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Methods of revision surgery

Correction of a thick line

Double eyelids with a line that is excessively thick look artificial and awkward, and give the impression of having had surgery not long ago.

A natural and appropriate height is one where the line is only slightly visible when the eyes are open.

Thick double eyelids are the most common indication for revision surgery.

Causes of a thick line

1. When the initial surgery was designed too high

2. When the skin is thick

3. When ptosis is present

4. Protruding eye shape

5. Adhesion of the scar line

6. Excessive skin excision

Surgical method for a thick line

1. The scar is excised.

2. The area between the levator palpebrae superioris and the orbital fat is precisely dissected so that tissue repositioning can take place.

3. To dissect the tissue and prevent adhesion of scar tissue, the fat is advanced and repositioned.

4. To prevent the skin below the excision line from being pulled upward, the skin below the excision line is firmly fixed to the tarsal plate.

5. A levator shortening procedure is performed so that the eyes open a little wider.

As the eyes open wider, the double eyelid line becomes narrower.

6. Firm layered suturing through the tissue completes the tissue repositioning and prevents the tissue from being pulled upward.

7. Sutures are removed a little later so that the scar does not widen and the repositioned tissue can stabilize.

Correction of an asymmetric line

Double eyelids with a large difference in the lines look awkward and create a poor impression.

In cases of asymmetric lines, the principle is to correct the less satisfactory side based on the side with the preferred double eyelid. If neither side is satisfactory, both sides need correction.

Causes of an asymmetric line

1. When the heights of the double eyelid lines differ

2. When one eye has ptosis

3. When one double eyelid line has loosened

4. When the skin on one side has sagged

5. When orbital fat is insufficient and the eyelid hollows, causing the line to be pulled upward

6. When the line is pulled upward due to scar adhesion

Surgical method for an asymmetric line

If there is a difference in the height of the initial double eyelid line, the heights must be matched. If the surgery was done with the buried suture method, the height of the line on the other side is adjusted to match the desired side using the same buried suture method or the partial incision method.

If the newly created line has stronger tension, the existing buried-suture line generally loses its tension and disappears on its own.

Correction of a loosened line

This refers to cases where the line becomes blurred, thinner, or disappears.

When the line loosens, the goal is to restore it to the original line.

If the original line is not satisfactory, a new line is created again.

Causes of a loosened line

1. When the skin is thick

2. When there is a lot of orbital fat

3. When the orbicularis oculi muscle is thick

4. When scar tissue does not form properly

5. When the eyes are rubbed frequently out of habit

6. When buried suture surgery is performed forcefully even though it is not indicated

Surgical method for a loosened line

When the line has loosened, the correction method must be considered differently depending on whether loosening occurred after the incision method or after the buried suture method.

If loosening occurred after the buried suture method, the first option is usually to correct it with the partial incision method. If it is judged that the partial incision method will not correct it well, the line is recreated with the full incision method.

To prevent loosening, scar tissue and fat tissue beneath the line must be completely removed, and the sutures must be firmly fixed to the tarsal plate.

Severe out-fold line - making it into an in-fold line

An out-fold refers to a line in which the inner line is visible all the way to the end. A thin out-fold may suit some people depending on the individual, but a severe out-fold creates an awkward eye shape and therefore should be changed into an in-fold line.

This is the highlight and core of double eyelid revision surgery, and the peak of skill is transforming an out-fold into an in-fold.

If the inner line cannot be arranged as desired, the overall line becomes awkward and it is difficult to achieve the desired line.

Transforming an out-fold into an in-fold in a state where there is no extra skin or where scarring is severe can be said to be the most difficult surgery among revision procedures.

Causes

○ When the double eyelid line is designed too high overall

○ When the inner design line is set too high

○ When unnecessary epicanthoplasty or excessive epicanthoplasty was performed

○ Excessive skin excision

Surgical method

In most cases, it is only possible with the full incision method. There are also cases where the buried suture method or partial incision method can be used, but this is only possible when adhesions are weak and partially loosened.

When adhesions are strong or the scar line is deeply marked, correction with the buried suture method or partial incision method is almost impossible.

The method is to perform a full incision, precisely dissect between the orbital fat and the levator palpebrae superioris, then reposition the inner orbital fat and also dissect and flatten the inner scar line.

This is a surgery that requires very advanced skill and accumulated experience.

Thick sausage-like swelling below the incision line

This refers to a swollen appearance in which the area below the double eyelid line bulges up like a pouch, looking as if the surgery had been done only a few days ago.

