REVISION DOUBLE EYELID SURGERY
Revision double eyelid surgery is not uncommon. In Dr Huang’s practice, it comprises a significant part of his eyelid surgery workload. The commonest patient complaints after double eyelid surgery are unnatural looking double eyelids, asymmetric double eyelids and inadequate removal of excess skin and fat. Other less common causes of suboptimal results are one eye looking bigger than the other, unsightly scars, and upward eversion of the upper eyelid causing the eyelashes to curl up unnaturally and exposing the inside of the eyelid.
What are the causes of these suboptimal results? In almost all cases, they are due to technical errors or poor surgical technique. The causes of technical errors could be inadequate training, inadequate experience, or both. Technical errors can also be caused by poor preoperative planning, inaccurate eyelid measurements, lack of attention to detail, trying to operate fast at the expense of quality, or inadequate knowledge of eyelid anatomy.
Poor surgical technique refers to things like rough tissue handling, inaccurate placement of sutures, poor judgment in terms of how much tissue to remove and how to retain, lack of finesse in manipulating tissues and stitching them together, an inadequate number of sutures, and lack of meticulous wound closure. Sometimes, the poor result is due to incorrect preoperative assessment and wrong choice of procedure. For example, the patient may have needed a browlift but a double eyelid procedure was performed instead.
Is it possible to correct such suboptimal results? Yes, but it is not easy, and it may not be possible to achieve a perfect correction. However, in Dr Huang’s considerable experience, it is usually possible to achieve a significant improvement in the patient’s condition.
ASSESSMENT AND DIAGNOSIS
All the patient’s complaints and concerns are listened to, noted and documented. The patient’s eyelids are carefully and meticulously assessed, and the findings are correlated to the patient’s complaints and concerns. An accurate diagnosis is made as to what the problems are and their causes. A solution is formulated and fully explained to the patient.
Careful measurement is taken of the existing double eyelid creases, and the height and design of the new double eyelid crease is determined based on both Dr Huang’s judgment as well as the patient’s preferences. The patient is therefore greatly involved in this process. The amount of excess skin that needs to be removed is determined, measured and marked.
If the problem is straightforward it may be possible to address it adequately with the scarless double eyelid stitching technique (revision suture upper blepharoplasty). More commonly however, a revision open upper blepharoplasty is required, involving making incisions over the eyelids and correcting the problem through invasive surgery. Whenever possible, the incision is made over the existing scar, but sometimes the incision is made above or below the scar and the scar (especially if it is unsightly) is removed. Occasionally and in some situations, it may be necessary to make a new incision away from the existing scar without removing the scar. In such cases, the patient will have to accept having two scars, which fortunately does not end up as bad looking as it may seem.
If there is excess skin that had previously been inadequately removed, then the appropriate amount of skin is now removed. All the relevant eyelid tissue layers and important structures are now carefully and meticulously dissected and exposed, and any scar tissue or sutures from previous surgery are completely excised. Excess fat if any, which is present in two different layers in the upper eyelid, is removed as required. At this point, all the eyelid tissue layers and structures should be in their natural state without any abnormal attachments and without the presence of mechanical forces caused by previously placed sutures and previous surgery.
If the degree to which the eyes open requires correction or adjustment, this step is now carried out by separating the muscle responsible for opening the eye (the levator muscle) from the cartilage plate (the tarsal plate) to which it is normally attached. Sometimes, the levator muscle is found to have been inadvertently detached from the tarsal plate by the previous surgery. In any case, the levator muscle is now reattached properly and at the right tension to the tarsal plate with fine sutures so that both eyes can open optimally and symmetrically.
Next, multiple fine sutures are placed which connect the underside of the skin and some of the superficial muscle fibers of the lower wound edge to the levator muscle, so that whenever the eye opens, a double eyelid crease is formed. Finally, the skin is meticulously closed with fine skin sutures.
Anesthesia options for revision double eyelid surgery include local anesthesia for the entire operation or intravenous sedation for the first part of the surgery only and local anesthesia for the rest of the surgery.
The rationale behind the latter strategy for anesthesia is that towards the end of the operation, the patient will need to open their eyes normally and without any effects of sedation being present, so that the degree and symmetry of eye opening and the quality and symmetry of the double eyelid creases can be assessed before finalizing everything. Therefore, if intravenous sedation is chosen by the patient, this is administered only for the first one hour, so that by the time it is necessary for the patient to open their eyes to assess the aforementioned parameters, the patient is fully awake and cooperative, ensuring that whatever is assessed will be fine.
During that first hour of intravenous sedation, all the local anesthetic that is required is injected. When the patient wakes up after the first hour, he or she will not feel any pain due the previously injected local anesthetic, which is long acting and lasts for six to seven hours. On the other hand, during the injection of local anesthetic, which is the most painful part of the operation, the patient would not have felt any pain because of the intravenous sedation. This way of using anesthesia enables us to maximize patient comfort without compromising the surgical result.
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