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Section: Complications

Revision After Poor Result

"The key steps in complex Asian revision surgery are adding to and adjusting the orbital fat. Unfortunately, only a handful of doctors know anything more about managing fat than how to take it out."

Three years after double eyelid surgery performed elsewhere.

Three months after orbital pearl fat grafting and internal fat repositioning.

Aesthetic Complications

Although Asian cosmetic eye surgery, or double eyelid surgery, is the most common cosmetic operation performed worldwide, the incidence of aesthetic and functional complications is surprisingly high. Not counting insufficient patient education leading to unrealistic expectations, the most frequent reasons for dissatisfaction in an approximate order of frequency are

Less severe problems:
more than mild asymmetry of the creases
overly low creases
incomplete or shortened creases
loss of creases over time, especially after suture methods
overly noticeable scarring

More severe problems:
overly high, deep, or arched creases
formation of highly irregular or multiple creases
ptosis (inability to lift the eyelid fully)
upper eyelid hollowness
skin shortage or tissue damage preventing adequate lid closure
eversion of the upper eyelid margin with upturned lashes

Double eyelid surgery is sometimes described as "simple" and yet in the hands of the occasional eyelid surgeon who may lack a thorough understanding of Asian eyelid anatomy and the experience to properly plan and meticulously execute the most appropriate procedure, the rate of aesthetically disappointing asymmetry is reported to vary between 13 and 35 percent.


The most common causes of problems following double eyelid surgery include:

insufficient preoperative evaluation
poor choice of surgical procedure
unpredictable tissue healing
poor execution of the surgical procedure, including

incorrect placement of skin incisions
incorrect amount of skin removal
excessive fat resection
failure to treat the orbicularis muscle and orbital septum optimally

What Can Be Done

The subject of revisional Asian eyelid surgery is technical and demands a professional understanding of operative technique and eyelid anatomy. While a full description of surgical options is thus beyond the scope of this discussion, an overview of advanced techniques can be gleaned from the case studies of actual patients shown below.

Each revisional surgery must be custom-tailored to the problem at hand. Although a variety of procedures have been described for treating the less severe group of problems noted above, most previously published approaches provide suboptimal results in more advanced cases due in large measure to shortcomings in reestablishing more normal orbital and periorbital fat relationships (video).

The key requirement in complex Asian revision surgery is augmenting or relocating the upper orbital fat. Unfortunately, only a handful of doctors know anything more about managing fat than how to take it out.

Because double eyelid surgery is performed commonly, many patients seem surprised that correction of surgical flaws is so difficult. However, once tissue has been removed, damaged, or scarred, efforts to restore an eyelid are challenging and not always successful. For this reason, undergoing more surgery simply to refine an acceptable result into "perfect" is not recommended.

Examples of Available Techniques

Several revisions by Dr. Meronk photographed below demonstrate examples of more innovative approaches used in complicated and/or previously untreatable cases. Such techniques are of limited availability since most doctors have little familiarity with orbital hollowness surgery designed to restore fat volume, anatomic compartments, and tissue relationships.

Eyelid crease revision 1
Crease undefined & multiplied

Eyelid crease revision 2
Crease high & hollowed

Eyelid crease revision 3
Creases irregular

Double eyelid revision 4
Ptosis, hollowness, no crease


Unless the eyelids have been severely compromised, revisional surgery will generally yield improved function and a more aesthetically-pleasing shape to the lid and crease. Perfection or near-perfection, on the other hand, are never realistic goals in secondary surgery. The limitation is usually not with the surgeon but rather the damaged tissues and their reduced and unpredictable capacity for healing. Patients who cannot understand or accept this reality will always be disappointed.

Since revisional double eyelid surgery requires one year or more to reach a final result, over-analyzing progress during the early months will only lead to unnecessary worry and frustration. In complex cases, more than one operation may be required.

Some conditions (especially those that persist after multiple previous operations) may prove highly resistant to even the most advanced revisional techniques.


Costs for revision of unsatisfactory results following Asian double eyelid surgery (whether incisional or suture technique) generally range from between three and five times the cost of primary surgery depending on the nature and severity of the problem. Unusually complex problems or treatment after previous failed revision surgery performed elsewhere may cost more. If more than one surgery is required, each is considered a new operation and is billed separately.

Next: Premature Lid Hollowing

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Frank Meronk, Jr., M.D.
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