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Nonincisional Blepharoplasty Using the Debulking Method
Young-Joon Lee, M.D.,
1
Rong-Min Baek, M.D.,
2
and Woo-Jin Chung, M.D.
2
1,2
Seoul, Korea
Abstract. As more women work outside home, a growing
number of women who want to have a natural-looking
double eyelid choose the method with a short healing time
and less pain. Thus blepharoplasty by the nonincisional
method is performed frequently. This technique uses 7-0
nylon for simple triple ring–shaped or center doubled triple
ring–shaped suture, with removal of subcutaneous fat,
pretarsal muscle, and orbital septum through small inci-
sions. This prevents the possibility that the folds will be
loosened. By creation of a scar adhesion between the wider
portion of the dermis and the tarsal plate after debulking of
the soft tissue, the nonincisional method can be applied to a
very thin eyelid without any difficulty.A retrospective re-
view of the data for 327 patients who underwent noninci-
sional blepharoplasty using the debulking method from
November 24, 2000 through March 9, 2003 is presented.
Except for four cases, the procedures were successful. Two
complications of conjunctivitis occurred, requiring removal
of the buried suture, and two patients reported a mild scar.
Key words: Loosening—Scar-adhesion—Debulking
The desire for cosmetic plastic surgery has been in-
creased by an growing interest in aesthetics. Blepha-
roplasty has been one of the most popular and
common procedures among Korean people. As more
women work outside home, a growing number of
women who want to have a natural-looking double
eyelid choose the method with a short healing time
and less pain. Thus blepharoplasty by the noninci-
sional method is performed frequently. This nonin-
cisional method, however, can loosen the folds
afterward, making it difficult to apply in cases of
thick or very thin upper eyelids and risking the po-
sibility of asymmetric folds. We therefore suggest
nonincisional blepharoplasty using the debulking
method.
Materials and Methods
Between October 2000 and March 2003, 327 patients
underwent nonincisional blepharoplasty using the
debulking method at the Lee Young-Joon Aesthetic
Clinic. The mean age of the patients was 22 years
(range, 18–47 years). All the patients were women,
Fig. 1. The two-forceps test. Two or three points of entry
are determined by making the desired fold using a fine
forceps.
Correspondence to Woo-Jin Chung, M.D., Department of
Plastic and Reconstructive Surgery, Inje University Medical
Center, 85 2-Ga Jeo-dong, Jung-Gu, Seoul, Korea100-032;
email: wjchung@chungbuk.md
Aesth. Plast. Surg. 27:434–437, 2004
DOI: 10.1007/s00266-003-3096-9
and the purpose for the surgery was cosmetic in all
cases. The choice of whether the incision or nonin-
cision method would be used was based on the age of
the patient, the amount of subcutaneous fat, and the
desire of the patient.
Technique for Surgery
The height of the fold was determined according to
the desire of the patient, as expressed in an interview
with the physician. In general, the chosen height of
the fold was 4 to 8 mm. If necessary, intravenous
midazolam was administrated for sedation, and local
anesthesia was achieved by infiltrating 2%lidocaine
with epinephrine solution into the incisional region of
the upper eyelids. Depending on the results of the
two-point forceps test (Fig. 1), only two small inci-
sions (<3 mm) were made before surgery on the skin
of the upper eyelids when the double eyelids formed
the line more naturally. Three to four small incisions
were made when there was difficulty in forming the
inner or outer line with a no.11 blade.
To make the scar adhesion, pretarsal soft tissues
(muscle, preseptal fat, and septum) were debulked
with fine-tipped bipolar electrocautery and small
scissors (Figs. 2 and 3). The lid then was everted, and
a 7-0 nylon suture was inserted through the con-
junctiva, entering and exiting at opposite points by
the use of simple triple ring–shaped or center doubled
triple ring–shaped continuous buried suture ligation
methods (Fig. 4). The two ends of the suture were
tied, and the knot was placed deep in the orbicularis
oculi muscle. A single 7-0 black silk was used to close
the small incisions. Open dressing was used with
application of antibiotic ointment. The skin sutures
were removed 3 days after surgery (Fig. 5).
Result
A total of 327 patients underwent nonincisional ble-
pharoplasty using the debulking method, and the
patients were satisfied with the result except in four
cases. In two of these cases, the buried suture should
have been removed because of conjunctivitis. In the
other two cases, the patients reported a mild scar.
