Modern cataract surgery entails creating an opening into the interior of the eye, dissolving and suctioning away the cataract, and inserting an artificial lens to help with focusing. At the conclusion of the operation, the incision is, in many cases, left as is - unstitched or secured in any special way. The eye remains unpatched, and the patient is allowed to walk away from the operating room table. How is this possible?

With careful planning and precise placement of the initial incision, the tissues not only seal themselves but, in most cases, heal better and faster than if stitches were used. "Going stitchless" speeds up the operation by eliminating unnecessary manipulation of delicate tissue and decreases the chance of inducing astigmatism from overly tight or slightly misaligned sutures.

What's True for the Eye is True for the Lower Eyelid

Transconjunctival lower eyelid blepharoplasty (that is, a blepharoplasty undertaken through an incision made on the back side of the lower eyelid) offers a similar opportunity. When first described over a decade ago, the incision (which traverses nearly the entire length of the eyelid) was always stitched tightly at the conclusion of the operation.

Over time, though, some surgeons came to question the need for this final step. After all, if the incision is placed in or near the natural trough ("cul de sac") where the eyeball meets the eyelid, there are no appreciable forces conspiring to pull its edges apart. The conjunctiva in this area is remarkably free of any tugging or tension from either gravity or eye movement. During the operation, in fact, an assistant must manually retract the lower eyelid away from the eyeball in order to expose a space just big enough for the surgeon to gain access. After surgery, the eyelid automatically returns to its normal relationship with the eyeball, thereby protecting the surgical field and sealing the incision.

Eager to test common sense, some surgeons abandoned the traditional "water-tight" closure for a looser approximation of the cut edges using only two or three dissolving stitches. With time, "two or three" became one, and then "one" became none.

Today, the stitchless transconjunctival lower blepharoplasty is routine. Not only does the operation progress faster than if stitches were used, but by allowing the cut tissues to fall together and adjust themselves to their own liking, the final scar is minimized. Suture-induced irritation and cyst (or granuloma) formation are eliminated. Swelling and bruising are minimized, and recovery is hastened.

The Upper Eyelid

If no stitches work well in the lower eyelids, why not apply the same methods in the uppers? Unfortunately, it's doesn't work because of two major difference. First, to reach the fat pockets from the back side of the upper eyelid would require severing the main elevating muscle and tendon (levator muscle system) that open the upper eyelid. Second, upper eyelid surgery always includes at least some removal of skin. Thus, in contrast to the lower eyelid, approaching an upper blepharoplasty from the conjunctival side of the lid makes little sense.

But then something new came along. Three years ago, Johnson and Johnson introduced a tissue adhesive called Dermabond (Ethicon brand of octyl-2-cyanoacrylate, FDA approved), a medical version of "super-glue" designed to close wounds and surgical incisions that are not under undue tension. Distributed as a thin liquid inside of a tiny vial, the adhesive is applied to the skin by rubbing an applicator tip over the incision in order to apply three or more layers of adhesive, which then dry to form a shiny, flexible bond. The adhesive fosters a moist wound-healing environment, which promotes quicker healing, and creates a barrier against the entry of bacteria. After about five to ten days, it flakes off on its own.

Several studies have compared the use of Dermabond with traditional suturing in upper eyelid blepharoplasty. The results are comparable in operative time, amount of inflammation, rate of healing, and final appearance.

As added insurance against the wound opening during healing, some eyelid surgeons who employ Dermabond still use one or two dissolving sutures to reinforce the closure.

There are several drawbacks. Some patients find the tethering effect of the adhesive layered on the eyelid skin to be mildly annoying. Of more significance is the fact that a deep fixation method of closure often used to enhance the upper eyelid crease and to prevent later migration of the scar upward cannot be accomplished without the use of traditional sutures.

So, yes -- a stitchless method of closure in upper eyelid blepharoplasty is now available. In contrast to the situation in the lower eyelid, however, it offers no significant surgical advantage.

Still, the concept of stitchless eyelid surgery is intriguing, and so don't be surprised if you hear more about it.

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