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What is double eyelid revision surgery?

When the double eyelid line is too large, asymmetrical, or has loosened, this is a surgery that revises the double eyelid line and restores it to its original natural yet clear double eyelid shape.

Indications for double eyelid revision surgery

When the double eyelid line is too large

When the double eyelid line has loosened

When the line is asymmetrical

When the eyes feel tired after double eyelid surgery

When there is a thick sausage-like appearance in the area below the incision line

When the impression looks worse after double eyelid surgery

When you want to restore beautiful, natural eyes

The purpose of general double eyelid surgery

The purpose of double eyelid surgery is not simply to create a double eyelid line.

The purpose of double eyelid surgery is to make the eyes look larger and clearer, and to create bright eyes and a refined eye shape.

Surgery performed only to create a double eyelid line can easily lead to unwanted results.

The same applies to the purpose of double eyelid revision surgery.

The goal is to correct the eye shape so it looks larger, clearer, and more natural.

Requirements for successful double eyelid revision surgery

For revision surgery, more than anyone else, you yourself must first understand the cause of why the original double eyelid surgery went wrong. It is not easy to undergo revision surgery without recognizing the cause of the problem.
Only when you understand the cause and the doctor also identifies the cause can you proceed with surgery with trust between patient and doctor.
In order to understand the cause of the failed double eyelid surgery, it is essential to seek a detailed consultation with an experienced board-certified plastic surgeon whenever possible.

Success requirement NO. 1 - The surgery must be performed by a board-certified plastic surgeon.

Even revision surgery should not produce unwanted results.

You should confirm whether the surgeon holds a board certification in plastic surgery, and if not, determine whether they are a specialist in another field or a general doctor with only a medical license, and then proceed accordingly.

There are many hospitals where the signboard only says plastic surgery, but in reality non-specialists are providing care.

It is important to distinguish this well and avoid surgery by a non-specialist.

Success requirement NO. 2 - There must be extensive surgical experience in double eyelid revision surgery.

Even among board-certified plastic surgeons, their specialties may differ slightly.

Therefore, if you are considering double eyelid revision surgery, it is better to entrust the procedure to a specialist who focuses on double eyelid revision surgery for better results.

Double eyelid revision surgery is considered one of the more difficult, high-level procedures among plastic surgeries.

Receiving surgery from a specialist with solid know-how and accumulated experience in double eyelid revision surgery makes it more likely to restore a beautiful and natural eye shape.

Success requirement NO. 3 - Double eyelid revision surgery should not be taken lightly.

If revision surgery is treated lightly, the chance of failing again becomes very high.

Compared with the first surgery, revision surgery is several times more delicate and is one of the most difficult types of plastic surgery.

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

Having vague expectations alone can lead to another poor result.

Success requirement NO. 4 - The cause of the failed double eyelid surgery must be identified accurately.

To succeed with revision surgery, the first priority is for the patient to understand why the eyes ended up looking unattractive after the first surgery.

To avoid repeating surgical failure, both the patient and the surgeon must accurately understand through consultation why the first surgery went wrong and by what mechanism, so that the correct revision surgery can be performed based on that.

Through consultation, you should be able to clearly understand why the first surgery was wrong and by what process the double eyelid revision surgery will be performed, so that you can approach the surgery with trust and obtain good results.

Success requirement NO. 5 - The surgery time for double eyelid revision surgery should not be too short.

Double eyelid surgery usually takes about 30 minutes to 1 hour.

However, full-incision double eyelid revision surgery cannot be finished in a short amount of time.

If the revision surgery is finished in less than 1 hour, there is a high possibility that the procedure was insufficient.

Unlike the initial double eyelid surgery, revision surgery proceeds from releasing the original double eyelid, to separating scar tissue, repositioning the tissue, and performing delicate layered suturing.

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

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

The same applies to revision surgery.

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

Success requirement NO. 6 - The eyes should open well immediately after double eyelid revision surgery.

A double eyelid line that is too large and eyes that look half-open are called pseudoptosis.

Most revision cases involve these patients.

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

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

If the appearance immediately after revision surgery is not much different from before surgery, there is a high chance the surgery failed.

The appearance right after revision surgery should not look awkward; in many cases, once the swelling subsides later, the appearance becomes natural.

Success requirement NO. 7 - The thick inner line should be reduced immediately after surgery.

The highlight of double eyelid revision surgery is naturally converting a severe out-fold line into an in-fold line.

If the inner line is reduced and still does not look natural, the overall line correction has not been achieved.

Only when the inner line, which is the first step, is properly formed immediately after surgery can the line naturally continue outward and show a good prognosis.

