Blepharoplasty in Asian patients is performed not only for aesthetic enhancement but also for functional improvement, as the formation of a double eyelid facilitates eyelid opening [1,2]. Achieving this outcome requires precise repositioning of eyelid tissues and the reduction of redundant tissue that impedes double eyelid formation [3,4]. Additionally, appropriate reduction of orbital fat is critical for maintaining the long-term stability of the double eyelid structure.

Buried suture double eyelid blepharoplasty (BSB) is one of the most commonly performed cosmetic procedures in Japan due to its minimally invasive nature [5-7]. However, postoperative complications, including hematoma, wound infection, granulation formation on the upper eyelid skin, and conjunctivitis, have been reported [5,8,9]. These complications are influenced by the preoperative thickness of the upper eyelid, which also affects the persistence of the postoperative double eyelid line [5,10]. Upper eyelid lipectomy (UEL), when performed in conjunction with BSB, has been suggested to reduce complications and prolong the longevity of the double eyelid line [11,12]. Nevertheless, statistical and comparative studies evaluating the benefits of combining UEL with BSB in Japan remain insufficient. Therefore, this study retrospectively compared the incidence of postoperative complications in patients undergoing BSB with or without concurrent UEL.

A total of 102 patients who underwent BSB performed by a single surgeon at Tokyo Chuo Beauty Clinic between January and December 2024 were included in this study. For BSB and UEL indications, patients with significant preexisting conditions—including hypertension, diabetes, collagen disorders—those on anticoagulant therapy, as well as individuals with malignancies or intractable infections (e.g., human immunodeficiency virus [HIV]), were excluded. All patients were of Japanese ethnicity. Clinical characteristics, including age, sex, follow-up duration, and postoperative complications, were retrospectively reviewed using medical records.

All BSB procedures utilized the continuous suturing technique [6]. In summary, continuous sutures were placed between the transconjunctival and upper eyelid skin, extending from the medial to the lateral canthus, with the suture anchored at the lateral canthus (Fig. 1A). UEL was performed using a percutaneous orbital fat removal technique (Fig. 1B and C). The incision site was marked on the upper eyelid skin, approximately 20 mm from the inner canthus (corresponding to two-thirds of the width of the ocular fissure from the inner canthus). A small incision of 2 mm or less was made over the planned eyelid line, and the following tissues were excised through the incision: orbicularis oculi muscle, preseptal fat, and orbital fat.

Patients were divided into two groups: (1) the monotherapy group, consisting of those who underwent BSB alone; and (2) the combination group, comprising those who received concurrent UEL. Indications for UEL included: (1) cases where the double eyelid line created by a probe disappeared with a single blink (Fig. 2A and B); (2) cases where the anterior portion of the upper eyelid extended beyond the ciliary body attachment site in the lateral view (Fig. 2C); and (3) patients who specifically requested UEL.

Postoperative complications were classified as either objective or subjective. For patients reporting postoperative concerns and seeking consultation with the surgeon, subjective complications were evaluated using a standardized questionnaire. This included: (1) assessment of overall satisfaction with surgical outcomes; (2) identification of specific concerns in cases of dissatisfaction; and (3) determination of the patient’s desire for revision. Based on questionnaire responses and surgeon evaluation, subjective complications—such as corneal irritation and difficulty in accepting the double eyelid appearance—were assessed. Objective complications included depression, elevation (granulation formation), ligature exposure at the upper eyelid skin, conjunctival inflammation characterized by hyperemia, excessive lacrimation, eye discharge, and loss of the double eyelid fold. Subjective complications encompassed foreign body sensation and patient requests for correction of asymmetry or width discrepancies.

Statistical analyses were conducted using JMP Pro 17.0.0 (SAS Institute), applying t-tests, chi-square tests, and logistic regression analyses for intergroup comparisons. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for clinical factors using both univariate and multivariate analyses. Statistical significance was defined as P<0.05.

All 102 cases included in this study were analyzed, comprising 95 female and seven male patients. Patient ages ranged from 13 to 77 years, with a mean age of 32.1 years. The postoperative follow-up period ranged from 1 to 13 months, with an average duration of 7.51 months (Table 1).

To assess the incidence of postoperative complications, patients were categorized into two groups: the monotherapy group (BSB alone; n=61) and the combination group (BSB with concurrent UEL; n=41). No significant differences were observed between the groups in terms of sex distribution or follow-up duration; however, the combination group was significantly younger than the monotherapy group (P<0.001) (Table 2).

Analysis of postoperative complications showed a significantly higher incidence in the monotherapy group compared to the combination group (13 cases [21.3%] vs. 2 cases [4.9%], P=0.035) (Table 3). In the monotherapy group, complications included depression or elevation of the upper eyelid skin (granulation) or suture exposure in six cases, foreign body sensation in two cases, conjunctivitis in one case, and requests for correction of asymmetry or width discrepancies in four cases (Fig. 3). In contrast, in the combination group, only two cases involved correction for asymmetry or width discrepancies.

