[Duhan Plastic Surgery Revision Double Eyelid Surgery] - [Double Eyelid Revision Surgery Process]

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Process of revision double eyelid surgery with the full incision method

■ Full incision method (Full incision method)

For correcting ptosis with a thick line, the full incision method can be used.

The full-incision revision process is very complicated and requires extensive experience, advanced technical skill, and know-how.

It usually takes about 2 to 3 hours.

The surgical process proceeds in 10 steps, and if even one step is omitted, it can lead to results below expectations.

Even if it takes a bit more time, better results can be achieved only by carefully checking each of these steps and performing the surgery with great care.

■ Two goals of full incision method surgery (Full incision method)

There are two major goals for correcting a thick line and ptosis.

① To reduce a thick, unattractive double eyelid line and make it into a natural, thin inner double eyelid

② To make sleepy-looking, half-open eyes open more widely and look brighter and clearer

With these two goals in mind, revision double eyelid surgery is performed as described below.

■ Full incision method surgical process

1. Design the incision line, including the existing scar tissue from the previous incision.

Before surgery, the design is made to create a new double eyelid line below the scar line, and the width of skin to be excised up to the scar line is determined.

The width to be removed is based on the new double eyelid line, so it extends to the existing scar line.

For example, if the existing scar line is 10 mm above the eyelashes and the new double eyelid line is set at 7 mm, the skin excision width would be 3 mm.

The standard is determined based on the width at the center.

The position of the new double eyelid line is decided by considering how much the line should be reduced and how much excess skin is available.

The average height of the line in revision surgery is about 5 to 7 mm.

2. Remove the skin and scar tissue.

The scar tissue is excised along the design line.

The incision is made precisely with a scalpel, and then the tissue is excised with surgical scissors.

The lower excised line becomes the new double eyelid line, and the upper line must be naturally pulled downward after tissue dissection so that it can be sutured in place.

3. Dissect the orbicularis oculi muscle, orbital fat, and skin that are adherent to the levator aponeurosis.

Because the skin above the incision line must be pulled downward, the firm scar tissue that has adhered must be dissected.

Scar tissue dissection proceeds by separating the area between the orbital fat layer and the levator aponeurosis, and in some cases the space between the muscle and fat is also dissected in order to reposition the fat forward.

Through this dissection process, the tissue can be advanced and repositioned downward, and it is important as a preparatory step for achieving a natural double eyelid line.

4. If there is contracture of the orbicularis oculi muscle, the muscle is incised or excised to release the contracture.

If scar tissue adhesion is too severe, in rare cases a 1 to 2 mm vertical incision may be made in the orbicularis oculi muscle to release the contracture.

5. To prevent readhesion, the orbital fat is repositioned to the incision line.

Forward repositioning of the orbital fat is performed to prevent the tissue from readhering.

If the fat is not repositioned, the tissue can adhere again, which may lead to ptosis and cause the eyes to look sleepy and half-open.

In some cases, a triple double eyelid can occur, which becomes a cause of a distorted double eyelid line.

Another effect of repositioning the orbital fat is that if the eyelid is sunken, the sunken appearance can be corrected to some extent. In cases where fat grafting would otherwise be needed later, the surgery itself may provide enough improvement that fat grafting is no longer necessary.

6. Shorten the levator aponeurosis to strengthen its function.

Levator shortening is one method of correcting ptosis.

It is simple yet effective, and has the advantage of being able to correct the problem with little tissue damage.

This method does not cut out the levator aponeurosis, but simply advances it and ties it to the tarsal plate.

In revision surgery, the effect of levator shortening is twofold: it allows the eyes to open wider so they appear brighter and more refreshed, and by opening the eyes more widely, it also reduces the double eyelid line.

7. After incising the orbicularis oculi muscle at the inner canthus, orbital fat is inserted between the muscles to prevent readhesion.

Along with forward repositioning of fat, fat is inserted at the inner canthus of the eye to prevent adhesion of the orbicularis oculi muscle.

The inner part of the eye is the area where scar tissue adhesion occurs most easily, and adhesion in this area can make the eyes look sleepy and make it difficult to open them fully, causing discomfort when opening the eyes.

To prevent this, orbital fat that can act as a lubricant is placed between the orbicularis oculi muscle and the tarsal plate and fixed with sutures.

8. During suturing, layered closure is performed so that the repositioned structures do not shift.

The suturing method in revision surgery is not simple.

The purpose of suturing is to close the open wound and create the double eyelid line.

Therefore, in order to achieve the double eyelid line designed at the beginning, the skin below the incision line must not be pulled upward.

To do this, the skin below the incision line must be firmly fixed to the tarsal plate, and the forward-repositioned fat must also be secured with sutures so that it is not pulled upward.

In addition, only when the orbicularis oculi muscle and skin above the incision line are all passed through by the sutures and firmly closed in layers can the desired double eyelid line be achieved.

9. To prevent hematoma and inflammation, a small amount of anti-swelling agent (hyaluronidase) is administered to the surgical site.

The anti-swelling agent hyaluronidase is a medication with a water-dispersing effect, and it can quickly reduce swelling as soon as it is administered.

However, using too much can instead cause more bruising as a side effect, so it is used selectively only for reducing swelling.

10. Suture removal is left for a relatively long period, from 7 to 14 days depending on the patient's condition.

Stitches are removed in two stages, on day 4 and day 7.

The reason stitches are removed late is that in revision surgery, most patients generally do not have enough excess skin, and because the surgical process involves advancing all the tissues, a great deal of tension is placed on the suture line.

If the stitches are removed on day 3 or 4, the tense suture line may open or the scar line may widen, resulting in a larger scar, and the tissue may gradually be pulled upward, which can also cause the double eyelid line to become larger.

Therefore, before the tissues stabilize, the stitches need to hold the tissue in place, so it is better to leave them in longer.

In most hospitals, stitches are sometimes removed early because of concern about stitch marks, but that applies only to the initial double eyelid surgery.

It does not apply to revision surgery.

To minimize stitch marks, most of the stitches are removed on day 4, leaving about 3 to 4 stitches in place, and these are removed on day 7. This can minimize stitch marks and prevent the scar from widening while also minimizing distortion of the double eyelid line.

To reduce early inflammation and swelling quickly, steroids are administered for about 2 days.

After surgery, artificial tears are used for about 1 month to prevent dry eyes.

When all of the above principles are followed with skilled technique, satisfactory results can be achieved.

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Process of revision double eyelid surgery when the eyelid is sunken

A sunken eyelid causes the double eyelid line to be pulled upward and become distorted.

As people get older, crease lines often appear.

In such a case, the first step is to correct the sunken eyelid with fat grafting.

When the eyelid is sunken, even revision surgery often does not produce a pretty double eyelid line.

After micro fat grafting using microneedles, the sunken eyelid is corrected.

Compared with the original, the line is narrower, but fine wrinkles remain in the line and the inner line is thick, so it does not look natural.

The line must be naturally corrected through revision surgery, and the revision should be planned 3 months after the fat grafting, once the graft has fully taken.

Three months after fat grafting, revision double eyelid surgery is performed to restore a natural line.

A natural double eyelid is narrower on the inside and gradually becomes wider toward the outside.

→ As in the example above, the sunken eyelid should first be corrected with fat grafting, and after 3 months, once it has fully settled, the appearance should be checked and revision surgery should be planned accordingly. Only then can the operation be accurate and good results be obtained.

Examples of revision double eyelid surgery with the full incision method

Process of revision double eyelid surgery with the partial incision method

■ What is the partial incision method (Partial incision method)

​This is a surgical method used to restore a blurred line back to its original clear line.

It is a method that can make a small double eyelid line somewhat larger.

■ Partial incision method surgical process

1. Design the desired double eyelid line.

In many cases, the design is made along the existing scar line.

Sometimes it is designed to match the height and shape the patient wants, or the surgeon may determine the most suitable line and design it accordingly.

Also, depending on whether an outfold or an infold is desired, the direction of the design line changes.

2. Mark three points on the design with ink to indicate where the incision will be made.

The points are lightly marked on the inner, middle, and outer parts.

3. Under sedation anesthesia, while the patient is asleep for about 5 minutes, local anesthetic is administered to the three marked points.

Local anesthetic is administered in the smallest amount possible so as not to cause swelling.

4. Make very small incisions of about 2 mm at the three marked points.

If the incision is made too large, many scars will remain, so the surgery is performed with the smallest possible incision to leave almost no scar.