If the line is still thick immediately after surgery and the inner line has not been properly narrowed, the prognosis cannot be considered good.

Success requirement NO. 8 - There should be a slight inability to fully close the eyes for a period of time after double eyelid revision surgery.

Surgery in which the eyes can be fully closed immediately after surgery is considered an incorrect surgery.

Most double eyelid revision cases involve insufficient skin reserve.

If surgery is performed in this condition, the skin must stretch somewhere for the eyes to close properly, and in most cases the skin stretches below the incision line.

If that happens, the double eyelid line becomes larger again.

Therefore, revision surgery is considered successful when the eyes do not close fully for a short time after surgery.

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

The duration of lagophthalmos after surgery varies somewhat depending on the degree of ptosis correction and the amount of available skin.

If there was not enough skin reserve, recovery from lagophthalmos is slower; conversely, if there is skin reserve, recovery is faster.

Success requirement NO. 9 - The sutures should be removed a little later after double eyelid revision surgery.

The sutures should be removed later.

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

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

If the sutures are removed too early after double eyelid revision surgery, the scar may widen and the tissues above the incision line may be pulled upward again, resulting in a procedure that might as well not have been done.

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

If the sutures are removed before the tissues have settled, the tissues that have not yet stabilized may be pulled upward again, resulting in a failed surgery.

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When the double eyelid line is too large

A double eyelid line that is too large is rarely suitable in any case.

A natural line is appropriate when it is only slightly visible when the eyes are open.

A large line is a representative example of an unattractive double eyelid and one of the most common indications for revision surgery.

When the area below the line looks swollen (sausage appearance)

This refers to swelling below the double eyelid line, commonly called the sausage appearance.

It gives the impression that the surgery was done only a few days ago and makes the viewer feel uncomfortable.

The causes of the sausage appearance include thick skin and orbicularis oculi muscle, designing the line too high, or partial loosening of the line.

Correction is performed by partially removing the orbicularis oculi muscle and then pulling the skin taut.

When the incision scar is dark

If you slightly lower your gaze, the incision mark is very visible, creating an unattractive double eyelid that looks as if it was cut with a knife.

The causes may include constitutional factors, but also incorrect suturing and inappropriate timing of suture removal.

Correction should be performed according to scar revision principles, by excising the scar and suturing carefully.

Target for double eyelid revision surgery: when the double eyelid line is too thick

Generally speaking, a double eyelid line that is only slightly visible looks natural and beautiful.

If the line is too thick, the eyes appear half-open, and the other person may perceive a strong and rough impression.

Cause	Correction
Line designed too high	The existing high line should be released or removed through incision, and a new line should be designed at an appropriate level to create the line. However, the height of the new line varies from person to person, and it is important to design the most natural height for each individual while considering skin reserve, eye size, and other factors.
Scar adhesion
Ptosis
Insufficient skin reserve, etc.

Target for double eyelid revision surgery: when the eyes look half-open (ptosis)

If the eyes do not open naturally after double eyelid surgery and remain half-open, they need to be corrected so that they open naturally and clearly again.

A half-open appearance can easily leave a poor impression on anyone.

Cause	Correction
Congenital ptosis	In the case of ptosis, the most common surgical method is to correct it with levator palpebrae superioris shortening or resection.
Pseudoptosis
Scar adhesion, etc.

Target for double eyelid revision surgery: when the incision scar is too severe

If the scar is very visible when the eyes are closed after incision double eyelid surgery, it should also be corrected through incision surgery so that almost no scar remains.

Cause	Correction
Incorrect suturing of the incision line	The existing scar should be excised, and the muscle and skin should be sutured separately in a solid layer, with very precise suturing so they do not become misaligned. It is also important to remove the sutures at an appropriate time so that they do not affect the scar.
Suture removal too early, causing the scar gap to widen
Suture removal too late, leaving suture marks
Constitutional individual differences

Thick tissue below the incision line (sausage) and eyelid correction

This refers to a swollen appearance below the double eyelid line, shaped like a bulging pouch, as if the surgery had been done only a few days earlier.

Causes

◇ When the line is designed too high

◇ When the skin and orbicularis oculi muscle are thick

◇ When the buried suture for the double eyelid line is placed below the incision line height

◇ When the sutured area loosens and the double eyelid line shifts downward

Sausage appearance after full incision surgery

In most cases, surgery is possible only with full incision, and some of the orbicularis oculi muscle below the incision line should be removed to reduce muscle thickness.

The sagging skin is pulled upward, tightened, and fixed in place.

Sausage appearance after buried suture method

This occurs because the line was designed too high and partially loosened after surgery; it can be corrected by pulling the partially loosened line upward and firmly retightening it.

