[Duhan Plastic Surgery Blepharoptosis Correction] - [Reoperation for Blepharoptosis Correction]

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Problems when ptosis correction is not possible

In cases where the levator palpebrae superioris has no function, further ptosis correction may not be possible, or the problem of lagophthalmos may occur.

There are cases where the eyes still look sleepy even after several ptosis corrections have already been performed.

Even if ptosis correction is performed again, correction may be impossible when the levator palpebrae superioris has almost no function.

In such cases, ptosis correction is not performed and only the line is adjusted.

If an excessive ptosis correction is attempted, the problem becomes worse only with lagophthalmos, and the ptosis is hardly corrected at all.

Problems when blepharoptosis correction is overdone

It is much more difficult to bring an overcorrected eye back down to a normal size than to correct ptosis.

When ptosis correction or blepharoptosis correction is overdone and the white of the eye becomes exposed,

to reduce the eye size again, levator palpebrae superioris relaxation surgery must be performed.

However, if the levator palpebrae superioris is relaxed carelessly, ptosis may be induced several months later and the eye may not open as well.

Surgery to bring an overcorrection back down is much more complicated than ptosis correction, and the later outcome is harder to predict.

The degree of levator palpebrae superioris relaxation must be carefully controlled through extensive experience and know-how.

Problems when a releasing surgery has been performed before visiting the clinic

When a patient visits after having had a releasing surgery at another hospital, recreating the line is often difficult or impossible.

One of the hardest problems to overcome in double eyelid reoperation is when the patient visits after having had a releasing surgery at another hospital.

Nine out of ten such cases cannot undergo reoperation.

The reason is that, to release the line, the incision is made very low and thick tissue is laid down so that no line forms at the incision site.

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

For the future as well, releasing surgery is a procedure that should be avoided whenever possible.

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Candidates for double eyelid reoperation: when the eyes look sleepy (ptosis)

After double eyelid surgery, if the eyes do not open naturally

and look sleepy, this should be corrected so that the eyes open naturally and clearly again.

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

○ Causes

• Congenital ptosis

• Pseudoptosis

• Scar adhesion, etc.

○ Correction

In cases of ptosis, the most common surgical method is correction by levator palpebrae superioris shortening or resection.

Candidates for double eyelid reoperation: when the double eyelid line is asymmetric

A slight amount of asymmetry is normal for anyone, but noticeable asymmetry should be corrected.

○ Causes

• Incorrect design

• Line loosening

• Scar adhesion

• Ptosis on one side, etc.

○ Correction

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

However, if only one side undergoes double eyelid reoperation, symmetry will not be perfect immediately after surgery. Therefore, even with a properly performed operation, you must be patient for at least 1–2 months and observe the correction of the asymmetry, so such one-sided surgery should be decided carefully.

Candidates for double eyelid reoperation: when the double eyelid line has loosened

After surgery, it may look good at first, but over time the width of the line may narrow or become loose again.

In such cases, the line often gradually loosens and descends after buried-suture surgery.

○ Causes

• When buried-suture surgery was performed forcefully despite thick skin

• Incorrect double eyelid surgical technique

• When there is a lot of fat

• When the skin or orbicularis oculi muscle is naturally thick for the individual

• Factors that make line adhesion difficult constitutionally, etc.

○ Correction

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

Ptosis

When the eyes do not open clearly

and always look sleepy, this is called ptosis.

It is broadly divided into congenital ptosis and acquired ptosis.

It is divided into true ptosis, where the function of the levator palpebrae superioris, the muscle that lifts the eyelid, has decreased,

and pseudoptosis, which only appears as if it is simple ptosis.

The purpose of correcting ptosis (sleepy eyes) is

to restore a large and clear eye shape.

Depending on the severity of the condition,

the appropriate method must be selected,

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

The purpose of double eyelid surgery is

to create a large and clear eye shape while forming a line on the eyelid

to make the eyes look more refined.

However, if the eyes actually look sleepier after surgery,

it is worse than not having surgery at all.

Examples of ptosis

Types of ptosis

① Congenital true ptosis

This occurs because the function of the levator palpebrae superioris, the muscle that lifts the eyelid, is reduced. Most congenital ptosis falls into this category, and ptosis can also occur due to trauma.

