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Problems when ptosis correction is not possible

In cases where the upper eyelid levator muscle has no function, further ptosis correction is no longer possible, or problems with lagophthalmos occur.

There are cases where the eyes still look sleepy even after multiple ptosis corrections.

Even if ptosis correction is performed again, if the function of the upper eyelid levator muscle is nearly absent, correction may be impossible.

In such cases, the line is corrected without ptosis correction.

If an excessive attempt is made to correct ptosis, lagophthalmos only worsens and ptosis is barely corrected.

Problems when eye-opening correction has been overdone

Reducing an overcorrected eye-opening result to a normal size is much more difficult than ptosis correction.

If ptosis correction or eye-opening correction has been overdone and the white of the eye becomes exposed, upper eyelid levator muscle relaxation surgery is needed to reduce the eye size again. However, if the levator muscle is relaxed carelessly, ptosis may develop several months later and the eye may not open well.

Surgery to lower an overcorrection is much more difficult than ptosis correction, and it is hard to predict the outcome later on.

The degree of relaxation of the upper eyelid levator muscle must be carefully controlled through extensive experience and know-how.

Problems when a releasing procedure has already been done elsewhere

When a patient comes in after having a releasing procedure at another clinic, recreating the line is often difficult or impossible.

One of the hardest problems to overcome in double eyelid revision surgery is when the patient has already had a releasing procedure at another clinic.

Nine out of ten patients cannot undergo revision surgery.

The reason is that, in order to release the line, the incision is made very low and thick tissue is laid down in the incision area so that no line forms there.

Because this tissue later turns into thick scar tissue, it is almost impossible to remove the thick scar tissue again and create a natural line.

A releasing procedure is a surgery that should be avoided as much as possible, even for the future.

Who is a candidate for double eyelid revision surgery? Cases where the eyes look sleepy (ptosis)

After double eyelid surgery, if the eyes do not open naturally and look sleepy, this should be corrected so the eyes can open naturally and more clearly again.

A sleepy-looking impression can easily leave a bad impression on anyone.

Causes

1. Congenital ptosis

2. Pseudoptosis

3. Scar adhesion, etc.

Correction

In cases of ptosis, the most common surgical method is to correct it by shortening or resecting the upper eyelid levator muscle.

Who is a candidate for double eyelid revision surgery? Cases where the double eyelid line is asymmetrical

A slight asymmetry is present in everyone to some extent, but a noticeably large asymmetry should be corrected.

Causes

1. Incorrect design

2. The line has loosened

3. Scar adhesion

4. Ptosis on one side, etc.

Correction

If the double eyelid lines on both sides are uneven, double eyelid surgery must be performed again to match the desired side.

However, if revision surgery is performed on only one side, the eyes will not be completely symmetrical immediately after surgery. No matter how properly the surgery is done, you must be patient for at least 1–2 months and observe the correction of the asymmetry. Therefore, when operating on only one side, the decision must be made carefully.

Who is a candidate for double eyelid revision surgery? Cases where the double eyelid line has loosened

After surgery, it may look fine at first, but as time passes, the width of the line becomes narrower or loosens again. In such cases, this often happens after the buried-suture method, with the line gradually loosening and dropping.

Causes

1. Performing the buried-suture method despite thick skin

2. Incorrect double eyelid surgical technique

3. Excess fat

4. An individual tendency toward thick skin or thick orbicularis oculi muscle

5. Constitutional factors that make line adhesion less likely, etc.

Correction

Considering the patient’s eye condition, the line is corrected through the incisional method or partial-incisional method so that it does not loosen again and becomes a clear line.

Ptosis

When the eyes do not open clearly,

and always look sleepy, it is called ptosis.

It is broadly divided into congenital ptosis and acquired ptosis.

It is divided into true ptosis, in which the function of the upper eyelid levator muscle, the muscle that lifts the eyelid, is reduced, and pseudoptosis, which only looks like simple ptosis.

The purpose of ptosis correction (sleepy-eye correction) is

to restore a large, clear eye shape.

Depending on the severity of the symptoms,

a proper method must be chosen,

and the surgeon’s skilled know-how and technique are required.

The purpose of double eyelid surgery is to create a large, clear eye shape while

forming a line on the eyelid

so that the eye looks more refined.

However, if the eyes end up looking even sleepier after surgery,

it is worse than not having had surgery.

Examples of ptosis

Types of ptosis

1. Congenital true ptosis

This occurs because the function of the upper eyelid levator muscle, which lifts the eyelid, is reduced. Most cases are congenital ptosis, and in some cases ptosis occurs due to trauma.

