Chapter 5 - Suture Ligation

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    Chapter 5 Suture Ligation Methods

    tissue or mild puffiness only. They quoted the advan-tages as including minimal postoperative swelling, thecrease can be reversed by cutting the stitch, and noapparent scarring. The procedure involved everting thetarsus and applying a 7/0 nylon suture through the con-junctiva at a point 3mm above the superior tarsal bor-der, traversing the conjunctiva for 5mm. One arm isreinserted through the conjunctiva 1mm adjacent towhere it came out, exiting through the anterior skinsurface. This is followed by the second arm of the

    conjunctival suture, exiting the skin in the same fash-ion. The first suture is then passed subcutaneously tojoin the second suture, now on the skin side, and thetwo are tied and cut close to the knot.

    Other authors, including Tsurukiri,24 reported aregression rate of 10%. Satou and Ichida25 reported aregression rate of 16.8%. Homma and Mutou23 pos-tulated that the disappearance rate is higher in indi-viduals with thicker skin or who possess excesssubcutaneous fat. They acknowledged the difficulty ofassessing the true rate of disappearance, as patients

    often do not return for follow-up and often seek otherdoctors for revision when the first procedure is subop-timal. A significant factor not discussed is the fact thatmost patients who undergo the stitch methods realizethat when the crease does disappear they are often can-didates for the incision method, and therefore may pro-ceed to seek consultation directly with those whopractice the open incision method.

    Fig. 5-1 Young Asian adult who

    underwent crease placement by the

    conjunctival suturing technique. The

    crease on the right is well-formed; that

    on the left has disappeared.

    There are other papers describing the use of smallincisional approach with the removal of tissues alongthe superior tarsal area, together with the passage ofburied sutures. For example, Lee et al.26 described theuse of 7/0 nylon through small skin incisions, applyingit as a buried figure-of-eight continuous suture form-ing three hexagonal loops spanning the width of thecrease; this was combined with removal of tissue (mus-cle, preseptal fat, and septum). They used this tech-nique in 327 patients with a mean follow-up of 13

    months only.From 1970 to 1990 at least a dozen articles describ-

    ing the external incision methods were published (seeAppendix 2). Zubiris27 article in 1981 described meas-urement of the vertical dimension of the upper tarsusas a way to guide placement of the lid crease incision.I favor this method because it is a logical and anatom-ically correct way to tailor the incision lines andbecause it approximates the true position of the crease.

    The wealth of information from earlier clinical prac-titioners helped lay the foundation for the continued

    evolution of cosmetic upper eyelid surgery for Asians.During the 12 years since the first edition of this bookwas published there have been at least an additional 22publications, whose topics included epicanthoplasty aswell as papers describing smaller skin incisions or par-tial incision variations of the external incision tech-niques, and various forms of crease fixation, includingseptodermal and orbicularislevator fixation.

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    The rest of this chapter will now concentrate on thesuture ligation method. Almost all the published paperson suture ligation methods can be subcategorized intosix variations.

    Suture Ligation Method

    In this technique the goal is to create adhesionsbetween the levator aponeurosis along the superiortarsal border and the subdermal tissue overlying itwithout making a significant skin incision.

    The eyelid is first anesthetized by local infiltration oflidocaine hydrochloride. The upper eyelid is everted,and three double-armed sutures are placed from theconjunctival side (transconjunctival) in a subconjunc-tival fashion above the superior tarsal border (Step 1).

    One of the following three alternative steps may beperformed to complete this procedure.

    Variation 1: Full-Thickness Suture Technique

    Both ends of the suture pass through to the skin sur-face (Step 2); one end is then passed subcutaneouslyagain to exit through the exit site of the second needleon the skin (Step 3). The two ends are tied and buriedsubcutaneously (Fig. 5-2).

    Variation 2: Full-Thickness Suture Technique

    with Stab Skin Incisions

    One end of the suture passes through the lid and exitsthrough a stab skin incision (Step 2). The other endgoes through skin next to the stab incision and isrepassed subcutaneously to join the first suture, whichexited through the stab incision (Step 3). The two endsof the suture are tied in the stab incision and buried(see Boo-Chai17 and Appendix 2). As in Alternative 1,the suture knot encompasses the Mller muscle, leva-tor aponeurosis, and some pretarsal orbicularis oculimuscle, producing a scar or a tightening process

    between the subdermal tissues along the superior tarsalborder and the levator aponeurosisMller musclecomplex (Fig. 5-3).