A subgroup analysis of postoperative complications was conducted using both objective and subjective criteria. Objective complications occurred in seven cases in the monotherapy group, whereas no objective complications were identified in the combination group, representing a statistically significant difference (P=0.025). For subjective complications, six cases were reported in the monotherapy group and two in the combination group, with no significant difference between groups.

Further analysis was performed to identify factors influencing postoperative complications. Univariate analysis revealed no significant differences in age, sex, or follow-up duration (Table 4). However, additional treatment with UEL in combination with BSB was associated with a significant reduction in postoperative complications (P=0.035). Moreover, multivariate analysis indicated that concomitant UEL significantly lowered the risk of complications and was an independent predictive factor (OR, 0.16; 95% CI, 0.03–0.81; P=0.027).

This study evaluated the impact of concurrent UEL on postoperative complications following BSB performed by a single surgeon. A significant reduction in postoperative complications was observed in the combination group compared to the monotherapy group, indicating that UEL is an independent factor for minimizing complications associated with BSB.

Further analysis revealed that the combination group had significantly lower rates of complications based on objective criteria. Upper eyelid skin depressions, granulation bumps, and suture ligature exposure, which were present in the monotherapy group, were entirely absent in the combination group. The stability of the double eyelid formed by BSB depends on adhesion between the levator aponeurosis and the upper eyelid skin during eyelid movement. Inadequate adhesion may result in the disappearance of the double eyelid crease due to facial muscle contraction, potentially leading to upper eyelid depression or protrusion secondary to buried sutures. Orbital fat is known to move with eyelid activity, and excessive fat can compromise suture stability [13]. Thus, excising upper eyelid orbital fat may enhance adhesion between the levator aponeurosis and the orbital septum, improving long-term double eyelid stability and reducing complications. Additionally, buried sutures are susceptible to mechanical effects from orbital fat during eyelid movement, and excessive fat can cause complications such as suture ligature exposure. Thus, concurrent UEL appears to be a reasonable approach to minimize postoperative complications.

Regarding subjective complications, no significant difference was found between the combination and monotherapy groups. This likely reflects the multifactorial nature of patient satisfaction in aesthetic procedures, which is influenced by economic, psychological, and personal preferences. Therefore, subjective complications may be largely unrelated to the surgical procedure itself. However, a decreasing trend in subjective complications was noted in the combination group compared to the monotherapy group (4.8% vs. 9.8%), suggesting that UEL combined with BSB may contribute to improved postoperative satisfaction. Larger studies are warranted to clarify this association.

Loss of the double eyelid fold due to knot loosening is an important complication of BSB. At our institution, several preventive measures have been implemented to minimize this risk: (1) avoiding excessively wide double eyelid designs; (2) ensuring appropriate ligature tension to prevent tissue damage; and (3) providing postoperative counseling, including instructions to avoid touching or rubbing the upper eyelid. As a result, no complications related to knot loosening were observed in either group during the follow-up period of this study. However, the mean observation period of 7.5 months is relatively short and may underestimate long-term complications. Further investigations are needed to assess the incidence of knot loosening over an extended follow-up.

In this study, patients in the combination group were significantly younger than those in the monotherapy group. The criteria for UEL included both objective evaluation by the surgeon and patient preference, suggesting that younger patients may have had thicker upper eyelids or were more likely to opt for the combined approach. This introduces the possibility of age-related selection bias. To address this, a multivariate analysis including age was performed to determine the risk ratio for complications. The findings showed that age did not reduce complication rates, whereas the addition of UEL significantly decreased the complication rate associated with BSB. Previous studies have reported that age-related changes in the epidermis and dermis affect the skin’s resistance to injury and damage [14]. Specifically, the flattening of the dermal-epidermal junction increases tissue susceptibility to shear and friction, while changes in collagen content and structure in the dermis increase tissue rigidity, leading to delayed wound healing and a higher incidence of complications [15,16]. Although some reports indicate that aging does not directly impair wound healing, others emphasize that age-related comorbidities may play a role, making this relationship a matter of debate [16]. Given the relatively short follow-up period in this study, further research is required to clarify the influence of age on long-term complications.

Several limitations should be acknowledged. First, due to its retrospective design, standardized criteria for assessing subjective or objective complications were not established. Second, as a single-center study performed by a single practitioner, the generalizability may be limited, and the possibility of confounding factors cannot be excluded. Although the findings indicate that the addition of UEL reduces complications associated with BSB, the potential for new complications arising from concurrent procedures must be considered. To address these limitations, prospective studies involving multiple institutions and surgeons are needed to further validate these results.

This study demonstrated that combining UEL with BSB significantly reduces postoperative complications compared to BSB alone. A notable reduction in objective complications was observed in the combination group, indicating enhanced double eyelid stability. The findings suggest that incorporating UEL into the BSB procedure may further decrease the incidence of postoperative complications and improve patient satisfaction.