2. Pseudoptosis after surgery

The function of the upper eyelid levator muscle, which lifts the eyelid, is normal, but external factors interfere with the function of the upper eyelid levator muscle so that the muscle cannot properly exert force.

• The double eyelid line was made too high

• Habitual rubbing of the eyes causes scar tissue inside the eyelid, interfering with the function of the upper eyelid levator muscle

3. Pseudoptosis due to eyelid sagging

When the eyelid sags, the pupil becomes covered, so it can look as if the eye is not opening properly, like ptosis.

In such cases, the eyelid skin should be temporarily lifted or a temporary double eyelid should be created to check the actual vertical width of the pupil.

Simply having the eyelid cover the eye should not be diagnosed as ptosis.

Difference between ptosis and a normal eye

○ When the eyes are opened naturally and looking straight ahead

It is normal if the upper part of the black pupil is slightly covered by about 1–2 mm.

If more of the black pupil is covered than that, ptosis should be suspected.

○ When the eyes are opened naturally and looking straight ahead, the vertical width of the eye should be 8 mm or more for normal eyes.

If the vertical width is smaller than that, it is ptosis.

○ When looking upward from the maximum downward gaze position, the eyelid should move by about 14–16 mm.

If it is less than that, it can be judged as true ptosis.

How to examine ptosis

The method of examining ptosis is to check the vertical width of the pupil in a frontal gaze.

In a normal person, the vertical width is between 8 and 9 mm, and generally 8 mm or less is considered ptosis.

However, because eye shapes and sizes differ from person to person, ptosis is not diagnosed based only on an exact numerical value.

The diagnosis is made by judging whether the impression is objectively sleepy-looking and comparing it with the measurement.

The function of the upper eyelid levator muscle is also measured and assessed.

1. Measure the vertical palpebral fissure height (vertical width of the eye)

2. Check whether the impression looks sleepy

3. Measure the function of the upper eyelid levator muscle (normal 14–16 mm)

Upper eyelid levator muscle shortening surgery

This method shortens the length of the eyelid-lifting muscle (upper eyelid levator muscle) by overlapping and suturing it by about 4–8 mm, and it is mainly applied in cases of mild ptosis.

Because the operation must always be performed through an incision, a double eyelid line is created during the process. Therefore, for people without a double eyelid, an inner double eyelid must be created at least.

○ Surgical process for upper eyelid levator shortening

1. Design is made and local anesthesia is administered.

2. An incision is made along the design line.

3. After the incision, the orbital septum is opened to expose the upper eyelid levator muscle.

4. After exposing the upper eyelid levator muscle, markings are made to indicate how much it will be shortened, and the marked portion is tied to the upper edge of the tarsal plate with sutures.

5. Three sutures are embedded to create the double eyelid line.

6. The outer skin is sutured.

Upper eyelid levator resection

This method removes about 5–10 mm of the eyelid-lifting muscle (upper eyelid levator muscle) to shorten its length, and the cut end of the resected upper eyelid levator muscle is sutured to the tarsal plate.

It is mainly applied in cases of moderate ptosis.

Frontalis suspension

This method is performed in cases of severe ptosis with an upper eyelid levator function of 5 mm or less, and is used when recovery of function through upper eyelid levator shortening or resection is difficult to expect.

The forehead frontalis muscle is advanced and tied to the eyelid tarsal plate so that the frontalis muscle 대신 the function of the upper eyelid levator muscle.

General anesthesia is required, and severe lagophthalmos may occur as a side effect.

Müller muscle shortening

Instead of upper eyelid levator shortening, shortening using the Müller muscle beneath the upper eyelid levator is sometimes performed.

The advantage of Müller muscle shortening is that it can minimize lagophthalmos, but it is difficult to predict the surgical prognosis and recurrence is common.

Because access to the Müller muscle requires surgery that damages the upper eyelid levator muscle, it is a surgical method with no special advantages.

Anatomically, many people have little or very thin Müller muscle tissue, so in such cases Müller muscle shortening cannot be applied.

Postoperative care instructions after ptosis correction surgery

1. Apply cold compresses with the cool pack provided by the hospital.

This should be done for 3 days, 2 hours a day.

The cooling time may be done continuously for 2 hours, or split into 20–30 minute sessions.

It is usually convenient to do this before sleeping.

2. Use the prescribed artificial tears and eye drops to prevent dry eyes.

3. Follow-up visits after surgery are usually twice: the day after surgery and on the day of suture removal.

The stitches are removed on day 3 or 4.

4. Makeup and facial washing are allowed after the stitches are removed.

Until the stitches are removed, wash your face with a damp towel.

5. Since no bandage is applied to the surgical site, daily life is possible.

6. Postoperative swelling varies from person to person, and in most cases the swelling subsides considerably in about 7 days, but the period until it fully settles is about 1–3 months.