    Variation 3: Transconjunctival Intramuscular

    Suture Technique

    Without piercing the skin, one end of the double-armedsuture is passed through the Mller muscle and leva-

    tor aponeurosis to the subcutaneous plane along thesuperior tarsal border. The needle remains in the sub-cutaneous plane; the suture arm is reversed through thesame tissue and exits through the conjunctiva (Step 2).The two ends of the suture are knotted and buriedwithin the conjunctiva above the superior tarsal bor-der. Some surgeons prefer to cut out a small piece oftarsus and bury the knot within the space to preventcorneal or conjunctival irritation (Fig. 5-4).

    There are three other variations of the suture liga-tion method worthy of discussion. Approaching fromthe skin side, they are discussed below.

    Variation 4: Transcutaneous Intramuscular

    Suture Technique (Without Piercing the

    Conjunctiva)

    Two small stab incisions are made on the skin side atthe level of the eyelid crease. Sutures of 6/0 nylon orpolypropylene are passed from the first stab incisionthrough levator aponeurosis and some Mller muscle.The suture material is then passed a short distancealong the proposed level of the crease before beingreturned on the skin side through the second stab inci-sion (Step 1). The other end of the suture is repassedsubcutaneously to join the first half of the suture in thesecond stab incision; it is then tied and buried subcu-

    taneously (Step 2) (Fig. 5-5). Mutou and Mutou20

    usedtwo of these sutures to form the crease (see Appendix2).

    Variation 5: Twisted Needle and Compression

    Method (Transcutaneous and Intratarsal

    Suturing with Twisted Needle Tracking

    Method)

    In China, Yang27 made several stab incisions along thesuperior tarsal border (Fig. 5-6A). A needle with screw

    threads (or an equivalent tool, such as a no. 6 rootcanal dental file; Fig. 5-6D) is twirled through the sub-cutaneous plane and then through the suborbicularisplane along the pretarsal region of the upper lid (stepA in illustration), first from the lateral to the centralstab incision and then from the central to the medialincision. Sutures of 4/0 silk are then used to close thewound in a continuous manner, taking a bite of the tar-sus and passing back to the skin side, as in steps B or

    Asian Blepharoplasty and the Eyelid Crease

    42

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    Chapter 5 Suture Ligation Methods

    2

    2

    3

    Skin

    Orbicularis muscle

    Levator aponeurosis

    Muller's muscleConjunctiva

    ..

    1 2 2

    3

    Fig. 5-2 Variation 1. Full-thickness suturing technique.

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    Asian Blepharoplasty and the Eyelid Crease

    44

    Stab incision2

    2

    3

    Skin

    Orbicularis muscle

    Levator aponeurosisMuller's muscle

    Conjunctiva

    ..

    Stab incision

    2

    3

    21 1Fig. 5-3 Variation 2. Full-thickness suturing technique with stab incisions.

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    Chapter 5 Suture Ligation Methods

    Strategic placement

    of intramuscular

    sutures creates

    infolding of crease

    2 1Exit

    Entry for both needles

    of double-armed sutures

    Indentation of skin

    Skin

    Orbicularis muscle

    Levator aponeurosis

    Muller's muscleConjunctiva

    ..

    Fig. 5-4 Variation 3. Transconjunctival intramuscular suturing technique. Note the absence of passage through the skin.

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    Asian Blepharoplasty and the Eyelid Crease

    46

    First stab incision1

    2

    1

    2

    1

    Skin

    Orbicularis muscle

    Levator aponeurosisMuller's muscleConjunctiva

    ..

    Fig. 5-5 Variation 4. Transcutaneous intramuscular suturing technique.

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    Chapter 5 Suture Ligation Methods

    Skin

    Subcutaneous tissue

    Pre-tarsal orbicularis

    Tarsus

    Continuous

    subcutaneoussuturing

    Continuous

    reverse-loop

    suturing

    A

    B

    C

    Fig. 5-6 Variation 5. (Top) Twisted

    needle and compression technique

    with transcutaneous intratarsal

    suturing. (Bottom) Root canal dental

    files.

    D

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