Upper Asian bleph: does the suture method create scar tissue?

Thank you for your question. You are planning to have a suture technique for your Asian eyelid procedure to bring the crease level higher and to make it more defined. You do intend in the future to have the incisional method to deal with any sagging skin. You express a concern about the non-incisional technique or suture method causing scar tissue, where it will be, and if it will challenge the outcome of a future surgery.
I can share with you how I discuss this exact question with my patients pretty much every day in my practice. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. Asian eyelid surgery using both the non-incisional and incisional methods have been a significant part of my practice for many years.
First to go over the basic principles of what is intended when you do Asian eyelid surgery, it is to create a crease or a fold where a crease is not well defined. That entails creating a connection between the skin and the muscle that lifts the eyelid, and that muscle is called the levator muscle. When I see a patient in examination, and we decide what kind of eyelid crease they want,  I look if there is excess fat, and excess skin, and if there is none, I recommend the non-incisional approach.
In response to the question about scar tissue, I think it’s very important to differentiate what a physician’s definition of scar tissue is, and a non-physician’s definition. When people think of the word scar tissue, they often perceive it as a disfigurement, or something that complicates the outcome of anything. The reality is a certain amount of scar tissue as defined medically is a normal part of healing. What it basically means is when we place the skin in a way to attach to the levator muscle, the suture will approximate or put the skin in place to create this fold. What we expect to occur is eventually, the body forms collagen, which we describe as scar tissue to help create those connections such that if those sutures were to get loosened or removed for any reason, the body will still have a connection there.
For the volume of scar tissue, I don't think you can have any less volume than using a suture technique. The suture technique does vary between practitioners. I usually use three separate areas or three different spots on the eyelid where I attach a stitch. I will only do one stitch, sometimes I’ll only do two, but those little areas where the sutures are placed create very little scar tissue.
As for the future when you will be ready to have incisional surgery,as a general rule the non-incisional technique leans toward younger patients because they don't have a lot of excess skin. With facial aging, there are a lot of changes, including the skin’s elasticity, so in those situations, you are going to remove some skin.
Understanding that, you can imagine there are also remodeling changes that would make this procedure in no way significantly impact future surgery. I’ve done revision surgeries on patients who had suture technique done within a short period of time like a couple of years, and I would do revision surgery with an incision technique. I do not find those sutures to be problematic for the procedure. There is a lot of nuance in what we do, and unless something more complicated transpired before any further surgery, it’s not unusual for me to see a patient perhaps in their mid 40s who had a non-incisional surgery done in their 20s. When I do their surgery, whether it’s another non-incisional or more likely to be an incisional procedure, I don't find much of an issue with their previous operation.
Again, there are definitely variations as some doctors use different types of stitches that can create more inflammation compared to others. Some maybe are more aggressive about different ways to anchor the skin. I think you can discuss this with your doctor. I think it’s not likely to be an issue in terms of future planned surgery given the limited amount of trauma that occurs with non-incisional Asian eyelid surgery. I hope that was helpful, I wish you the best of luck, and thank you for your question.

Hello and thank you for this question about your blepharoplasty. Even minimally-invasive surgical procedures will induce your body’s natural healing mechanisms and leave behind some scarring. This is true of blepharoplasty using the suture method as well. However, the scarring you will have will be minimal and should not interfere with future procedures. Since you are already contemplating having an incisional blepharoplasty in the future, you may want to discuss the benefits of having that procedure now with your board certified facial plastic surgeon during an in-person consultation. Most patients who have an incision based surgery are pleased and have a long-lasting result. Good luck!
- Jacqueline T. Cheng, MD

Visible external scar is minimal with the suture technique because typically no incision is made.  However, internally, there is some scar tissue formation that allows the skin to adhere to the underlying tissue to create a supratarsal crease. Since no incision/ dissection is performed, scarring is minimal and generally speaking does not interfere with a full incision upper blepharoplasty in the future.  Goretti H. Taghva MD