Surgery is performed using a partial incision or full incision method.

Examples of thick skin below the incision line, the so-called sausage appearance, and eyelid correction

If there is a sausage appearance, it can be corrected through double eyelid revision surgery.

First, it is necessary to clearly understand what went wrong with the original surgery and how to improve it in order to achieve good results.

During the consultation, the surgery is planned after several examinations and tests to predict the post-operative result, and surgery is performed only when there is a sufficient possibility of improvement after surgery.

If there is enough skin reserve, revision surgery is entirely possible.

There are two main goals of revision surgery.

Restoring a larger, clearer eye shape and restoring a natural double eyelid line.

After revision surgery, the double eyelid line will be made thinner and more natural.

A thick sausage-like appearance occurs when the skin is thick and the line was designed too high, causing the skin to shift downward.

The surgery should remove the existing scar line and create a new line below it.

Some of the orbicularis oculi muscle under the skin, which causes the sausage appearance, should be partially removed to make it thinner.

If ptosis is present, revision surgery also helps the eyes open wider and corrects a sleepy-looking eye shape.

The surgery takes about 2 to 3 hours, the recovery period is about one week, and sutures are usually removed around one week after surgery.

When the double eyelid scar line is dark

In incision surgery, a scar forms at the surgical site.

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

In such cases, the scar line needs to be made lighter so that the double eyelid line is not easily visible even when the eyes are closed.

Causes

◇ When excessive skin removal causes the scar to widen

◇ When leftover skin is not removed, causing the skin to cover the incision line and make it darker

◇ When there is insufficient skin reserve and the scar line gradually widens or becomes distorted

◇ When excessive removal of the orbicularis oculi muscle under the skin causes a depressed scar

◇ When there is a habit of rubbing the eyes frequently after surgery

◇ When the person is constitutionally prone to scarring

Surgical method

The edges of the scar line are precisely designed, and only the scar portion is excised and removed.

The orbicularis oculi muscle under the skin and the normal skin are carefully sutured together in a precise manner.

If there is insufficient skin reserve, it may be necessary to delay suture removal, so it is also important to remove the sutures only after confirming that the wound has healed enough not to widen the scar.

If there is thick tissue below the incision line, the so-called sausage double eyelid appearance, part of the orbicularis oculi layer under the skin is removed and the skin is pulled upward and flattened for correction.

Examples of surgery for dark scar lines after double eyelid surgery

Precautions

◇ After suture removal, continue disinfecting for a few more days until the holes in the suture line close.

◇ Wipe the scar area well with disinfectant so that foreign substances or dead skin cells do not collect there.

◇ Do not rub with your hands just because your eyes feel tired or have discharge. It is better to wipe with a cotton swab.

◇ Rubbing the eyes can distort the double eyelid line or make the scar messy, so never rub them.

The timing of double eyelid revision surgery is at least 6 months after the last surgery.

The reason for waiting 6 months is to allow the scar tissue from the previous surgery to soften.

Because scar tissue has a strong tendency to cling together, if surgery is performed again before the scar tissue has fully matured, unpredictable results can occur.

The time when these changes have settled is considered the time when revision surgery can be performed, and that is judged to be about 6 months after surgery.

In the end, only after 6 months, when the scar tissue has softened and the previous surgery has fully settled, can the result of a later revision surgery be predicted.

If pulling and sausage-like appearances remain after 6 months, revision surgery with full incision is performed.

Various examinations and tests are conducted to predict the post-operative result, and surgery is performed only when there is a sufficient possibility of improvement after surgery.

If there is enough skin reserve, revision surgery is entirely possible.

A thick sausage-like appearance occurs when the skin is thick and the line was designed too high, causing the skin to shift downward.

The surgery should follow the existing scar line, then partially remove the orbicularis oculi muscle under the skin, which causes the sausage appearance, to make it thinner.

Correcting thick-line pseudoptosis - full incision method

Two goals of full incision method surgery

The goals of correcting thick-line pseudoptosis are largely twofold.

① First: reduce the large, unattractive double eyelid line and make it a natural, thin double eyelid line

② Second: make the half-open, sleepy-looking eyes open larger and more clearly

With these two goals, double eyelid revision surgery is carried out as follows.

Full incision method surgical process

▼ Step 1 - Design the planned incision line including the existing incision scar tissue.

Preoperative design is performed to create a new double eyelid line below the scar line and determine the width of skin removal up to the 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 will be 3 mm.

The new double eyelid line is determined by considering how much the line should be reduced and how much skin reserve there is.

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

▼ Step 2 - Cut the skin and scar tissue.

The scar tissue is excised along the design line.