② Postoperative pseudoptosis

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

○ When the double eyelid line is made too high

○ When the eyes are habitually rubbed, scar tissue forms inside the eyelid and interferes with the function of the levator palpebrae superioris

③ Pseudoptosis due to eyelid sagging

When the eyelid sags, the pupil is covered, making the eyes look as if they do not open fully, like ptosis.

In such cases, you should temporarily lift the eyelid skin or create a temporary double eyelid to check the actual vertical height of the pupil.

A simple condition of eyelid covering should not be diagnosed as ptosis.

Differences between ptosis and a normal eye

① When the eyes are naturally open and looking straight ahead

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

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

② When the eyes are naturally open and looking straight ahead, the vertical opening of the eye should be at least 8 mm.

If the vertical opening is narrower than that, it is ptosis.

③ When looking upward after looking downward as much as possible, the range of eyelid movement should be 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 height of the pupil while looking straight ahead.

For a normal person, the vertical height is between 8 and 9 mm,

and generally a case of 8 mm or less is considered ptosis.

However, because each person’s eye shape and size are different,

ptosis is not diagnosed based only on an exact number.

The diagnosis is made by judging whether the face has a strong sleepy-looking impression,

and comparing this with the measurements.

The function of the levator palpebrae superioris is also measured and evaluated.

① Vertical fissure height of the eye (measurement of vertical eye opening)

② Check whether the impression looks sleepy

③ Measure the function of the levator palpebrae superioris (normal: 14–16 mm)

Ptosis surgery method - levator palpebrae superioris shortening

This method shortens the eyelid-lifting muscle (levator palpebrae superioris) by folding and suturing it with an overlap of about 4–8 mm.

It is mainly applied in cases of mild ptosis.

Because the surgery must be performed through an incision,

a double eyelid line will form during the process,

so for those without a double eyelid, a hidden double eyelid may have to be created.

○ Surgical process of levator palpebrae superioris 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 levator palpebrae superioris.

4. After exposing the levator palpebrae superioris and marking the amount to be shortened, the marked part and the upper border of the tarsal plate are tied together with thread.

5. To create the double eyelid line, the thread is buried at three points.

6. The outer skin is sutured.

Ptosis surgery method - levator palpebrae superioris resection

This method shortens the eyelid-lifting muscle (levator palpebrae superioris) by resecting about 5–10 mm, and suturing the cut end of the levator palpebrae superioris to the tarsal plate.

It is mainly applied in cases of moderate ptosis.

Ptosis surgery method - frontalis suspension

This method is performed in cases of severe ptosis with a levator palpebrae superioris function of 5 mm or less,

and is used when it is difficult to expect functional recovery through levator palpebrae superioris shortening or resection.

By advancing the frontalis muscle in the forehead and tying it to the tarsal plate of the eyelid,

the frontalis muscle takes over the function of the levator palpebrae superioris.

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

Ptosis surgery method - Müller's muscle shortening

Instead of levator palpebrae superioris shortening, shortening using the Müller muscle beneath the levator palpebrae superioris is sometimes performed.

Müller muscle shortening has the advantage of minimizing lagophthalmos, but it is difficult to predict the postoperative prognosis and recurrence is common.

To access the Müller muscle, surgery must be performed while damaging the levator palpebrae superioris, so it is not a method with any special advantage.

Anatomically, there are many cases in which the Müller muscle itself is almost absent or very thin, and in such cases Müller muscle shortening cannot be applied.

Postoperative care guidelines after ptosis correction surgery

① Use the cold pack provided by the hospital for cold compresses.

Do this for 3 days, 2 hours a day.

The cold compresses may be done continuously for 2 hours or divided 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 are usually twice: the day after surgery and on the day the stitches are removed.

The stitches are removed on day 3 or 4.

④ Makeup and face washing are possible after the stitches are removed.

Until then, wash the face with a damp towel.

⑤ Since no tape is applied to the surgical site, daily activities are possible.

⑥ Postoperative swelling varies by person, and in most cases the swelling subsides to a large extent in about 7 days, but it takes about 1 to 3 months for the result to fully settle.

⑦ Lagophthalmos, in which the eyes do not close completely, varies depending on the degree of ptosis and the amount of levator palpebrae superioris shortening, but in most cases it takes 15 days, and in some cases as long as more than 6 months.

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

Examples of ptosis correction

A line becoming 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 reoperation, and uneven eyes can also be improved.

