Revision Surgery for “Sausage Eyes”: How Should Thick Double-Eyelid Folds Be Corrected?

Thick folds · High fixation · Organized by ptosis-related causes

Key Summary

• For revision surgery for “sausage eyes,” the cause of the thickened double-eyelid fold must be identified first.

• If the fold is fixed too high, the existing adhesions may need to be released and the fold redesigned at a lower position.

• If ptosis is also present, the strength of eyelid opening should be evaluated rather than simply lowering the fold.

• If there is hollowing above the eyes or insufficient fat, volume enhancement may also be considered.

• For revision surgery, it is important to assess existing scar tissue, adhesions, and skin laxity before determining the timing.

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Some people become concerned when their double-eyelid fold remains thicker and puffier than expected after surgery. The commonly used term “sausage eyes” refers to a condition in which the area below the double-eyelid fold appears swollen, or the eyelid folds inward heavily, making the eyes look unnatural. At first, people may assume this is swelling and wait, but if the fold still looks thick and heavy over time, it is necessary to determine whether this is simply part of the recovery process or a condition requiring revision surgery.

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1. Why Do Sausage Eyes Occur?

Summary: Sausage eyes are a condition in which the area around the double-eyelid fold appears thick and puffy.

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The term “sausage eyes” is used because the area where the double-eyelid fold was created appears thick and swollen. Medically, this may also be described as pre-tarsal hypertrophy or double-eyelid hypertrophy. In some cases, swelling simply persists for a long time. Therefore, with revision surgery for sausage eyes, it is more important to first distinguish the cause than simply to “reduce the thickness of the fold.”

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2. When the Double-Eyelid Fold Is Fixed Too High

Summary: When the fold has been positioned too high, the existing fold may be released and redesigned at a lower position.

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If the double-eyelid fold is fixed higher than the eye’s natural structure, the tissue below the fold may crease thickly and create a sausage-like appearance. In this case, the height of the current fold, the depth of fixation, and the amount of available skin should all be evaluated. If there is sufficient skin, adjusting the skin between the existing fold and the new fold to lower the position may be considered. Conversely, if there is insufficient skin, rather than performing excessive excision, it may be necessary to release the existing fold by dissecting the adhesions and create a new fold using a double-line technique. At Ainique, when performing this type of revision surgery for sausage eyes, we place importance on checking the extent of the existing adhesions and the thickness of the eyelid before redesigning a natural-looking fold within the range that can be safely lowered.

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3. When Ptosis Is Also Present

Summary: If the strength of eyelid opening is insufficient, the eyes may look thick and heavy even when the fold is not positioned high.

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The cause of a sausage-eye appearance is not necessarily a high fold. When ptosis is present, the eyelid covers part of the eye, making the eyes look heavy and sleepy; as a result, the double-eyelid fold may appear relatively thicker. In this situation, simply lowering the fold may make the eyes look even heavier. If necessary, eyelid correction may be considered together to adjust the strength of eyelid opening, followed by repositioning the double-eyelid fold accordingly. At Ainique, we plan the direction of revision surgery by evaluating not only the height of the fold but also the strength of the eyelid-opening muscles, eyelid movement, and left-right asymmetry.

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4. When There Is Insufficient Fat Above the Eyes

Summary: Hollowing above the eyes can make the double-eyelid fold look deeper and thicker.

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People with little fat or hollowing above the eyes may have a double-eyelid fold that appears more deeply creased. This is because when the upper area is hollow, the tissue below the fold appears relatively more prominent. In such cases, simply lowering the fold may not be sufficient. Depending on the situation, adding volume to the hollow area may also be considered, and whether to use filler or fat enhancement should be determined after evaluating the condition and thickness of the eyelid. In other words, although it may appear to be a simple revision procedure to reduce a thick area, achieving balance may sometimes require addressing areas that lack volume as well.

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5. Timing of Eyelid Revision Surgery

Summary: Revision surgery is generally considered after the tissue has stabilized, but the timing may vary depending on the condition.

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After double-eyelid surgery, the skin and tissue are affected, and swelling and scar tissue may remain during the recovery process. For this reason, revision surgery is often planned after the tissue has stabilized to some extent. Generally, the condition is often evaluated after approximately six months, but if the fold is excessively high or there is significant functional discomfort, the timing should be determined separately through consultation with a medical professional. In particular, revision surgery for sausage eyes requires a more detailed evaluation of existing adhesions, scar tissue, and skin laxity than the initial surgery, so it is important to accurately assess the current condition rather than rushing the process.

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6. Ainique’s Approach to Revision Surgery

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Summary: At Ainique, the fold, adhesions, strength of eyelid opening, and skin laxity are evaluated together.

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At Ainique Plastic Surgery, we do not view this simply as surgery to lower the fold. We first determine why the existing fold became thick, how strong the adhesions are, and whether the strength of eyelid opening is insufficient. If necessary, we then release the existing adhesions through dissection and redesign the fold. When there is insufficient skin, a double-line approach that considers skin preservation may be reviewed rather than excessive excision. In addition, if ptosis or hollowing above the eyes is present, a comprehensive plan involving eyelid correction and volume enhancement may be necessary. Even when the eyes look similar to sausage eyes, the surgical method may differ depending on the cause, making individualized diagnosis important.

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7. Points to Check Before Revision Surgery

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Summary: Identifying the exact cause should come before trying to eliminate the thick fold.

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Sausage eyes may appear externally to be a simple problem of overly thick double-eyelid folds, but in reality, the height of the fold, strength of fixation, adhesions, strength of eyelid opening, skin laxity, and volume above the eyes may all contribute. Therefore, if you are considering revision surgery for sausage eyes, you should first determine why your eyes appear thick. The plan may differ depending on whether the fold needs to be lowered, the existing fold needs to be released, or eyelid correction is necessary. At Ainique Plastic Surgery, we carefully evaluate the condition after the previous surgery and the eyelid structure before providing guidance on a revision approach suited to the individual. Because revision surgery varies greatly from person to person, it is advisable to consult a medical professional to determine the method appropriate for your current condition.

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At a Glance

• For revision surgery for sausage eyes, the cause of the thick double-eyelid fold must be identified first.

• If the fold is fixed too high, redesigning it at a lower position may be considered; if ptosis is present, eyelid correction may also need to be evaluated.

• If the fold appears prominent because of insufficient fat above the eyes, volume enhancement may be necessary.

• For revision surgery, it is important to evaluate the existing adhesions and scar tissue before determining the appropriate timing.

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