Causes

○ When the line was made too high

○ When the skin and orbicularis oculi muscle are thick

○ When the buried suture for the double eyelid line was placed below the height of the incision line

○ When the sutured area loosens and the double eyelid line is pushed downward

Surgical method

1. Sausage phenomenon after the full incision method

In most cases, surgery is only possible with the full incision method. Some of the orbicularis oculi muscle below the incision line must be removed to reduce the thickness of the muscle, and the sagging skin is pulled upward, tightened, and fixed.

2. Sausage phenomenon after the buried suture method

This is a phenomenon that occurs because the line was designed too high and partially sags after surgery. It can be corrected by pulling the partially loosened line upward and firmly, tightly refixing the line.

It is treated with the partial incision method or the full incision method.

Triple double eyelid line

This refers to a case where three lines appear, and they need to be consolidated into one line.

Usually, the upper line among the two lines is removed and the correction is made to match the lower single line.

Causes

○ When a line loosens and loses its center of tension, causing an additional line to form above the incision line

○ When an additional line forms above the incision line due to scar adhesion caused by excessive fat removal

○ When the skin pushes downward below the scar line, creating a new line

○ When excessive scarring occurs at the sutured area and a line forms above the scar

Surgical method

1. When scar adhesion is not severe

In the case of a triple line caused by loosening of the line, the existing line is firmly fixed with the partial incision method, allowing the line above the incision to loosen on its own.

2. When scar adhesion is severe

The surgery is performed with the full incision method.

The correction is done by full incision, removing the scar tissue and dissecting to reposition the orbicularis oculi muscle and orbital fat.

Eyelash eversion

This refers to a case where the skin below the incision line is pulled upward tightly, exposing the mucosa beneath the eyelashes.

If the mucosa is excessively exposed, it gives a poor impression, so correction is recommended.

Causes

○ Excessive skin excision

○ When suturing was done while pulling too far upward, resulting in excessive tension

○ When there is not enough extra skin and the skin below the incision line is pulled upward

○ When scar line adhesion is severe

Surgical method

Correction is possible only through the full incision method, and if surgery is delayed, the eyelash-eversion shape may become fixed and correction may no longer be possible.

In cases of eyelash eversion, surgery should be performed as soon as possible to achieve corrective effect, but if correction is done months or years later, it may not be properly corrected.

In other words, surgery must be performed before the shape becomes fixed for correction to be possible to some extent.

The scar line is incised, the skin below the incision is lifted, dissected downward, and the tension of the skin that had been pulled tightly upward is released.

Usually, dissection is done up to near the eyelashes, and in some cases, part of the orbicularis oculi muscle is also removed.

After adjusting the relaxed skin to an appropriate height, it is fixed with sutures so it does not move, and then the skin is closed.

When the scar line is dark

When the incision method is used, scarring necessarily occurs at the surgical site.

If the scar line is faint and light, there is no problem. However, if the scar line is dark and deeply indented, it can feel objectionable even when the eyes are closed.

In such cases, it is necessary to make the scar line lighter so that the line is not easily visible when the eyes are closed.

Causes

○ When the scar widens due to excessive skin excision

○ When leftover skin is not excised and the skin covers the incision line, making it darker

○ When a sunken scar occurs due to excessive excision of the orbicularis oculi muscle beneath the skin

○ When there is not enough extra skin, causing the scar line to gradually widen or deform

○ The habit of frequently rubbing the eyes after surgery

○ When the person is constitutionally prone to scarring

Surgical method

The edges of the scar line are precisely designed, only the scar area is excised and removed, and the normal skin is meticulously sutured together along with the orbicularis oculi muscle beneath the skin.

If there is not enough extra skin, it may be necessary to delay the time of suture removal, so it is also important to remove the sutures only after confirming that it has healed sufficiently and will not cause the scar to widen.

If there is a thick so-called sausage phenomenon below the incision line, part of the orbicularis oculi muscle layer beneath the skin is removed and the skin is pulled upward and flattened for correction.

Postoperative precautions

○ After suture removal, continue disinfecting for a few more days until the holes in the suture line are filled in.

○ Wipe the scar line area well with disinfectant so that foreign substances or dead skin do not accumulate.

○ If your eyes feel tired or eye discharge forms, do not rub them with your hands. It is better to wipe them with a cotton swab.

○ If you rub your eyes, the double eyelid line may become deformed or the scar may become messy, so do not rub them at all.

Success requirements for revision surgery

01. For revision surgery, more than anyone else, you must first understand the cause of why the double eyelid surgery went wrong. It is not easy to undergo revision surgery without recognizing the cause yourself.
02. If you recognize the cause yourself and the doctor in charge also identifies the cause correctly, patient and doctor can proceed with surgery based on mutual trust.
03. To understand the cause of the failed double eyelid surgery, it is essential to visit an experienced board-certified plastic surgeon and receive a detailed consultation.

