Background: Most double-eyelid operations emphasize the levator insertion into the upper eyelid skin and some surgeons preferred the non-incisional suture ligation method with the merit of invisible scar, short healing time and less pain. However, it still shows the high rate of fading of the lid fold at long-term follow-up especially in patients with thick, puffy eyelids. The authors describe a new tissue thread grafting non-incisional method for the stable, natural looking double-eyelid operation. 
Methods: Instead of applying suture materials for supratarsal fixation, we used autogenous tissue threads from the patients’ own temporal fascia, periumbilical tissues, capsulopalpebral fascia and allogenic human dermis. They were prepared in 1 X 15 mm – sized multiple strips. After several stab incisions on imaginary fold line, we engaged tissue threads using newly designed Yop’s needle or modified 5-0 Vicryl suture material which was looped and tied up using 8-0 Nylon sutures. It passed through whole layer of the upper lid as a same pattern with the conventional non-incisional technique. We made a fine knot of tissue thread subcutaneously within the upper lid at 4 points using 8-0 Vicryl sutures to immobilize the thread loop. It allowed the safe interposition of the tissue thread within the upper eyelid without any disruption of the tissue layer continuity.
Results:  A total of 58 double-eyelid operation were performed by a senior surgeon at Seoul. It included 31 primary and 27 secondary cases. Patients were followed up for 6 to 24 months (mean, 12 months). Tissue threads were maintained for 9 days in average. In cases the buried tissue thread was partly exposed, it was left out in situ until the spontaneous dried up change was progressed. There were no complications regarding tissue threads including infection or granuloma on upper eyelid and donor sites. There were fixation failures in one with autologous tissues and three with AlloDerm^® thread graft who required reoperation due to disappearance of the fold. However, all the patients were satisfied with final results.
Conclusions:  We introduce a new double-eyelid operation interposing various tissue threads on the upper eyelids. Tissue thread grafts do not only play a safe role in fixation of the palpebral crease but also incorporate safely into the eyelid tissues for scarless, natural looking double-eyelids.