There were no revisional operations to correct loos-
ening of a double fold or asymmetry. Fortunately,
there also were no conventional complications such
as corneal injury or cyst formation. The follow-up
periods ranged from 2 months to 2 years (mean,
13 months) (Figs. 6 and 7).
Discussion
Blepharoplasty, used to make a double fold, is the
most common cosmetic procedure performed on
young oriental adults [21]. Statistically, only 30%to
60%of Asian people are born with double eye folds
[2,3,5,6,8]. The methods of blepharoplasty can be
classified as incisional or nonincisional. According to
Shirakabe et al. [7], the nonincisional technique was
first announced by Mikamo of Japan in 1896. These
authors reported that the three-stitch technique with
silk thread created a double eyelid margin that was 6
to 8 mm from the cilia. The depth was determined
when the stitches were removed 2 to 6 days postop-
eratively. Since their first report, there have been
Fig. 2. The technique of debulking pretarsal soft tissues
(muscle, preseptal fat, and septum) with small scissors
and fine-tipped bipolar electrocautery to create a scar
adhesion between the dermis and the tarsal plate.
Fig. 3. Instruments for debulking soft tissue. Small
scissors (above) and fine-tipped bipolar electrocautery
(below).
Fig. 4. Various methods of continuous buried suture
ligation. (A) Simple triple ring–shaped ligation method.
(B) Center doubled triple ring–shaped ligation method.
(C) Doubled twin ring ligation method. (D) Double
triple ring–shaped ligation method.
Nonincisional Blepharoplasty 435
numerous reports on the nonincisional blepharopl-
asty.
Currently, patients prefer the nonincisional meth-
od because of its advantages such as noninvasiveness,
less scar, shorter operating time, early return life ac-
tivities, and the like. However, the nonincisional
techniques still have some problems, although vari-
ous suturing techniques are yielding good results. For
example, the double fold may loosen over time. This
usually results when the dermal insertions of the le-
vator muscle disappear. That is, the degree of scar
adhesion created for the artificial insertion of the le-
vator muscle becomes small or nonexistent.
In 1962, Uchida et al. [8] claimed that it is
very important to fix the tarsal plate to the skin of
the eyelid. In conventional nonincisional blepha-
roplasty, two or three points of scar adhesion are
created or there is dependence on string force alone.
With time, however, its whole area is too small to
sustain its function as a dermal insertion. Accord-
ing to Homma et al. [4], approximately 1%of the
patients who have undergone nonincisional blepha-
roplasty lose their double fold within 1 year after
surgery, and about 3%of the patients lose it within
5 years.
Our technique uses 7-0 nylon for the simple triple
ring–shaped or center doubled triple ring–shaped
suture after removal of the pretarsal muscle, orbital
septum, and subcutaneous fat through small inci-
sions. The removal of the soft tissue prevents the
Fig. 5. Photographs of the operative
procedure. (A) Preoperative design. (B)
Debulking procedure. (Cand D) Simple
triple ring–shaped ligation procedure.
(E) Immediate postoperative view. (F)
A single 7-0 black silk stitch is used to
close each stab incision.
Fig. 6. Preoperative photograph and
postoperative photograph 3 months after
a 28-year-old patient underwent surgery
using the debulking method.
436 Y.-J. Lee et al
possible loosening of the folds after the nonincisional
procedure by the creation of scar adhesion between
the wider portion of the dermis and the tarsal plate.
Thus, this method can be applied to a thin eyelid
without any difficulty. In addition, debulking of the
soft tissue prevents jeopardization of the suturing
effect by migration of excessive orbital fat to the area
of fixation in the puffy eyelid. Post surgical assess-
ment was based on the surgeon’s assessment and
patient’s degree of satisfaction.
Oriental blepharoplasty requires careful pre-
operative consultation with each patient as well as
thorough discussion of goals and anticipated results.
Satisfactory results for most of our patients prompted
us to report this method. We hope this debulking
method can complement the existing nonincisional
method.
Acknowledgments. We thank professor Se-Min Baek, M.D.
who has advised and imported to us a profound and
comprehensive knowledge of the aesthetic surgery.
References
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Fig. 7. Preoperative appearance and postoperative appearance 6 months after an 18-year-old patient underwent surgery
using the debulking method.
Fig. 8. Preoperative appearance and
postoperative appearance 2 months after
a 22-year-old patient with an asymmetric
fold underwent surgery using the de-
bulking method.
Nonincisional Blepharoplasty 437
