[Duhan Plastic Surgery Double Eyelid Revision Surgery] - [Ptosis Correction Surgery]

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Problems when ptosis correction is not possible

In the case of a nonfunctional levator palpebrae superioris,

further ptosis correction may not be possible, or the problem of lagophthalmos may occur.

Even after ptosis correction has been performed several times,

there are cases where the eyes still look sleepy.

If the levator palpebrae superioris has almost no function even after another ptosis correction,

correction may not be possible.

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

If an unreasonable attempt at ptosis correction is made, only lagophthalmos becomes more severe,

and ptosis is hardly corrected at all.

Problems when eyelid correction is excessive

Reducing an overcorrected eyelid line to a normal size is much more difficult than ptosis correction.

When ptosis correction or eyelid correction has been done too much and the sclera is exposed,

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

However, if the levator palpebrae superioris is relaxed carelessly,

ptosis may be induced several months later and the eyes may not open properly.

Surgery to lower an overcorrected result again is much more difficult than ptosis correction,

and it is hard to predict the outcome later.

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

Problems when a release surgery patient comes in

When a patient comes in after having had release surgery at another clinic,

a new line is often difficult or impossible to create.

One of the most difficult problems to overcome in double eyelid revision surgery

is when the patient has had release surgery at another clinic.

Nine out of ten cases cannot be revised.

The reason is that, in order to release the line, the incision is made very low

and thick tissue is laid down at the incision site so that no line forms.

Because this tissue later turns into thick scar tissue,

it is almost impossible to remove the thick scar tissue and create a natural line again.

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

Candidates for double eyelid revision surgery

→ Eyes that look sleepy (ptosis)

If the eyes do not open naturally after double eyelid surgery and look sleepy, they should be corrected so that the eyes open naturally and clearly again.

A sleepy appearance easily leaves a bad impression on anyone.

Causes include congenital ptosis, pseudoptosis, and scar adhesion.

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

Candidates for double eyelid revision surgery

→ Cases where the double eyelid line is asymmetrical

A slight asymmetry is something everyone has to some degree, but a noticeably large asymmetry should be corrected.

Causes include poor design, line loosening, scar adhesion, and ptosis on one side.

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

However, if revision surgery is performed on only one side, symmetry will not be complete immediately after surgery. Even with a properly performed operation, at least 1 to 2 months of patience are needed to observe the correction of the unevenness, so such one-sided surgery should be decided carefully.

Candidates for double eyelid revision surgery

→ Cases where the double eyelid line has loosened

After surgery, the appearance may be good at first, but as time passes the width of the line may narrow or loosen again. In such cases, the line often gradually loosens and descends after buried suture surgery.

Causes include performing buried suture surgery despite thick skin, incorrect double eyelid surgical techniques, excessive fat, personally thick skin or orbicularis oculi muscle, and constitutional factors that make line adhesion less likely.

Considering the patient’s eye condition, correction is performed through incision or partial incision so that the line does not loosen again and remains clear.

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Ptosis

Eyes that do not open clearly and always look sleepy are called ptosis.

It is broadly divided into congenital ptosis and acquired ptosis.

It is divided into true ptosis, in which the levator palpebrae superioris—the muscle that lifts the eyelid—has reduced function,

and pseudoptosis, which only appears to be simple ptosis (false ptosis).

The purpose of ptosis correction (sleepy-looking eyes correction) is to restore large, clear eyes.

Appropriate method selection according to the severity of symptoms, as well as the surgeon’s skilled know-how and technique, are required.

The purpose of double eyelid surgery is to create large, clear eyes while forming a line on the eyelid,

with the goal of making the eyes look more refined.

However, if the eyes look even 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, preventing the muscle from exerting force properly.

□ When the double eyelid line has been made too high

□ When the eyes are habitually rubbed, scar tissue forms on the inner side of the eyelid and interferes with levator palpebrae superioris function

3. Pseudoptosis due to eyelid drooping

When the eyelid droops, the pupil is covered, so it may look as if the eyes are not opening fully, 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.

A condition where the eyelid is simply covering the eye should not be diagnosed as ptosis.

Difference between ptosis and a normal eye

□ 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 to 2 mm.

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

□ When the eyes are naturally open and looking straight ahead

The vertical width of the eye should be at least 8 mm to be considered normal.

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

□ When looking upward while in the maximum downward gaze position

The range of eyelid movement should be about 14 to 16 mm.

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

How ptosis is examined

The method for examining ptosis is to check the vertical width of the pupil while looking straight ahead.

For a normal person, the vertical width is between 8 and 9 mm, and cases of 8 mm or less are generally considered ptosis.