You must have surgery performed by a board-certified plastic surgeon.

You should not end up with an undesired result from revision surgery as well.

You must check whether the surgeon holds a board certification in plastic surgery, and if not, determine whether they are a board-certified specialist in another field or simply a general physician with only a medical license before proceeding.

There are many clinics whose signboards say plastic surgery, but in reality they are operated by non-specialists.

It is important to distinguish this carefully and not undergo surgery by a non-specialist.

There must be extensive surgical experience in double eyelid revision.

Even among board-certified plastic surgeons, their areas of specialization differ somewhat.

Therefore, if you are considering double eyelid revision, it is better to consult a specialist who focuses on double eyelid revision surgery for a better result.

Double eyelid revision is one of the most difficult procedures in plastic surgery.

Having surgery performed by a specialist with proven know-how and accumulated experience in double eyelid revision makes it more likely that the eye shape can be restored in a more beautiful and natural way.

Double eyelid revision should not be taken lightly.

If revision surgery is treated lightly, the probability of another failed surgery is very high.

Revision surgery is several times more complicated and difficult than the first surgery and is among the most challenging plastic surgery procedures.

Therefore, it is better to think more carefully and decide on surgery more cautiously.

Proceeding with surgery based only on vague expectations can lead to another poor outcome.

The cause of failure in double eyelid surgery must be identified accurately.

To succeed in revision surgery, the first step is for the patient to understand for themselves why the eye shape became unattractive after the initial surgery.

To avoid repeating the failure of surgery, through consultation both the patient and the operating plastic surgeon must accurately understand why the initial surgery went wrong and by what mechanism, so that proper revision surgery can be performed based on that understanding.

Only when you can precisely understand through consultation why the initial surgery was wrong and by what process the revision is being performed can you proceed with confidence and obtain a good result.

The surgery time should not be too short.

Double eyelid surgery usually takes about 30 minutes to an hour.

However, double eyelid revision with the full incision method is not a surgery that can be finished in a short time.

If the revision is finished in less than one hour, there is a strong possibility that the surgery was insufficient somewhere.

Unlike the first double eyelid surgery, revision surgery proceeds from loosening the original double eyelid, to dissecting scar tissue, to tissue repositioning, and precise layered suturing.

Therefore, the surgery inevitably takes longer, and good results come only when every step is performed according to principle.

If double eyelid revision ends too quickly, it is like a runner not following the proper course and cutting straight across to the finish line.

The same applies to revision surgery.

Only when every step is completed without omission can a better result be achieved.

It is good if the eyes open widely immediately after surgery.

A double eyelid line that is large and eyes that look drowsy are called pseudoptosis.

Most revision cases involve such patients.

The goal of double eyelid revision is to make the double eyelid line as thin as possible and to make drowsy-looking eyes open clearly and refreshingly.

If the surgery goes smoothly, in most cases the eyes should open clearly as soon as the operation is finished, and that indicates a successful surgery.

If even after revision surgery the immediate postoperative appearance is not much different from before surgery, the surgery is likely to have failed.

The immediate postoperative appearance should not look awkward, because in most cases it will look natural after the swelling goes down later.

There should be a slight inability to close the eyes for a certain period after surgery.

If the eyes close properly immediately after surgery, that is considered an incorrect operation.

Most double eyelid revision cases do not have enough extra skin.

When surgery is performed in this state, if the eyes close well, the skin has to stretch somewhere, and in most cases the skin stretches below the incision line.

Then the double eyelid line becomes larger again.

Therefore, in revision surgery, it is a good operation if the eyes are temporarily not able to close well after surgery.

However, during the adaptation period, the skin above the incision line gradually stretches and after some time the eyes close naturally.

The duration of postoperative lagophthalmos varies somewhat depending on the degree of ptosis correction and the amount of extra skin.

When there was not enough extra skin, recovery from lagophthalmos is slow; conversely, when there is extra skin, recovery is fast.

The sutures should be removed a little later.

The sutures should be removed later.

Usually, sutures are removed in two stages on day 4 and day 7, depending on the amount of extra skin.

Unlike the first double eyelid surgery, where all sutures are removed around 3 to 4 days after surgery, in double eyelid revision the last suture is removed around day 7.

If sutures are removed too early after double eyelid revision, the scar may widen and the tissues above the incision line may be pulled upward again, resulting in a surgery that is no different from having not done it at all.

Because the suturing in revision surgery is done in a state where tissue is insufficient, the sutures must hold the tissues in place until they settle into their new position.

If the sutures are gone before they have settled, the tissues that have not yet settled may be pulled upward again, leading to a failed surgery.

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