7. Lagophthalmos, in which the eyes do not close completely, varies depending on the degree of ptosis and the amount by which the upper eyelid levator muscle was shortened. It usually takes 15 days to as long as 6 months or more.

On average, it progresses for about 2–3 months and then the eyes naturally close normally.

Examples of ptosis correction

The condition where the line is asymmetrical is usually caused by different design, excessive skin removal on one side, partial loosening on one side, adhesion of scar tissue on one side, or the development of ptosis on one side.

Ptosis can be corrected through revision surgery, and uneven eyes can also be improved.

At our clinic, based on over 20 years of extensive clinical experience and know-how, surgery is planned after various examinations and tests during consultation to predict the postoperative result, and surgery is performed only when there is a good chance of improvement after surgery.

The most important factor in revision surgery is the amount of remaining skin and the location and degree of darkness of the scar line.

The purpose of revision surgery can be broadly divided into two things.

Restoring a large, clear eye shape and restoring a natural double eyelid line.

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

The surgery must erase the existing scar line and create a new line below it.

During revision surgery, the eyes are opened larger to correct the sleepy eye shape as well.

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Ptosis eye-opening correction surgery method -

Partial incision method

This is a surgical method used to restore a blurry line to its original clear line again.

It is a method that can make a small double eyelid line slightly 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 the design is made according to the height and shape the patient wants, or the surgeon may judge and design the line that best suits the patient.

Also, depending on whether it will be an outer fold or an inner fold, the direction of the design line changes.

2. Mark the incision locations in three places with design ink.

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

3. Under sedation anesthesia, after about 5 minutes of sleep, local anesthetic is injected into the three marked areas.

The local anesthetic is administered in the minimum amount possible to avoid swelling as much as possible.

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

If the incision is made too large, a lot of scarring will remain, so the surgery is done with the smallest possible incision to leave almost no scar.

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

The orbicularis oculi muscle is the muscle layer covering the eyelid, and it is tissue that interferes with double eyelid formation, so it must be removed in order to prevent the double eyelid line from loosening.

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

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

Fat removal is mainly performed from the outer side.

7. The fat is grasped with a hemostatic forceps, and the base of the protruded fat is cut with a scalpel.

Excessive removal of fat can cause eyelid hollowing, so it is better to remove only as much as protrudes.

8. After fat removal, bleeding is stopped with an electrocautery device so that no bleeding occurs.

If hemostasis is not properly achieved, orbital hemorrhage may occur and bruising and swelling may become severe, so careful hemostasis is important.

9. Through the three incision sites, a very fine absorbable suture is used to connect the upper eyelid levator muscle and the skin to create the double eyelid line.

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

Face washing and makeup are possible starting the next day.

Apply cold compresses for 3 days using the cool pack provided by the hospital.

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

Examples of the partial incision method

Ptosis eye-opening correction surgery method -

Full incision method

For correcting pseudoptosis with a thick line,

the full incision method can be used.

The full-incision revision process is very difficult and

requires extensive experience, advanced skill, and know-how.

It usually takes about 2–3 hours.

The surgical process proceeds in 10 steps,

and if any one step is omitted, the result may be less than expected.

Even if it takes some time,

it is necessary to carefully check all of these steps

and perform the surgery with full dedication to achieve a better result.

The goal of correcting pseudoptosis with a thick line is broadly divided into two parts.

1. First: reduce the large and unattractive double eyelid line to a natural, thin double eyelid line

2. Second: make the sleepy-looking eye open more widely and clearly

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

Full incision method surgical process

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

Before surgery, the design is made to create a new double eyelid line below the scar line and determine the amount of skin to be removed 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 the amount of remaining skin.

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

▶ Step 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 excision line becomes the new double eyelid line, and the upper line must be pulled down naturally after dissection so that it can be sutured.

▶ Step 3 - Dissect the orbicularis oculi muscle, orbital fat, and skin that are adherent to the upper eyelid levator muscle.

Because the skin above the incision line must be pulled downward, the hard scar tissue that is stuck together must be dissected.

Scar tissue dissection proceeds by dissecting between the orbital fat layer and the upper eyelid levator muscle, and sometimes dissection is also performed between the muscle and fat to advance and reposition the fat.

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

▶ Step 4 - If there is contracture of the orbicularis oculi muscle, incise or resect the muscle to release it.

Because the adhesion of scar tissue is sometimes very severe, in rare cases the orbicularis oculi muscle is vertically incised by about 1–2 mm to release the contracture.

▶ Step 5 - Reposition the orbital fat to the incision line to prevent readhesion.

Advancing the orbital fat is part of preventing tissue readhesion.