5. Through the incision, the orbicularis oculi muscle is first pulled out and removed with scissors.

The orbicularis oculi muscle is the muscle layer covering the eyelid, and because it interferes with the formation of a double eyelid, it must be removed to prevent the line from loosening.

Along with removal of the orbicularis oculi muscle, the pre-tarsal fat beneath the muscle layer is also removed.

6. If there is a lot of orbital fat, the fat is pulled out through the outer incision.

Fat removal is mainly performed from the outer side.

7. Grasp the fat with a hemostatic forceps and cut the base of the protruding fat with a scalpel.

Excessive removal of fat can cause the eyelid to become sunken, so it is better to remove only the amount that protrudes.

8. After fat excision, bleeding is controlled with electrocautery to prevent bleeding.

If hemostasis is not performed properly, orbital hemorrhage can occur, making bruising and swelling worse, so proper hemostasis is important.

9. Through the three incision sites, a very fine dissolvable thread is used to connect the levator aponeurosis and the skin to create the double eyelid line.

10. After the thread is buried, ointment is applied and the surgery is finished.

Washing the face and wearing makeup are possible from the next day.

Use the cold pack provided by the hospital to apply cold compresses for 3 days.

If cold compresses are applied for more than 3 days, the swelling may not go down further, so it is best to do it for exactly 3 days only.

Examples of revision double eyelid surgery with the partial incision method

Process of performing fat grafting and revision double eyelid surgery at the same time when the eyelid is sunken

If the eyelid is sunken and the line is pulled upward and loosened, micro fat grafting can be used to correct both the sunken eyelid and the loosened line.

However, this applies only when the cause of the loosened line is solely the sunken eyelid. The main purpose of the procedure is to correct the sunken eyelid, and correction of the double eyelid line is a secondary purpose.

If the line does not naturally recover even after the eyelid has been restored, revision surgery must be performed.

■ When fat grafting and revision double eyelid surgery are performed at the same time for a sunken eyelid

There are hospitals that perform both at the same time when the eyelid is sunken and revision double eyelid surgery is needed, but this should not be done.

Fat grafting should be performed first, and revision double eyelid surgery is possible 3 to 6 months later.

When revision double eyelid surgery is performed, tissue must be dissected, and fat grafting cannot be done into dissected tissue. If fat grafting and revision double eyelid surgery are performed at the same time, it is like scattering fat into the dissected empty space, so the fat does not properly take, and it ends up damaging only the double eyelid line.

■ How to reduce a thick double eyelid line - micro fat grafting

This is applied only when the upper eyelid is sunken.

Micro fat grafting requires very advanced skill and know-how.

The anatomical structure of the eyelid must be accurately understood.

Eyelid fat grafting can only be done properly by someone with extensive experience in revision double eyelid surgery.

It is a very difficult procedure that must take into account the correction of the sunken eyelid as well as the awkward double eyelid line.

It is better not to undergo the procedure from someone with insufficient experience or from a non-specialist in plastic surgery.

1. Sedation anesthesia and local anesthesia are administered.

2. Fat is finely harvested from the abdomen with a syringe.

3. The harvested fat is centrifuged and purified.

4. The purified fat undergoes a second oil-removal process.

5. Tunneling is performed in the treatment area to secure space for grafting.

6. Delicate grafting is performed into the orbital fat layer of the sunken eyelid.

7. The contour of the eyelid and the height of the double eyelid line are adjusted with molding and retunneling, then the procedure is finished.

Examples of correcting the double eyelid line and sunken eyelid with micro fat grafting

Causes of failure in revision double eyelid surgery

The biggest cause of failure is the patient thinking of revision double eyelid surgery too casually.

After a failed double eyelid surgery, the thought of “I can just fix it again” is what leads to failure in revision double eyelid surgery.

Only when the patient understands the cause of the original surgical failure can another failure be avoided.

The content below analyzes the reasons for failed revision surgery in cases where patients came to this clinic for another revision after a failed surgery at another hospital, based on various examinations.

Cases where revision surgery is performed together with epicanthoplasty

There are hospitals that perform revision surgery to reduce the line together with epicanthoplasty.

Epicanthoplasty causes the inner (medial canthus) line to become thicker.

It does not make sense to perform surgery intended to reduce the line while simultaneously doing a procedure that makes the inner line larger.

