Buried suture blepharoplasty is a minimally invasive procedure designed to create a natural-appearing double eyelid without requiring a skin incision. This technique offers several benefits, including shortened postoperative recovery, technical accessibility for surgeons, and a lower rate of complications compared to percutaneous incision blepharoplasty [1,2]. Due to its functional and aesthetic advantages, buried suture blepharoplasty has gained widespread popularity globally in recent years [3,4]. The procedure can be performed via two approaches: conventional percutaneous and transconjunctival [3,5]. Among these, transconjunctival buried suture blepharoplasty (TCB) has become widely utilized in cosmetic surgery in Japan, owing to its advantages of avoiding visible scars, minimizing postoperative swelling, and delivering more durable results compared to the percutaneous method [6].

A key concern with TCB is the placement of suture knots on the conjunctival side, which can complicate ligature removal and may increase the risk of associated complications [7-9]. Moreover, postoperative outcomes are highly dependent on the surgeon’s technical proficiency [10]. Preliminary observations suggest that less experienced surgeons are associated with a higher incidence of postoperative complications; however, systematic investigations into this relationship remain limited. In this study, we hypothesized that an increased number of TCB procedures performed would correlate with a reduced incidence of postoperative complications. Our objective was to examine the relationship between surgical experience and the frequency of complications.

A total of 200 patients who underwent TCB performed by a single surgeon at Tokyo Chuo Beauty Clinic between January 2023 and August 2024 were included in this study. All patients were Japanese and were evaluated for clinical characteristics, including age, sex, timing of complications, surgical procedures performed concurrently with TCB, and complication profiles. To standardize follow-up across all patients, the observation period was defined as up to 10 months postoperatively, with any complications arising within this timeframe classified as postoperative complications. The surgical technique utilized in this study was conducted as previously described [1]. In brief, a single suture was vertically inserted from the palpebral conjunctiva to the subcutaneous layer beneath the skin using a 7-0 non-absorbable monofilament. The needle was advanced approximately 12 mm through the subcutaneous tissue along the proposed double eyelid line and exited through the conjunctival side. The suture was then passed and secured within the subconjunctival layer, with the knot positioned on the conjunctival side. A second suture was placed in a similar fashion a few millimeters apart, resulting in a total of two sutures per eyelid.

Postoperative complications were categorized as subjective and objective symptoms. If patients experienced any postoperative issues and requested to see the surgeon, subjective complications were evaluated using a questionnaire: (1) whether the patient was satisfied with the surgery; (2) if dissatisfied, the specific problems experienced; and (3) whether the patient would request reoperation. Based on these responses and a consultation with the operating surgeon, subjective complications, including corneal irritation and difficulty in self-acceptance of the double eyelid appearance, were assessed. Objective complications, such as periorbital swelling, eyelid asymmetry, loss of the double eyelid fold, and suture exposure on the upper eyelid skin, were determined by the same surgeon.

Additionally, the timing of postoperative complications was analyzed by comparing events occurring within the first month after surgery to those that developed subsequently.

Statistical analyses were conducted using R software (version 4.4.2). Fisher exact test and Student t-test were used to compare complication rates between groups. Odds ratios (ORs) and 95% confidence intervals (CIs) for clinical factors were calculated for both univariate and multivariate analyses. P-values less than 0.05 were considered statistically significant.

This study was reviewed and approved by the Ethics Committee of Tokyo Chuo Beauty Surgery Clinic (UMEDAERB-2025Feb001). Given the retrospective nature of the investigation, the requirement for written informed consent was waived. The study was conducted in accordance with the ethical principles set forth in the 1964 Declaration of Helsinki and its most recent revision in Fortaleza, Brazil, in October 2013.

In this study, clinical factors were analyzed in 200 patients undergoing TCB. A representative TCB technique is shown in Fig. 1. Among the patients, 193 were female and seven were male. Patient ages ranged from 15 to 62 years, with a median age of 26 years. The postoperative follow-up period spanned 6 to 28 months, with a mean duration of 14.96 months (Table 1). To assess the effect of surgical experience, patients were divided into two equal groups according to the timing of their surgery: the early-phase group (n=100) and the late-phase group (n=100). A comparison of clinical backgrounds revealed no significant differences in age, sex, or time to complications between the two groups (Table 2). Additional procedures performed in conjunction with TCB included upper eyelid orbital fat removal, transconjunctival fat removal, facial thread lifting, and injectable treatments such as hyaluronic acid or botulinum toxin. More than 75% of patients in both groups underwent an additional procedure alongside TCB, with no significant difference observed between groups.

Analysis of postoperative complications revealed a significantly higher incidence in the early-phase group compared to the late-phase group (13 cases [13%] vs. 3 cases [3%], P=0.017). Complications were further categorized as subjective (patient-reported) and objective (clinician-assessed). In the early-phase group, five subjective complications were noted: three cases of corneal irritation and two cases of psychological difficulty in accepting eyelid appearance. In contrast, no subjective complications were identified in the late-phase group, resulting in a statistically significant difference (P=0.031). Regarding objective complications, eight cases were identified in the early-phase group: four cases of postoperative swelling, two of asymmetry, and two of loss of the double eyelid fold. The late-phase group had three objective complications: one percase of asymmetry and two cases of ligature exposure on the skin; however, there was no significant difference between the groups. Reoperation was required in seven cases in the early-phase group and three in the late-phase group, but this difference was not statistically significant. After reoperation, all cases in both groups were complication-free (Table 3). Subgroup analysis assessed the impact of concurrent procedures in TCB. In cases with additional procedures, the late-phase group exhibited a significantly lower incidence of postoperative complications than the early-phase group (Table 4). Complication rates were also compared for each type of concurrent procedure, but no significant differences were detected between groups.