If the fat is not repositioned, the tissue will stick together again, resulting in ptosis and a sleepy-looking eye.

Sometimes a triple eyelid occurs, which is one of the causes of a damaged double eyelid line.

Another effect of repositioning the orbital fat is that it can correct eyelid hollowing to some extent. If eyelid hollowing would otherwise require fat grafting later, the surgery itself may improve it to a certain degree, making fat grafting unnecessary in some cases.

▶ Step 6 - Shorten the upper eyelid levator muscle to strengthen its function.

Upper eyelid levator shortening is one method of correcting ptosis.

It is simple, effective, and has the advantage of correcting the condition with almost no tissue damage.

The muscle is not cut away; instead, it is simply advanced and tied to the tarsal plate.

During revision surgery, the effect of upper eyelid levator shortening is that it makes the eyes open wider so they can be corrected more clearly, and by opening the eyes wider, it also makes the double eyelid line smaller.

▶ Step 7 - After incising the orbicularis oculi muscle at the inner corner of the eye, orbital fat is inserted between the muscles to prevent readhesion.

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

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 sleepy-looking and make it difficult to open them comfortably.

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.

▶ Step 8 - During suturing, layered sutures are used 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 a double eyelid line.

In order to obtain 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, and the advanced fat must also be sutured so that it does not get pulled upward.

Also, only when the orbicularis oculi muscle and skin above the incision line are passed through by sutures and securely layered together can the desired double eyelid line be obtained.

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

Hyaluronidase, an anti-swelling agent, is a medicine with the action of dispersing fluid, and it has the effect of quickly reducing swelling as soon as it is injected.

However, if too much is used, it can instead cause a large amount of bruising, so it is used only in a limited way to reduce swelling.

▶ Step 10 - The sutures are removed in two stages, on day 4 and day 7.

Sutures are usually removed around day 7.

The reason for delaying suture removal is that in revision cases, most patients do not have enough remaining skin, and because the surgical process involves advancing all the tissues, a lot of tension is placed on the suture line.

Therefore, if the sutures 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, making the double eyelid line larger as well.

Therefore, the sutures should remain in place until the tissues stabilize, so it is better to leave them in for a longer time.

To prevent the suture marks from making the scar look messy, most of the sutures are removed on day 4 and only 3–4 sutures are left, so very little trace of the stitches remains.

To quickly reduce early inflammation and swelling, steroid medication is administered for about 1–2 days.

After surgery, artificial tears are administered for about 1–3 months to prevent dry eyes.

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

Examples of the full incision method

Surgical results are not a matter of luck.

Consistent and safe results are proportional to the surgeon’s skill and ability.

The more times double eyelid revision surgery is repeated, the lower the limits or surgical feasibility become.

Double eyelid revision surgery must be decided carefully.

Even for a board-certified plastic surgeon, not everyone can perform double eyelid revision surgery, and the results vary greatly depending on the surgeon.

It is a mistake to think that double eyelid revision surgery is easy or to think it can be finished quickly and simply.

Our clinic has over 20 years of accumulated know-how and many years of extensive experience in double eyelid revision surgery.

http://www.doublefold.co.kr

Double eyelid revision surgery is by no means an easy operation.

Whether the method is buried suture or incision, there has already been deformation and damage to the eye tissue, so the surgery must be performed based on sufficient experience and prediction of the outcome.

Also, double eyelid revision surgery is not a surgery that just anyone can perform.

It is performed at many clinics, but the results are generally not very good.

Double eyelid revision surgery is an operation that can only be performed after much experience and know-how have been accumulated.

Because people choose revision surgery based on low cost or advertisements, the results can be hit-or-miss, and in severe cases some people undergo double eyelid revision surgery 7–8 times.

Duhan Plastic Surgery’s double eyelid revision clinic places surgical effectiveness and safety first above all else.

We also confidently state that in extremely difficult eye revision surgery, we perform surgery using techniques that minimize side effects and have achieved consistent, safe results.

Severe side effects such as thick lines, ptosis, ectropion, and asymmetry are side effects caused by inexperienced doctors.

For each patient, surgery must be performed appropriately while considering factors such as skin tension and musculoskeletal factors.

In any surgery, creating high safety and accurate results is something made possible by the surgeon’s ability.

There are also unavoidable cases in which revision surgery is not possible due to insufficient remaining skin and various other issues.

After consultation, the exact possibility of surgery is determined. Our clinic performs only surgeries whose safety and effectiveness have been verified, and for any surgery, only when the postoperative effect and satisfaction are expected to be at least 80 out of 100 depending on the patient do we proceed.

People who have failed eye surgery multiple times worry about the result, but the result depends on the surgeon’s ability.

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