Various problems can arise from an unnecessary epicanthoplasty.

Epicanthoplasty should only be applied when necessary in eyes with an epicanthal fold, and unnecessary epicanthoplasty can cause several side effects, such as excessive exposure of the inner mucosa, a severe outfold line, eyes that appear too close together, or eyes that look overly sharp.

Unnecessary epicanthoplasty can instead damage the overall impression, so caution is needed.

When scar tissue is not sufficiently dissected

During revision surgery, the existing scar must be removed or thoroughly dissected to release the adhesion between the stuck tissues.

Otherwise, tissue repositioning cannot be achieved.

If the muscle layer and fat layer are not thoroughly dissected while releasing adhesions, tissue repositioning becomes impossible and it is difficult to narrow the double eyelid line.

If the area is sutured without proper dissection, the double eyelid line will not narrow at all; instead, the skin below the incision line may be pulled upward, causing an ectropion-like effect in which the eyelashes turn outward.

When orbital fat is not repositioned

Fat needs to be repositioned as in step 5 above, and if this is neglected, the dissected tissue will stick together again, the eyes will not open widely, and in some cases a triple double eyelid may even form.

Along with scar tissue dissection, orbital fat repositioning is one of the important steps that acts like a lubricant to prevent tissues from sticking together.

When fat is not repositioned to the inner canthus (inner part of the eye)

If the orbital fat repositioning corresponding to step 7 above is not done to the inner canthus, scar tissue forms on the inner side of the eye and interferes with opening the eyes widely.

Scar tissue should not form on the inner side of the eye.

The inner side of the eye plays an important role in allowing the eyes to open widely, and if too much scar tissue forms in this area, the eyes cannot be opened widely and a natural line cannot be created.

When levator shortening is not performed

Levator shortening must be performed to correct ptosis and sleepy-looking eyes, and if this step is omitted, the width of the line will not decrease and the eye shape will remain sleepy, resulting in an undesired outcome.

Ptosis correction is an essential part of the revision process.

When stitches are removed too early

The reason stitches are removed late in revision surgery is that most revision patients do not have much excess skin, and because tissue has been repositioned, the tissues must be held firmly in place by the strength of the sutures.

The repositioned tissues tend to return to their original position like a spring, so they must be held in place by the sutures. If the stitches are removed before the tissue has stabilized in its new position, the tissues may return to their original location, leading to poor surgical results.

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■ Choice when surgery is very difficult or complicated during consultation​In some cases, after visiting for consultation and examination, the surgeon may not feel confident that a very difficult eye shape can be improved to a satisfactory result.From the surgeon’s perspective, they cannot simply say with confidence that it will be fine, but if they answer that it is difficult, the patient’s trust in the clinic may decrease or the surgeon may be mistaken for someone without skill.If the surgeon wants to provide honest and principled care, they should accurately assess the patient’s condition and explain what is difficult and where the result may turn out poorly. Some people accept this, but more often people react differently.If patients are influenced by exaggerated consultations and proceed with surgery, the situation may become even more hopeless.From the patient’s perspective, it is very important to distinguish between a consultation that includes no exaggeration and a surgeon who is principled and honest.
■ There are various possible outcomes in revision surgery.​Some people think that if they meet a highly skilled doctor for revision surgery, they will always get a good result.This is a very dangerous way of thinking.Even with a skilled doctor, there are cases where surgery improves the result, cases where improvement is not possible, and sometimes cases where the outcome is insufficient.Before surgery, you should keep these three possibilities in mind when consulting: whether the surgery is possible, how much improvement can be expected if it is possible, or whether it is not possible, and make a realistic judgment.
■ Cases where revision surgery is difficult or impossible​There are many cases where revision surgery is impossible or difficult. These include cases where there is not enough excess skin, cases where the scar line is so severe that adhesions are difficult to release, cases where the skin and muscle are excessively thick, cases where the tissues have become hard and thick after multiple revision surgeries, cases with severe sausage-like swelling where the tissue is likely to be pushed down again and recur even after surgery, and cases with severe ptosis.If the surgery is very complicated and difficult, the patient must understand the limitations themselves, but there are people who do not want to accept those limits.If you undergo surgery with vague hope alone, you are setting yourself up to fall into a deep pit.The decision to have surgery should be made after carefully judging the limitations and prognosis in your current condition.