Double Suture and Twist (DST) - The Durable Non-Cutting Double Eyelid Procedure for Asians

Double-eyelid procedure is the most popular cosmetic procedure in Asia. Whereas most surgeons in the United States perform cutting-type double eyelid surgery, Japanese women prefer non-incisional or suture methods.

Publications in the early Japanese medical literature favoured the suture method. The first description of this method, by Mikamo was published in 1896. Between 1896 and 1950, 11 articles relating to the suture methods were published in the Japanese medical literature.

The configuration of a double eyelid consists of four important parameters, namely, height, shape, continuity and permanence. As the suture method has been criticized for its high breakage rate and poorly define crease which fade over time, permanency is the major challenge the suture method is facing along its evolution.

In 2001, an improved non-cutting method to create double eyelids in Asian patients is reported. Dr Katsuhiro Kure, and Dr Akihiro Minami described an improved procedure that uses double sutures and twists (DST) to create double eyelids in Asian patients. Dr. Kure says the non-incisional procedure is “simple, durable, and virtually scar free.” The method uses only two sutures on each upper eyelid, with the durability explained by the areas of ties and the central twists that result in more secure and therefore longer-lasting results.

The average operative time ranged from 20 minutes (one side) to 60 minutes (bilateral). Most patients did not require sedation, and the surgeries were performed with only local anesthesia. Recovery time was short (3-7 days), and complications were minor and rare.

The published report for breakage or loss of fold is approximately one percent per year (ten year follow up). An extraordinarily low failure rate for this method has therefore been scientifically established, comparable to an incision method. There is a notion that the DST technique frequently fails or disappears over time. In many anecdotal comments, the most common source of misinformation has been in confusing the DST technique with traditional suture techniques that are unreliable. It is therefore important to verify that the technique used is DST before you decide to undergo such procedure.

The credential of the doctor is of course first and foremost. The registration of a doctor can be verified at the Malaysian Medical Council website.

This method is suitable for younger candidates with eyelids which do not have lots of loose skin or fat, or any obvious eyelid deformities.

Some examples of double eyelids created using DST:

The types of eyelids which are not suitable for this non-cutting technique:

Obvious ptosis (droopy eyelids)

Obvious asymmetrical eyelids

 Dermatochalasis (Eyelid with lots of sagging skin)

Thick eyelids with lots of fat

These cases require incisional blepharoplasty (Cutting double eyelid surgery), a procedure which requires a highly meticulous and precise work of a well-trained and talented oculoplastic surgeon as it involves highly accurate measurements, skin removal, cutting into deeper structures and the ability and experience to manage possible complications promptly. Such invasive procedure if carried out by unscrupulous cosmetic practitioner is at risk of suffering a permanent deformity due to excessive fat removal, ptosis (droopy eyelid) due to damage to the muscle and tendon which opens the upper eyelid (levator muscle and aponeurosis), lagophthalmos (lid retraction or unable to close the eyelid fully) due to excessive skin removal and worst of all, blindness due to retrobulbar haematoma (accumulation of blood behind the eyeball) resulting in compression and damage to the optic nerve.

A thorough assessment is therefore crucial before deciding on which kind of double eyelid procedure is suitable for an individual. Appropriate referral to a talented and experienced oculoplastic surgeon has to be made where DST is not suitable to ensure safety and best outcome for the individual.

Double Eyelid Surgery

Eyes with a lid crease between the eyelashes and the eyebrows  are described as having a ‘double eyelid’, whereas those without a crease have a ‘single eyelid’.

We all know that having double eyelids makes our eyes look bigger, wider and culturally perceived to be more alert, friendly, confident  and attractive. Having a double eyelid also allows easier application of cosmetics and no need to stick eyelid tapes anymore.

Studies have shown that about 50% of Asians do not have an upper eyelid crease, the other 50% have a least some form of crease. Therefore, it has been very popular among the Asians to opt for procedures that create double eyelids.

There have been various popular methods of creating double eyelids. The decision on which procedure is most suitable depends on the type and condition of one’s eyelids.

There are incisional (cutting) and non-incisional (non-cutting) methods. The incisional method involves plastic surgery through which some of the eyelid skin is excised. The patient will be required to return to the clinic and have the sutures removed. It may leave a prominent scar on the eyelid where the skin is removed. This is an excellent approach for those eyelids with too much loose skin around the eyes or lots of fat.

The non-incisional method is called the suture (stitching) method. In this method, no removal of skin using the knife is involved. Instead, sutures are passed through the eyelids via small punctures to create a fold by pulling the underbelly of the skin inwards when the eyes are opened. This method does not leave a prominent scar, no removal of sutures is required and recovery time is very short as no significant incision is made.

However, the traditional suture method is highly criticized for it’s short lifespan. Until recently, the advent of a new suture method known as the Double Suture and Twist (DST) technique, well-known for its longevity, addresses these disadvantages but maintaining the benefits of a suture method such as the quick recovery, scarlessness, naturalness of the crease and reversibility. This method is suitable for younger candidates with eyelids which do not have lots of loose skin or fat, or any obvious eyelid deformities.

Some examples of double eyelids created using the DST technique: