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Section: Complications

Complex Revision Following
Multiple Previous Operations

The patient had undergone previous incisional double eyelid surgery with an unsatisfactory result. Following attempted revision elsewhere, both lids were worse and she had no crease on either side. When first seen in our office, each upper eyelid demonstrated:

No crease with noticeable asymmetry

Multiple incomplete lines, folds, and scars over the full expanse of skin

Hollowed eyelids with the deepest depression extending up to and under the rim of bone

Ptosis (lid droopiness covering too much of the eyeball)

Lashes pointed downward into the field of vision

Inability to close fully when asleep

Slight skin shortage

Without adequate orbital fat extending forward from the socket, the lids cannot form a natural crease and will instead crumple into mulitple uneven folds. The depression resulting from volume loss can be distressing since "ages" the lids and face.

Ptosis is common in the setting of hollowness but may also indicate damage to the tendon (levator aponeurosis) that connects the lids's opening muscle to the eyelid edge.

In patients who have undergone multiple previous operations, the extent of scarring and damage to internal tissues is unknown until actual surgical exploration. Unfortunately, this general constellation of findings is not uncommon in patients seeking revision.

Surgical Repair

1. Upon opening the lid along the site of the intended future crease, dissection and excision of scar tissue was accomplished until the levator muscle and aponeurosis were freed of adhesions. As seen in the photo to the right, the tendon had been disinserted from its normal attachment during previous operations and its edge had retracted upward (area colored in light green).

2. Normally, orbital fat from the socket extends forward and covers most of the levator aponeurosis (as drawn in light orange). In this case, a severe shortage of orbital fat was encountered (shown further in the photo directly below). Without adequate fat, the more exterior tissues of the lid can collapse onto the levator complex, prevent formation of a crease, tether movement of the lid when opening and closing, and bunch up into irregular external folds.

3. The free edge of the levator aponeurosis was freed from scar, advanced downward, and reattached to its normal anatomic position (ptosis repair). The blue arrows point to three sutures that have already been placed in this repair, while the green dots outline an area not yet repaired.

4. Following completion of the ptosis repair, the highest part of the levator was retracted downward by forceps to expose the full magnitude of missing fat. The purple arrows point to the edge of bone covered only by a thin layer of brow fat. Deep inside the cratered area, only a few globules of normal orbital fat can be seen.

5. To address an orbital volume deficiency requires grafting of structurally-intact fat from the abdomen. Care was taken to avoid injuring the eye muscles, nerves, blood vessels, and eye itself.

6. Remaining remnants of previously-damaged orbital septum were draped over the fat. The skin and closing muscle were draped over the septum.

7. A new crease was constructed utilizing deep fixation between the skin edges and the previously disinserted but now reattached levator aponeurosis. Because the grafted fat now inflates the lid above this area of fixation and helps prevent reformation of previous scar as well as collape of overlying tissue, a defined crease will be able to form during healing.

8. The wound was closed in several layers. Notice full reinflation of the hollowed area shown in the "Before" photo at the top of this page.



Six Months After
Hollowness eliminated, multiple folding reversed,
scarring corrected, creases established but still maturing
(images cropped for privacy)

Healing after revision in a patient who has undergone multiple previous operations may take a full year or longer. With time, the skin above the new creases will relax and drape over the incision, further lowering the platform of exposed skin above the lashes.

More Photos of Asian Eyelid Revision


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Frank Meronk, Jr., M.D.
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