Double eyelid surgery: incision or buried suture (non-incision), and how surgeons choose

Buried suture (non-incision) double eyelid surgery makes the crease with hidden stitches and removes no tissue, while incisional surgery opens the lid so skin, muscle or fat can be trimmed first. Surgeons choose between them by looking at skin, fat and lid height, not by fashion.

People type this question in many ways: "incision vs non-incision", "buried suture double eyelid", "partial incision", "which method lasts longer". The studies below describe how each method behaves; none of them crowns a winner. The crease itself, how its height is set and what recovery feels like are in my article on double eyelid surgery for Asian eyes. This one is only about the method, and it sits in the wider aesthetic eyelid section.

What is the difference between incision and buried suture double eyelid surgery?

Buried suture surgery ties the crease in with stitches passed through tiny openings and removes nothing; incisional surgery opens the lid along the crease line so tissue can be trimmed and the fixation made in view.

The surgical literature sorts the methods into three families. The first is non-incisional: stitches are buried under the skin to tether it to the lifting tissue of the lid, and no tissue is cut away. These can be placed as a continuous run or as separate interrupted loops. The second is small or partial incision, in which one to four small openings let the surgeon remove a little tissue in front of the tarsal plate (the firm plate inside the lid) and fix the fold firmly. The third is full incision, a single opening along the whole crease.

A 2023 systematic review pooled 13 studies and 4,177 patients who had small-incision surgery. Both the single-incision and three-incision groups had a pooled complication rate of 5% and a pooled fold-loss rate of 2%, with no significant difference between them. The authors call the fold-loss rate acceptable compared with non-incisional and full-incisional surgery. This is pooled case-series data, not a trial that randomly assigned people to different methods, so it describes how often problems were reported, not a promise for any one lid.

Which method suits which eyelid?

A thin lid with little fat and little excess skin suits stitches well; a thick, puffy or skin-heavy lid is more likely to need tissue removed so the crease can hold. That is a matter of lid anatomy, which is why it is judged on examination rather than chosen from a menu.

Three things drive the choice. The first is skin: a buried suture cannot take skin away, so if the lid hangs over the lashes because of loose skin, stitches alone leave the hood in place. The second is fat and puffiness. In a 2026 single-institution study of 513 patients who had non-incisional surgery, 54.5% had puffy eyelids, and creases survived longer in lids that were not puffy; continuous fixation protected the crease more than interrupted fixation, especially in puffy lids. A separate 2026 multicentre study that compared 188 buried-suture cases with fat removal and 188 without found that those who had upper eyelid fat removed needed a repeat operation for crease loss less often (17.0%) than those who did not (33.5%). Both are retrospective, so they show an association, not proof that one step caused the other.

The third is the lid itself. A lid that looks heavy may be heavy because of a low brow or a weak lifting muscle, and neither is fixed by a crease. How surgeons tell a hooded lid, ptosis and a heavy brow apart is worth reading before choosing any method. Tape or glue can preview where a fold would fall, but it cannot show how well the lid lifts; my page on eyelid tape explains that limit.

How long does a buried suture crease last compared with an incision crease?

No study cited here compares the two methods head to head over many years, so there is no honest single number. What exists are series that follow one method for months to a few years, and they define "loss" differently.

The figures give a sense of scale. In a database of 2,934 two-point buried suture operations followed for up to 4.5 years, reoperation for crease loss was 17.0% and 33.5% in the two groups of 188 described above. A national dataset of 52,281 procedures, sampled as 600 cases, found that 22.3% needed another operation because the suture loosened, ranging from 12% in people aged 30 to 39 to 41% in those under 20. A single-institution cohort of 788 buried suture patients found any reoperation or suture removal within 12 months in 16.3% of people aged 45 or over and 7.0% of those aged 18 to 39, mostly because of dissatisfaction with the shape of the lid rather than crease loss or infection. In the pooled small-incision review, fold loss was 2%.

Read these as different questions asked of different populations, not as a league table. They do show a pattern: the stitch holds a fold in place, but it depends on what the lid is made of, how the fixation is placed and who the person is. The incisional crease is generally described as the more robust attachment; that is the trade-off for a longer recovery and a scar that settles into the fold.

How do the risks and recovery differ between the methods?

Buried suture surgery generally means less swelling and a shorter recovery, with the main risk being a crease that loosens; incisional surgery means a longer recovery and a scar in the crease, with a firmer attachment. The 788-patient study describes the buried method as minimally invasive, with short recovery, and, usefully, reversible.

The families share most risks: asymmetry, a crease set too high or too low, extra creases, a visible scar or fold, a lid that sits lower than before, and infection. How these play out, and what a second operation can and cannot do, is set out in the article on revision double eyelid surgery. For the week-by-week picture, see the eyelid surgery recovery timeline. Dry or gritty eyes and a lid that does not close fully are covered in the article on recognised complications after eyelid surgery.

Why must a droopy eyelid (ptosis) be found before choosing a method?

Because a crease cannot lift a weak lid. Ptosis, the medical name for an upper lid that sits too low, is common in people who ask for double eyelid surgery, and a method chosen without noticing it can leave the lid heavy.

A five-year review of 127 patients states that people seeking double eyelid surgery frequently have mild to moderate ptosis, and that non-incisional surgery without correcting it tends to give unsatisfactory results. In that series, a single continuous stitch also tucked the Müller muscle (a small muscle that lifts the lid) and raised the margin reflex distance, the gap from the lid edge to the light reflex on the eye, from 1.62 mm to 3.97 mm on average. Whether that is the right fix depends on how well the lifting muscle works, which a surgeon measures first. My guide to ptosis surgery in adults explains the options, and the article on revision after ptosis surgery explains why lid height can drift.

What should I ask before choosing a method?

Ask which method is planned for your lid and why, whether ptosis has been measured and excluded, and what happens if the crease loosens. Those three questions turn a method label into a plan.

Add two more: whether the method can be reversed or revised later, and how many months the surgeon would wait before judging the result, since creases change in the first few months. I set out the wider checks in my guide to choosing an eyelid surgeon, and a second view before consenting is reasonable; the article on second opinions explains what that visit is for. For the wider picture of how eyelid problems fit together, my hub article on why eyes look tired is the place to start.