[Duhan Plastic Surgery Eye Surgery] - [Revision Surgery for a Dropped Double Eyelid]

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If you had double eyelid revision surgery but did not get the result you wanted, there can be several causes.

The biggest cause of failure is when the patient thinks of double eyelid revision surgery as something simple.

After a failed double eyelid surgery, trying to fix the shape

with the thought that “it can just be corrected again” leads to failure of the revision surgery.

Only when you understand the cause of the failed surgery yourself can you prevent another failure.

Double eyelid revision surgery

This refers to surgery that corrects the double eyelid line and restores it to a natural yet defined shape when the line is too large, uneven, or has loosened.

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 sausage-like fullness below the incision line

☆ When the impression looks worse after double eyelid surgery

☆ When you want to restore beautiful, natural-looking eyes

The purpose of 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 more open, 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 purpose of double eyelid revision surgery is the same.

Its purpose is to correct the eye shape so that it looks larger, more open, and more natural.

Correction of a loosened double eyelid line

This refers to a line that has become blurred, thinned out, or disappeared.

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

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

Causes of a loosened double eyelid line

☆ When the skin is thick

☆ When there is a lot of orbital fat

☆ When the orbicularis oculi muscle is thick

☆ When scar tissue does not form properly

☆ When the eyes are rubbed frequently out of habit

☆ When the surgery is forced with the non-incisional method even though the case is not suitable

Surgical method for a loosened double eyelid line

When the line has loosened, the correction method must be considered differently depending on whether it loosened after the incisional method or after the non-incisional method.

If it loosened after the non-incisional method, partial incision correction is usually the first method to consider.

When partial incision is judged unlikely to correct it well, the line is recreated with the full incision method.

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

Surgical method for a loosened double eyelid line - full incision method

If it has loosened after the incisional method, it may also be corrected with the partial incision method in some cases.

If the goal is to correct both the scar line and the height of the line at the same time, correction is done with the full incision method.

How to perform revision surgery with full incision for a loosened double eyelid line

To correct ptosis with a thick line, the full incision method can be used.

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

It usually takes about 2 to 3 hours.

The surgery proceeds in 10 steps, and if even one step is omitted, the results may fall short of expectations.

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

Full incision surgical process

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 width of skin to be removed up to the scar line.

The width to be removed is from the new double eyelid line 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 becomes 3 mm.

The standard is determined based on the midpoint width.

The new double eyelid line is set by considering how much the line should be lowered and the amount of remaining skin.

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

2. Cut away the skin and scar tissue.

Scar tissue is excised along the design line.

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

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

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 hardened scar tissue that has become stuck together must be dissected.

Scar tissue dissection proceeds by separating the area between the orbital fat layer and the levator palpebrae superioris, and in some cases the tissue is also dissected between the muscle and fat to advance the fat.

Through this dissection process, the tissue can be advanced downward and repositioned, 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 remove the contracture.

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

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

Advancing the orbital fat is a process to prevent the tissue from readhering.

If the fat is not repositioned, the tissue will stick together again, which can lead to ptosis and result in eyes that look drowsy and half-open.

In some cases, a triple eyelid may occur, causing the double eyelid line to become distorted.

Another effect of repositioning the orbital fat is that if the eyelid is sunken, the sunken appearance can be corrected to some degree. So in some cases where fat grafting would otherwise be needed later, the surgery itself can improve the condition to some extent and make fat grafting unnecessary.

6. Shorten the levator palpebrae superioris to strengthen its function.

Levator palpebrae superioris shortening is one method for correcting ptosis.

It is simple and effective, and has the advantage of being able to correct the condition with almost no tissue damage.

The method does not cut out the levator palpebrae superioris; it simply advances and fixes it to the tarsal plate.

In revision surgery, the effect of levator shortening is to open the eyes wider so they look more refreshed, and by opening the eyes more, it also helps reduce 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 advancing the 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 most prone to scar tissue adhesion, and adhesion in this area can make the eyes look half-open and make it difficult to open them comfortably.

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.