However, because each person’s eye shape and size are different, ptosis is not diagnosed based only on exact numerical values.

The diagnosis is made by judging objectively whether the expression looks sleepy, and this is compared with the measurements.

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

① Vertical palpebral fissure height measurement

② Check whether the expression looks sleepy

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

Ptosis surgery methods

1. Levator palpebrae superioris shortening

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

Because incision is always required, a double eyelid line will be created during the process, so for those without double eyelids, at least a hidden double eyelid must inevitably be created.

□ Levator palpebrae superioris shortening procedure

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 portion and the upper edge of the tarsal plate are tied with thread.

⑤ Three buried sutures are placed to create the double eyelid line.

⑥ The outer skin is sutured.

2. Levator palpebrae superioris resection

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

It is mainly applied in cases of moderate ptosis.

3. Frontalis suspension

This method is performed in cases of severe ptosis with levator palpebrae superioris function of 5 mm or less, when recovery of function cannot be expected with levator palpebrae superioris shortening or resection.

The frontalis muscle of the forehead is advanced and tied to the tarsal plate of the eyelid, allowing the frontalis muscle to substitute for the function of the levator palpebrae superioris.

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

4. Müller muscle shortening

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

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

To access the Müller muscle, surgery must be performed while damaging the levator palpebrae superioris, so it is a procedure with no special advantages.

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

Guidelines for care after ptosis correction surgery

① Use the cold pack provided by the hospital for cold compresses. This should be done for 3 days, 2 hours a day. Cold compresses may be done continuously for 2 hours or in 20 to 30 minute intervals. It is usually convenient to do it before going to bed.

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

③ Follow-up visits after surgery are usually two: the day after surgery and the day the stitches are removed. Stitches are removed on day 3 or 4.

④ Makeup and face washing are allowed after the stitches are removed. Until then, wash your face with a wet towel.

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

⑥ Swelling after surgery varies from person to person, but it usually subsides to a large extent in about 7 days. However, it takes about 1 to 3 months to fully settle.

⑦ Lagophthalmos, in which the eyes do not close completely, varies depending on the degree of ptosis and how much the levator palpebrae superioris was shortened, but it usually takes 15 days and in some cases more than 6 months. On average, it progresses for about 2 to 3 months and then the eyes close naturally.

Examples of ptosis correction

★ The problem of an asymmetrical line is usually caused by differences in design, excessive skin removal on one side, partial loosening on one side, adhesion of scar tissue on one side, or the occurrence of ptosis on one side.

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

Based on more than 20 years of extensive clinical experience and know-how, our clinic performs surgery only after various examinations and tests during consultation to predict the postoperative result, and only when there is a sufficient chance of improvement after surgery.

The biggest key in revision surgery is the amount of excess skin and the location and degree of the scar line.

There are two major goals of revision surgery.

Restoration of large, clear eyes and restoration of a natural double eyelid line.

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

During surgery, the existing scar line must be removed and a new line created below it.

In revision surgery, the eye is opened wider to correct sleepy-looking eyes as well. ★

Complete incision method

To correct thick pseudoptosis lines, the complete incision method can be used.

The complete incision revision procedure is very difficult,

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

It usually takes about 2 to 3 hours.

The surgical process proceeds in 10 steps,

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

Even if it takes a little longer,

better results can be obtained only by carefully checking all of these steps and performing the surgery with full dedication.

Two goals of surgery

​The goals for correcting thick pseudoptosis lines are broadly twofold.

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

Second: to make sleepy-looking eyes open wider and more clearly

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

Surgical process

Step 1 - The incision line is designed, including the existing scar tissue.

Before surgery, the design is made so that a new double eyelid line is created below the scar line and the width of skin excision up to the scar line is determined.

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 how much excess skin is available.

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

Step 2 - The skin and scar tissue are removed.

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 line that has been removed becomes the new double eyelid line, and the upper line must be naturally pulled downward after tissue dissection so that it can be sutured.

Step 3 - The orbicularis oculi muscle, orbital fat, and skin adherent to the levator palpebrae superioris are dissected.

Because the skin above the incision line must be pulled downward, the hard 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 area between the muscle and fat is also dissected to advance the fat.

Through this dissection process, the tissue can be advanced 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, the muscle is incised or resected to remove the contracture.

In rare cases where adhesion of scar tissue is severe, the orbicularis oculi muscle may be vertically incised by about 1 to 2 mm to release the contracture.

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

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

If the fat is not repositioned, the tissue will stick together again, which can cause ptosis and easily result in sleepy-looking eyes.