The timing of postoperative complications was also assessed, classified as occurring within 1 month or after 1 month postoperatively. In the early-phase group, seven cases of complications occurred within the first month (four postoperative swelling and Fthree corneal irritation), whereas no such early complications were observed in the late-phase group, indicating a significantly higher incidence in the early-phase group (P=0.014). Complications occurring after 1 month were documented in six early-phase cases (two each of eyelid asymmetry, psychological difficulty with appearance, and double eyelid crease loss). The late-phase group had three late complications: two cases of suture exposure and one of eyelid asymmetry, with no statistically significant difference between groups. Notably, two cases of buried ligature exposure through the skin were reported, both involving a 2-mm segment of exposed suture on the upper eyelid at 6 and 8 months postoperatively (Fig. 2). Both were successfully managed with simple ligature removal.

Further analysis was conducted to identify risk factors for postoperative complications. Univariate analysis revealed no significant associations with age or sex (Table 5). However, early-phase surgery and the combination of cosmetic procedures with TCB were both significantly associated with increased postoperative complications (OR, 4.83; 95% CI, 1.33–17.52; P=0.017; OR, 5.26; 95% CI, 1.12–25.01; P=0.035, respectively).

This study examined the pattern of postoperative complications following TCB performed by a single surgeon over time. A marked reduction in complications was observed in the late-phase group compared to the early-phase group. While TCB is frequently performed alongside other cosmetic procedures, no significant differences in the rate of combined procedures were noted over the study period, indicating consistent surgical practice (Table 2). Despite this consistency, the proportion of complications significantly decreased in the late-phase group, as demonstrated in the subgroup analysis. This suggests that ongoing improvements and greater technical efficiency contributed to the reduced incidence of complications.

However, the addition of other cosmetic procedures to TCB was associated with a significant increase in complication rates. This elevation likely results from longer operative times, increased tissue handling, and a wider area of surgical intervention, thereby increasing risks of swelling and bleeding. Furthermore, simultaneous procedures may lead to patient dissatisfaction with one component impacting their perception of the overall outcome, potentially increasing the rate of reported complications. Accordingly, careful precautions are warranted when performing TCB together with other cosmetic procedures to minimize risk.

The reduction of postoperative complications is likely attributable to refinements in surgical technique, such as minimizing tissue trauma and optimizing suture placement and embedding depth. Notably, early complications—such as postoperative swelling and corneal irritation—were absent in the late-phase group. Clinical experience suggests that longer operative time and excessive manipulation elevate the risk of eyelid swelling [11,12]. Preventive strategies for corneal irritation have also improved, including precise adjustment of suture knot position, embedding technique optimization, and lateral repositioning of the knot while ensuring proper concealment under the conjunctiva [13]. Nonetheless, it was observed that buried ligature exposure through the skin occurred only in the late-phase group, with no such cases reported in the early-phase group. This outcome is likely due to adjustments made to reduce other complications—for example, a slight loosening of suture tension was adopted to minimize postoperative swelling during the observation period. This modification reduced excessive tissue stimulation and effectively eliminated swelling-related complications in the late-phase group. While this adjustment proved beneficial in reducing postoperative swelling, the reduction in suture tension resulted in a more superficial position for the embedded suture, which, combined with repetitive eyelid movement, could gradually displace the suture toward the skin, particularly in patients with thinner eyelid skin. These findings highlight the potential for procedural modifications to introduce new types of complications. Despite this, the overall complication rate remained significantly lower in the late-phase group. Therefore, continued refinement of surgical techniques and accumulation of surgeon experience can reduce overall complication rates, even as new issues arise. In addition, to decrease the risk of buried ligature exposure, the following techniques have been implemented: ensuring the ligation point is securely placed beneath the conjunctiva, maintaining sutures within the correct tissue plane to avoid unnecessary trauma to the epidermis and dermis, and confirming by direct visual inspection after suturing that no suture is visible beneath the skin. Further investigation will be needed to validate the effectiveness of these approaches.

This study has several limitations. First, the evaluation criteria were not strictly standardized. In particular, the assessment of both subjective and objective complications was left to the discretion of the surgeon, and the lack of uniform evaluation criteria may have led to variability in assessment accuracy or missed cases of patient dissatisfaction. Additionally, data on certain surgical factors—such as blood loss and operative time—were difficult to collect, which may have resulted in unmeasured confounding variables. Second, as a single-center study performed by a single surgeon, a total of 200 cases were included. This case number is considered the approximate threshold for supervising surgeons, based on customary practice and experience in Japanese cosmetic surgery. Given the aim of evaluating whether surgical proficiency affects complication rates, this threshold was suitable for the study design. Nevertheless, the influence of potential confounding biases cannot be entirely excluded. To overcome these limitations, future studies should use prospective, multicenter designs involving multiple surgeons.

In conclusion, this study demonstrated a significant reduction in postoperative complications in the late-phase group of TCB performed by the same surgeon, indicating a negative correlation between complication rates and increased surgical experience. The implementation of efficient strategies and educational programs aimed at improving surgical expertise has the potential to further decrease the incidence of complications associated with TCB.