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

The lower excision line becomes the new double eyelid line, and the upper line should be drawn downward naturally after tissue dissection so it can be sutured.

▼ Step 3 - Dissect the orbicularis oculi muscle, orbital fat, and skin that are adherent to the levator palpebrae superioris.

Since 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 space between the orbital fat layer and the levator palpebrae superioris, and in some cases, the space between the muscle and fat is also dissected to advance the fat.

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

▶ Step 4 - If there is contraction of the orbicularis oculi muscle, make an incision or remove part of the muscle to release the contraction.

If scar 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.

▼ Step 5 - Reposition the orbital fat up to the incision line to prevent re-adhesion.

Advancing the orbital fat is a process to prevent re-adhesion of the tissue.

If the fat is not repositioned, the tissues will adhere again, which can lead to ptosis and a half-open, sleepy-looking eye.

Sometimes a triple eyelid can form, which becomes a cause of distorted double eyelid lines.

Another effect of repositioning the orbital fat is that if the eyelid is sunken, the depression can be corrected to some degree, so in cases where fat grafting might otherwise be needed later, the surgery itself may improve the condition enough that fat grafting is no longer necessary.

▼ Step 6 - Shorten the levator palpebrae superioris to strengthen its function.

Levator palpebrae superioris shortening is one method of correcting ptosis.

It is simple and effective, with the advantage that correction can be made with almost no tissue damage.

It is a method in which the levator palpebrae superioris is not cut out, but simply advanced and tied to the tarsal plate (cartilaginous plate).

In revision surgery, the effect of levator shortening is twofold: it makes the eyes open wider so they can be corrected more clearly, and it also helps reduce the double eyelid line as the eyes open wider.

How ptosis (sleepy-looking eyes) is corrected

Levator palpebrae superioris shortening

This is a method of overlapping and suturing the eyelid-lifting muscle (levator palpebrae superioris) by about 4 to 8 mm to shorten its length.

• Surgical process for levator palpebrae superioris shortening

1. Design is made and local anesthesia is administered.

2. An incision is made along the design line.

3. After incision, the orbital septum is opened to expose the levator palpebrae superioris.

4. After exposing the levator palpebrae superioris and marking the amount to be shortened,

suture the marked portion to the upper edge of the tarsal plate.

5. To create the double eyelid line, three buried sutures are placed.

6. The outer skin is sutured.

▼ Step 7 - After incising the orbicularis oculi muscle at the inner corner, orbital fat is inserted between the muscles to prevent re-adhesion.

Along with advancing the fat, fat is inserted into the inner corner of the eye to prevent scar tissue from adhering.

The inner part of the eye is the area most prone to scar adhesion; adhesion in this area causes the eye to look half-open and to open poorly, making it uncomfortable to open the eyes.

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

▼ Step 8 - During suturing, layered sutures are used so that the repositioned structures do not shift.

The suturing method for revision surgery is not simple.

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

To achieve the double eyelid line as originally designed, 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 (cartilaginous plate), and the advanced fat must also be secured with sutures so it does not get pulled upward.

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

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

Hyaluronidase, a swelling-reducing agent, is a medication that has the effect of dispersing fluid and can quickly reduce swelling as soon as it is injected.

However, if too much is used, it can instead cause significant bruising, so it is used only in a limited way for swelling reduction.

▶ Step 10 - Suture removal is divided into two sessions, on day 4 and day 7.

Sutures are usually removed around day 7.

The reason for delayed removal is that in revision surgery, most cases do not have enough skin reserve, and the entire surgical process involves advancing tissues, which places a lot of tension on the suture line.

If the sutures are removed on day 3 or 4, the tense suture line may open up or the scar line may widen, resulting in a larger scar,

and the tissues may gradually be pulled upward, making the double eyelid line larger as well.

Therefore, until the tissues stabilize, the sutures must hold the tissues in place, so it is better to leave them in longer.

To prevent the scar from becoming messy due to suture marks, most of the sutures are removed on day 4 and only 3 to 4 sutures are left, so there is almost no visible suture mark.

To quickly reduce early inflammation and swelling, steroids are administered for 1 to 2 days.

After surgery, artificial tears are used for 1 to 3 months to prevent dry eye.

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

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Examples of full incision surgery

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A doctor who performs double eyelid surgery among plastic surgeons

must have the sensibility of a designer as well.

What kind of line is beautiful,

If you insist only on a standardized double eyelid line that you prefer,

a perfect line that suits each individual patient will not be achieved.

If you do not have an eye for it,

or even if you do,

if you do not have the skill to reproduce it, a masterpiece will not be created.

We do our best down to the very last stitch to bring beauty and satisfaction to each and every patient.

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