Sometimes a triple eyelid may occur, which becomes a cause of the double eyelid line being distorted.

Another effect of repositioning the orbital fat is that if the eyelid is sunken, the hollowing can be somewhat corrected. Therefore, in cases where fat grafting would otherwise be needed later, the surgery itself may provide some improvement and make fat grafting unnecessary.

Step 6 - The levator palpebrae superioris is shortened 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.

Rather than cutting the levator palpebrae superioris, it is simply advanced and tied to the tarsal plate.

In revision surgery, the effect of levator palpebrae superioris shortening is to open the eyes wider so they can be corrected more clearly, and by opening the eyes wider, the double eyelid line also becomes smaller.

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

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

The inner side of the eye is the area where scar tissue most easily adheres. Adhesion in this area makes the eyes look sleepy, prevents them from opening well, and causes discomfort when opening the eyes.

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

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

The suturing method in revision surgery is not simple.

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

To achieve the double eyelid line that was designed initially, 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 likewise be secured with sutures so that it does not get pulled upward.

In addition, only when the orbicularis oculi muscle and skin above the incision line all pass through the sutures and are firmly layered and sutured can the desired double eyelid line be achieved.

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

The anti-swelling agent hyaluronidase is a medication that has the effect of dispersing fluid, and it quickly reduces swelling when administered.

However, excessive use can instead cause significant bruising, so it is used only in a limited way to reduce swelling.

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

Stitches are usually removed around 7 days after surgery.

The reason stitches are removed late is that in revision surgery there is usually not enough excess skin, and the surgical process involves advancing all tissues, which places a lot of tension on the suture line.

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. The tissue may gradually be pulled upward, which also adversely enlarges the double eyelid line.

Thus, until the tissue stabilizes, the sutures should hold the tissue in place, so it is better to leave them in longer.

To prevent the scar from becoming messy due to stitch marks, most of the stitches are removed first on day 4 and only 3 to 4 stitches are left, so stitch marks are barely left behind.

To quickly calm the initial inflammation and swelling, steroids are administered for about 1 to 2 days.

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

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

Examples of surgical application

Surgical procedure

1. Make a consultation appointment by phone or online in advance before visiting.

If you make a reservation in advance, you can receive a consultation more conveniently.

2. After making a reservation and visiting, if you decide to proceed with surgery after the consultation, schedule a surgery date.

You can make the surgery reservation later by phone or online.

3. Precautions before surgery

Once the surgery date is confirmed, those taking steroids or anticoagulants (aspirin), etc., should temporarily stop taking the medication starting 7 days before surgery.

Try not to drink alcohol the day before surgery.

Alcohol reduces the effect of local anesthesia, so anesthesia may not work well during surgery or may wear off quickly.

For women, try to avoid the menstrual period.

This may not matter for a simple procedure, but for a larger surgery, blood loss during surgery may increase, so caution is needed.

4. On the day of surgery

○ Arrive 30 minutes before the scheduled surgery time and receive an explanation of the precautions to follow during surgery.

○ Change into the surgical gown and receive an IV drip for preoperative care.

In the case of local anesthesia, an intravenous injection is given for painless anesthesia.

About 5 minutes after the intravenous injection, you enter a sedated state, and for patients undergoing double eyelid surgery or nose surgery, local anesthesia is administered to the surgical area while in that sedated state.

When you wake up from the sedated state after 5 minutes, the anesthesia is fully complete.

The patient does not feel any pain during anesthesia.

○ When the surgery is finished, you receive an intramuscular injection of antibiotics and anti-inflammatory medication and rest in the recovery room for about 30 minutes.

○ In the case of double eyelid or nose surgery, you will receive cold compresses using a cool pack.

○ For those who underwent general anesthesia, rest in the recovery room for 1 to 2 hours, and go home once dizziness from the anesthetic has completely disappeared.

○ When going home, receive postoperative instructions from the attending surgeon, schedule a follow-up visit, receive the prescription, buy the medication at the pharmacy, and take it.

5. Return on the scheduled date to check postoperative progress and receive an examination.

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★ In cases of revision surgery, sufficient clinical experience and the surgeon’s skill must be in place.

Revision surgery is performed at many clinics, but in most cases the results are not very good.

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

Please understand that there are not many people in our country who can always produce results that satisfy patients after revision surgery.

Only by accurately understanding what went wrong in the initial surgery and how it needs to be improved can good results be obtained.

If there is enough excess skin, revision surgery is fully possible.

The purpose of revision surgery is broadly twofold.

Restoration of large, clear eyes and restoration of a natural double eyelid line. ★

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