At our clinic, based on more than 20 years of rich clinical experience and know-how, we perform surgery only after various examinations and tests during consultation to predict the postoperative result, and only when there is a good possibility of improvement after surgery.

The most important factors in reoperation are the amount of available skin and the location and intensity of the scar line.

The goals of reoperation are broadly twofold.

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

After reoperation, 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 reoperation, the sleepy-looking eyes are also corrected by making the eyes open wider.

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Partial incision method

A surgical method used to restore a blurred line to its original clear line again.

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

Surgical process of the partial incision method

1. Design the desired double eyelid line.

Usually, the design is made along the existing scar line.

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

Also, the direction of the design line changes depending on whether an out-fold or in-fold is to be created.

2. Mark the incision points at three locations with design ink.

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

3. Under sedation, while asleep for about 5 minutes, 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 a very small incision of about 2 mm at the three marked areas.

If the incision is made too large, a lot of scarring remains, so the surgery is performed with minimal incisions to leave almost no scar.

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

The orbicularis oculi muscle is the muscle layer covering the eyelid and is tissue that interferes with double eyelid formation, so it must be removed for the double eyelid line not to loosen.

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

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

Fat removal is mainly performed from the outer side.

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

Excessive fat removal can cause a hollowed eyelid, so it is better to remove only the amount that protrudes.

8. After fat excision, use electrocautery to stop bleeding so that no bleeding occurs.

If hemostasis is not properly achieved, orbital bleeding may occur and bruising and swelling will worsen, so proper hemostasis is important.

9. Through the three incision sites, connect the levator palpebrae superioris and the skin with very thin absorbable thread to create the double eyelid line.

10. After burying the thread, apply eye ointment and the surgery is finished.

Face washing and makeup are possible from the next day.

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

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

Examples of the partial incision method

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Full incision method

To correct pseudoptosis with a thick line,

full incision surgery is possible.

Full-incision reoperation is very difficult,

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

It usually takes about 2–3 hours.

The surgery proceeds in 10 steps,

and if even one step is omitted, the result may fall short of expectations.

Even if it takes quite a long time, checking every step carefully

and performing the operation with sincerity leads to better results.

Two goals of the full incision method

The goals for correcting pseudoptosis with a thick line are broadly twofold.

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

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

With the above two goals, double eyelid reoperation proceeds as follows.

Surgical process of the full incision method

◆ 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 excision 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 becomes 3 mm.

The new double eyelid line is determined by considering how much the line should be reduced and the amount of available skin.

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

◆ Step 2 - Cut out 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 excised line becomes the new double eyelid line, and the upper line must be gently pulled down after dissection so that it can be sutured.

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

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

Scar tissue dissection proceeds by dissecting between the orbital fat layer and the levator palpebrae superioris, and in some cases between the muscle and fat for forward repositioning of the fat.

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

◆ Step 4 - If there is contracture of the orbicularis oculi muscle, cut or excise the muscle to remove the contracture.

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

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

The forward repositioning of orbital fat is a process to prevent re-adhesion of the tissue.

If the fat is not repositioned, the tissue will adhere again, and as a result ptosis may occur and the eyes may easily look sleepy.

Sometimes a triple eyelid also forms, which causes the double eyelid line to become distorted.

Another effect of repositioning orbital fat is that if the eyelid is hollowed, the hollowing is corrected to some extent, so in some cases where fat grafting would otherwise be needed later, the surgery itself improves 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, effective, and has the advantage of being correctable with almost no tissue damage.

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

In reoperation, the effect of levator palpebrae superioris shortening is twofold: it makes the eyes open wider so they can be corrected more clearly, and because the eyes open wider, the double eyelid line is also reduced.

◆ Step 7 - After cutting the orbicularis oculi muscle at the inner canthus, orbital fat is inserted between the muscles to prevent re-adhesion.

In addition to the forward repositioning of fat, fat is inserted into the inner canthus of the eye to prevent scar tissue adhesion.

The inner side of the eye is the area where scar tissue adheres most easily, and adhesion in this area makes the eyes look sleepy and causes difficulty in opening them.

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

◆ Step 8 - During suturing, layered suturing is used so that the repositioned structures do not move.

The suturing method in reoperation is not simple.

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

To obtain the double eyelid line as initially designed, the skin below the incision line must not be pulled upward.

To do that, the skin below the incision line must be firmly fixed to the tarsal plate, and the repositioned fat must also be similarly secured with thread so it does not get pulled upward.

