations that potentially compromise structural integrity over time. This limitation likely accounts for the significantly higher incidence of suture loosening (23.4%) observed in the two-point group, thus representing the least stable technique. Meanwhile, the transconjunctival method, which involves suture placement from the conjunctival side without external skin penetration, allows for stable adhesion between soft tissue layers. However, it lacks superficial scar reinforcement, potentially explaining its slightly higher reoperation rate relative to the continuous approach, although it still surpasses the two-point method. These findings emphasize that surgical techniques promoting uniform suture tension and broad fixation areas contribute significantly to superior long-term outcomes in double-eyelid surgery.
Long-term stability and Kaplan-Meier analysis
Kaplan-Meier analysis revealed significant differences in long-term crease retention among the three surgical techniques (P<0.001). At 500 days postoperatively, the continuous method exhibited the highest retention rate (85%), followed by the transconjunctival method (78%), with the two-point method demonstrating the lowest rate (72%). By 1,000 days, retention rates had declined across all techniques, yet the continuous method maintained the highest rate (81%), while the transconjunctival method decreased to 72%, and the two-point method fell further to 65%. These results underscore the pivotal role of suture techniques in achieving long-term crease stability. Among the evaluated techniques, the continuous method provided the most durable outcomes, reaffirming its status as the preferred method for sustained double-eyelid crease retention.
Detailed analysis of reoperation reasons
Among the 283 revision operations, suture loosening was the predominant reason, accounting for 73.4% of cases. However, the incidence varied significantly across techniques. The two-point method had the highest rate of suture loosening (23.4%), followed by the transconjunctival method (10.0%), with the continuous method demonstrating the lowest incidence (8.2%).
The reduced incidence of suture loosening with the continuous method can be attributed to its superior fixation mechanics, evenly distributing tension across the suture line and thereby minimizing localized stress and the likelihood of loosening. Similarly, the transconjunctival method, despite its minimally invasive nature, showed significantly lower suture loosening compared with the two-point method, further establishing its value as a stable alternative with reduced reoperation risk.
Overall, the continuous method consistently demonstrated the lowest complication rate, highlighting its reliability in long-term outcomes. Meanwhile, the transconjunctival buried method presented a lower-risk alternative to the two-point approach, providing enhanced stability without involving skin penetration.
Cox proportional hazards model findings and clinical implications
The Cox proportional hazards analysis confirmed that the choice of surgical technique is the most crucial determinant of reoperation risk. Specifically, both the continuous and transconjunctival buried methods significantly reduced reoperation risk compared to the two-point method. The continuous method had an HR of 0.46 (95% CI, 0.34–0.62; P<0.001), indicating a substantially lower likelihood of reoperation relative to the two-point method. Similarly, the transconjunctival method had an HR of 0.72 (95% CI, 0.55–0.94; P=0.014), reflecting a significantly reduced risk compared with the two-point approach.
In contrast, neither patient age (HR, 0.99; P=0.339) nor sex (HR, 0.87; P=0.531) significantly influenced reoperation probability, suggesting patient demographic factors have minimal impact on surgical longevity.
These findings underscore the clinical importance of selecting an optimal surgical technique based on mechanical stability, patient-specific anatomical considerations, and aesthetic goals. By prioritizing methods that maximize crease retention and minimize complications, surgeons can achieve enhanced functional and aesthetic outcomes in double-eyelid surgery.
Clinical and societal implications
The findings of this study have substantial implications for cosmetic practice and healthcare resource management. The continuous method, with its superior long-term stability, not only improves patient satisfaction but also reduces the frequency of revision surgery, thereby minimizing healthcare resource utilization.
The transconjunctival method serves as a minimally invasive alternative, providing significantly improved crease retention compared with the two-point method. This makes it an attractive option for patients who prefer a scar-free procedure while still prioritizing long-term stability.
Given these insights, surgical planning should emphasize techniques promoting uniform suture distribution and broad fixation areas, leveraging the mechanical advantages demonstrated by the continuous method. By prioritizing these surgical principles, clinicians can optimize both functional and aesthetic outcomes, decrease complication rates, and enhance the overall efficiency of cosmetic eyelid procedures.
Limitations and future directions
While this study provided robust comparative data, several limitations should be acknowledged to fully understand the scope and implications of the findings.
Single-institution data
All cases analyzed in this study originated from a single nationwide cosmetic surgery chain, potentially limiting the generalizability of the findings. Future studies should include multicenter trials involving diverse patient populations and varying clinical environments to validate these results across broader surgical contexts.
Lack of patient satisfaction metrics
Although this study focused on objective measures such as reoperation rates and mechanical stability, subjective patient-reported outcomes, including aesthetic satisfaction and quality-of-life assessments, were not evaluated. Incorporating these patient-centered measures into future research could provide a more comprehensive evaluation of surgical success and better reflect patient experiences.
Lack of consideration for anatomical variations
This study did not account for individual anatomical variations such as eyelid thickness, tarsal plate height, and preaponeurotic fat distribution, all of which may influence long-term surgical outcomes. Lew et al. [6] previously identified morphological factors, including eyelid thickness and tarsal plate height, as significant determinants affecting the outcomes of buried suture techniques. Future studies should include these anatomical variables, as their consideration could refine our understanding of factors impacting reoperation rates and crease stability, leading to more personalized surgical approaches and improved outcomes.
Refinement of surgical techniques
Further refinement of the transconjunctival method could enhance its long-term fixation strength, potentially reducing asymmetry rates and improving crease stability without increasing surgical invasiveness. Additionally, ongoing refinement of the mechanical advantages inherent in continuous suture methods could foster the development of new techniques that further improve stability and reduce reoperation rates, as suggested by Fan and Low [7]. Continued advancements in technique may expand the applicability of minimally invasive methods, optimizing both aesthetic and functional outcomes.
Addressing these limitations through future research can facilitate a more nuanced, evidence-based approach to double-eyelid surgery, ultimately improving patient outcomes and surgical precision.
Conclusion
This study clearly demonstrated that the continuous buried suture technique provides superior long-term crease retention compared with both the two-point and transconjunctival buried suture methods in double-eyelid surgery. These findings offer robust evidence for data-driven surgical decision-making, presenting meaningful implications for improving patient satisfaction, enhancing procedural efficiency, and advancing the development of standardized protocols in aesthetic eyelid surgery.
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