Causes of suture loosening or fold loss from suture technique double eyelid surgery

Many people wonder why double eyelid folds loosen with suture technique. Some people think that sutures break or the suture knot unravel over time. However, when we reoperate on these patients, the sutures are often intact and the knots have not unraveled. So then what is the cause when the sutures remain intact?

To understand the cause of suture technique double eyelid fold loss, we have to understand how double eyelid folds occur. Double eyelid folds occur when there is a connection between the skin and the eye elevating muscle — the levator aponeurosis. In patients with excellent eyelid elevating function, a connection occurs from the skin to the levator muscle over time. This connection is composed of connective tissue of new collagen that forms. However, in patients without excellent eyelid elevating function (levator function), patients will first open their eyes, but then the rest (or the later part of eyelid opening) of the eyelid elevation is done with their forehead. A forehead elevation brings the eyebrows up and thus help one to open eyes, but it does not aid in making a new connection from the skin to the levator aponeurosis. Therefore, over time with thousands of eye opening and closing, the suture will tear away from the skin. By this time, one’s own connective tissue has not formed a tract (a connection made of your collagen) from the skin to the levator aponeurosis.

The longevity of the suture maintaining a double eyelid fold, therefore, depends on the function of the eye elevating mechanism (levator aponeurosis). Another factor is the thickness of the eyelid skin. Thicker the eyelid skin, greater the weight shift and thus pull on the suture from the surrounding skin. Thus, a thicker skin will likely loosen faster over time compared to thinner skin from a suture technique double eyelid surgery.