Also, only when the thread passes through all of the orbicularis oculi muscle and skin above the incision line in a firm layered suture can the desired double eyelid line be achieved.

◆ Step 9 - In order to prevent hematoma and inflammation, a small amount of swelling inhibitor (hyaluronidase) is administered to the surgical site.

Hyaluronidase, a swelling inhibitor, is a drug with the effect of dispersing moisture, and it quickly reduces swelling as soon as it is administered.

However, using too much can instead cause more 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.

Stitches are usually removed around day 7.

The reason stitches are removed later is that in reoperation there is usually not enough skin available, and because the entire surgical process involves forward repositioning of all tissues, the suture line is under a lot of tension.

Therefore, if the stitches are removed on day 3 or 4, the tense suture line may open or the scar line may widen, causing a larger scar and negatively affecting the result by gradually pulling the tissue upward and making the double eyelid line larger as well.

Therefore, the stitches should remain in place until the tissue stabilizes, so it is better to leave them in for a longer time.

To prevent the scar from becoming messy due to stitch marks, most of the stitches are removed first on day 4, leaving only 3–4 stitches behind, so stitch marks are hardly left at all.

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

After surgery, artificial tears are used for 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

In cases of reoperation, sufficient clinical experience and the surgeon’s skill must be supported.

Although reoperations are performed at many clinics, the results are often not very good.

Reoperation is a procedure that can be performed only when extensive experience and know-how have been accumulated, so it is not a surgery just anyone can do.

Please note that in our country, there are not many surgeons who can consistently deliver results that satisfy patients after reoperation.

One must accurately understand what went wrong with the initial surgery and how it should be improved in order to obtain good results.

If there is enough available skin, reoperation is fully possible.

The goals of reoperation are broadly twofold.

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

Pre- and postoperative care guidelines

○ Preoperative care guidelines

1. Before surgery, you should fully understand the causes of the problem with the double eyelid surgery and the surgical process through sufficient consultation.

2. Do not consume alcohol the day before surgery.

Alcohol can reduce the effect of anesthetic drugs, which may cause anesthesia to work poorly during surgery.

3. Try to avoid scheduling surgery during menstruation if possible.

If there is a lot of bleeding during surgery, it can interfere with the operation and cause significant bruising.

○ Postoperative care guidelines

​The usual follow-up schedule after surgery is the day after surgery and again one week later, for two visits.

• Day 1 after surgery: the surgical site is disinfected at the hospital, an injection to reduce swelling is given, and the progress is checked.

• Day 4 after surgery: the progress is checked and the continuous sutures are removed.

• Day 7 after surgery: the progress is checked to see whether the surgery went well or whether there are any problems, and the remaining sutures are removed.

• One month after surgery: the double eyelid line is checked to see whether it is settling in well.

○ What to do at home yourself

• Cold compresses

Use the cold pack provided by the hospital.

Do this for 3 days, 2 hours a day.

The cold compress time may be continuous for 2 hours, or it may be divided into 20–30 minute sessions.

It is usually convenient to do it before sleeping.

• Disinfection and eye drops

Disinfect the surgical site with the prescribed medication.

Disinfection is done only until you remove the stitches yourself.

To prevent dry eyes, apply the artificial tears and eye drops prescribed by the hospital.

• Scar management

Apply the prescribed eye ointment to the surgical site for about one month.

The anti-scar eye ointment helps reduce scarring and calm redness, so apply it twice a day for 3–4 weeks.

• Makeup and face washing

These are possible one week after the stitches are removed.

Until then, use a damp towel instead of washing the face.

○ Postoperative swelling

It varies by person, and in most cases swelling subsides to some extent in about 7–14 days, but the period for the result to fully settle is between 1 and 3 months.

When levator palpebrae superioris shortening is performed during reoperation, temporary lagophthalmos may occur, meaning the eyes do not close fully.

Depending on the degree of ptosis and the amount of levator palpebrae superioris shortening, it usually takes 15 days, and very rarely more than 6 months.

○ Lagophthalmos management

When levator palpebrae superioris shortening is performed to make the eyes open wider, temporary lagophthalmos may appear. Depending on the degree of ptosis and the extent of shortening of the levator palpebrae superioris, it may take from 15 days to as long as more than 6 months.

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

To prevent dry eyes during this period, use the artificial tears (eye drops) prescribed by the hospital.

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