8. During suturing, layered suturing ensures 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, to achieve the originally designed double eyelid line, 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 advanced fat must also be sutured so it does not get pulled upward.

In addition, the orbicularis oculi muscle and skin above the incision line must both be passed through by the sutures and firmly layered together in order to obtain the desired double eyelid line.

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

The anti-swelling agent hyaluronidase is a medication with the effect of dispersing fluid, and it rapidly reduces swelling as soon as it is administered.

However, if too much is used, it can instead cause a lot of bruising, so it is used selectively only for reducing swelling.

10. The removal of sutures is kept relatively late, from 7 to 14 days, depending on the patient’s condition.

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

The reason for removing sutures late is that in revision surgery, most cases do not have enough extra skin, and the entire surgical process involves advancing the tissues, placing a lot of tension on the suture line.

Therefore, if sutures are removed on day 3 or 4, the tense suture line may open, the scar line may widen, and large scars may form. Tissue may gradually be pulled upward, which can also enlarge the double eyelid line and have negative effects.

So until the tissue stabilizes, the sutures need to hold the tissue in place, which is why it is better to leave them in longer.

Many clinics remove sutures early because they worry about suture marks, but that applies only to the initial double eyelid surgery.

It does not apply to revision surgery.

To minimize suture marks, most of the sutures are removed on day 4, leaving about 3 to 4 sutures, which are then removed on day 7. This helps minimize suture marks, prevent the scar from widening, and reduce deformation of the double eyelid line.

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

After surgery, artificial tears are used for about one month to prevent dry eye.

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

How to perform revision surgery with the partial incision method for a loosened double eyelid line

If it has loosened after the non-incisional method, the principle is to correct it with the partial incision method because correcting it again with the non-incisional method carries a high chance that it will loosen once more.

Partial incision surgical process​

1. Design the desired double eyelid line.

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

Sometimes it is designed to match the height and shape the patient wants, or the surgeon determines the most suitable line.

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

2. Mark three points for the incision location with design ink.

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

3. Under sedation, while the patient is asleep for about 5 minutes, local anesthetic is injected into the three marked points.

The local anesthetic is administered in the minimum 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 large, more scarring will remain, so the operation is done with minimal incisions to leave almost no scar.

5. Through the incision, first pull the orbicularis oculi muscle and remove it with scissors.

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

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

6. If there is a lot of orbital fat, pull it out through the outer incision so it becomes exposed.

Fat is usually removed mainly from the outer side.

7. Hold the fat with a hemostat and cut off the base of the protruding fat with a scalpel.

Excessive fat removal can cause the eyelid to become sunken, so it is best to remove only as much as protrudes.

8. After fat excision, cauterize to prevent bleeding.

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

9. Through the three incision sites, connect the levator palpebrae superioris and the skin using very fine dissolvable sutures to create the double eyelid line.

10. After burying the sutures and applying eye ointment, the surgery is finished.

You can wash your face and wear makeup starting the next day.

Use the provided cool pack for cold compresses for 3 days.

If cold compresses are done for more than 3 days, swelling will not go down further, so it is best to limit them to exactly 3 days.

How to perform revision surgery with micro-fat grafting for a loosened double eyelid line

If the eyelid is sunken and the line has been 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 loosened line is caused solely by eyelid sunkenness.

The main purpose of the procedure is to correct the sunken eyelid, and correcting the double eyelid line is a secondary goal.

If the line does not naturally restore even after the eyelid is restored, revision surgery must be performed.

Micro-fat grafting process​

Only applies when the upper eyelid is sunken.

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

The anatomical structure of the eyelid must be understood precisely.

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

It is a very high-difficulty procedure that must be performed while also considering correction of the sunken eyelid and the awkward double eyelid line.

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

1. Sedation and local anesthesia are performed.

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

3. The harvested fat is centrifuged and purified.

4. The purified fat then undergoes a second process to remove oil.

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

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

7. Finishing is done by adjusting the contour of the eyelid and the height of the double eyelid line through molding and retunneling.

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

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

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

When performing double eyelid revision surgery, tissue must be dissected. Fat grafting cannot be done into dissected tissue, and if fat grafting and double eyelid revision surgery are performed at the same time, it is like sprinkling fat into the empty space after dissection. The fat will not properly take, and it will only damage the double eyelid line.

※ Questions and answers about restoring the double eyelid line with fat grafting

Question) I was told that eyelid fat grafting has many side effects and should not be done at other clinics. Is that true?

Answer) That does not mean all other clinics are like that.

The areas that require the highest level of experience and skill in fat grafting are the upper eyelid and the under-eye dark circle area.

These are areas that cannot be treated carelessly without accumulated experience and skill.

We always say in the consultation room that fat grafting is absolutely not a procedure just anyone can do.

As with all surgeries, the results vary depending on the surgeon’s experience and know-how.

There are many clinics that perform fat grafting, but the number of clinics that do it properly can be counted on one hand.

Fat grafting is easy to do, but difficult to produce proper results.

In principle, fat grafting can produce good results only when it is performed accurately.

Different clinics use different methods, and the results vary greatly depending on experience.

You may have a poor impression after experiencing or hearing about bad fat grafting, but proper fat grafting can produce satisfying results in a single session.

In particular, the upper eyelid (a hollowed or sunken eyelid) is an area that requires a great deal of experience, skill, precision, and delicacy, so it cannot be performed by just anyone.

Question) I had eyelid fat grafting done at another clinic, but it has mostly disappeared and there is almost nothing left. Is it possible to have it done again?

Answer) Even after a procedure at another clinic with a low survival rate and the result has nearly disappeared, repeat treatment is possible.

However, it must be done at least 3 months later.

The graft take period for fat grafting takes at least 3 months, so once 3 months have passed since the last procedure, it can be done again.

Even if repeat treatment is done at our clinic, the result is almost the same as when it is done for the first time.

Question) I had eyelid fat grafting done at another clinic, but it is bumpy and uncomfortable to open my eyes. Is that a side effect?

Answer) The goal of eyelid fat grafting is to restore sunken eyelids and functionally improve the ability to open the eyes, thereby reducing eye fatigue.

To achieve this goal, the procedure must be accurate and precise.

With fat grafting by someone with somewhat insufficient experience, the fat may be grafted into the orbicularis oculi muscle layer rather than the orbital fat layer, causing unevenness, or it may be grafted near the deep levator palpebrae superioris layer, making it even more uncomfortable to open the eyes than before the procedure.

If such side effects occur, the fat must be removed again, which is a very difficult problem.

To prevent side effects, it is best not to receive the procedure from someone with insufficient experience or from a non-specialist in plastic surgery.

Question) What about injecting filler instead of fat grafting into the eyelid?

Answer) The eyelid is a structure that moves constantly, so procedures that interfere with eyelid movement should not be done.

Fat grafting can act as a cushion and lubricant that helps the eyelid move more smoothly, but if a foreign material such as filler is injected, it can seriously interfere with the function of opening the eyes regardless of the eyelid’s shape. In severe cases, the eyelid swelling may not go down or the eye shape may become distorted.

It can even cause inflammation, so filler should absolutely not be injected into the eyelid.

Question) Since eyelid fat grafting is close to the eyeball, isn’t it dangerous?

Answer) Not at all.

The risk is high only when the procedure is performed by a doctor with somewhat insufficient experience or by a non-specialist in plastic surgery. If it is done accurately by an experienced specialist, there is no need to worry.

Eyelid fat grafting must be performed by someone who has the precise anatomical knowledge and know-how gained through extensive experience with double eyelid surgery, and if the procedure is performed according to the principles, it is one of the safe procedures.

Question) I had eyelid fat grafting done at another clinic and developed a bulging side effect. Is correction possible?

Answer) Sometimes, after fat overinjection at another clinic, the eyelid becomes heavy and bulges, and patients come to our clinic for correction.

Depending on the condition, the fat must be removed by suction. If the fat mass can be grasped by hand, it can be corrected by inserting a microcannula and suctioning it out.

However, 100% removal is impossible, and usually about 50% to 80% can be removed by suction and corrected.

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