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What is double eyelid revision surgery?

It refers to surgery that corrects the double eyelid line and restores it to its original natural and refreshed shape when the crease is too large, uneven, or has unfolded.

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When the double eyelid line is too thick

♥ A double eyelid line that is only slightly visible is beautiful.

If the double eyelid line is too thick, the eyes look sleepy and the impression appears rough.

Possible causes include a line designed too high, scar adhesion, ptosis, or insufficient excess skin.

The correction method is to smooth out or remove the existing high double eyelid line, then design a new line at an appropriate height and recreate the crease.

The height of the new double eyelid line varies by individual, and it is important to design it by finding the most suitable height based on the available skin and eye size.

When the eyes look sleepy (ptosis)

♥ If the eyes do not open clearly after double eyelid surgery and look sleepy, they need to be corrected so they can open clearly again.

Sleepy-looking eyes create an unfavorable impression.

Possible causes include congenital ptosis, pseudoptosis, and scar adhesion.

The correction method is to perform levator palpebrae superioris shortening or resection.

When the double eyelid line is asymmetrical

♥ Everyone has a slight degree of asymmetry.

Noticeable asymmetry should be corrected.

Possible causes include poor design, unfolding of the double eyelid line, scar adhesion, or ptosis on one side.

The correction method is to repeat double eyelid surgery to match the desired side if the crease lines are uneven on both sides.

However, if only one side is corrected, complete symmetry may not be achieved, and the double eyelid shapes may not immediately match. Even with a properly performed surgery, there are cases where the two sides remain uneven for the first 1–2 months, so if only one side is corrected, the decision should be made carefully.

When the incision scar is too severe

♥ If the scar after incisional double eyelid surgery is highly visible when the eyes are closed, it should also be corrected with incisional surgery so that almost no scar remains.

Possible causes include poor incision closure, stitches removed too early leaving stitch marks, and constitutional factors.

The correction method is to excise the scar, then carefully suture the muscle and skin in firm layered stitches so they do not shift, and remove the stitches at the appropriate time.

When the double eyelid line has unfolded

♥ After surgery, the double eyelid line may initially look good, but as time passes the line may become narrower or unfold, in which case it needs to be corrected again.

This often happens after buried-method surgery, where the line gradually loosens and descends.

Possible causes include performing buried-method surgery on thick skin, incorrect surgical technique, excess fat, thick skin or orbicularis oculi muscle, or constitutional factors in which adhesion of the double eyelid line does not form well.

When the double eyelid line is distorted by scar adhesion

♥ After surgery, a second line may form above the double eyelid line due to scar adhesion above the incision line.

If another double eyelid line appears above the incision line, it is the result of an incorrect surgery and is a candidate for correction.

Possible causes include failure to reposition the orbital fat, atrophy of the orbital fat, or excessive fat removal.

The correction method in such cases is to release the adhesion and recreate a single double eyelid line.

The incision line should become the double eyelid line.

When a triple eyelid line occurs

♥ This is a case where another line forms in addition to the original incision line.

It may appear below the incision line or above it.

Possible causes include scar adhesion, sagging skin, sunken eyelids, or line unfolding.

The correction method varies depending on the cause, but the unwanted line must be excised and corrected.

When the inner line is thicker than the outer line

♥ Ideally, the double eyelid line should gradually widen from the inner side to the outer side.

However, if the inner line is wider than the outer line, it is an abnormal shape and should be corrected.

Causes include unnecessary epicanthoplasty, poor design, or excessive skin removal.

The correction method is to redesign the line, smooth out the existing scar line, and create the inner line so that it is close to an infold crease, allowing the double eyelid line to widen naturally from the inner side to the outer side.

Double eyelid revision surgery - full incisional method

The process is very demanding and requires extensive experience, advanced skill, and know-how.

It usually takes about 2 to 3 hours and is broadly carried out in 10 steps. If even one step is omitted, the result may be below expectations.

Therefore, no matter how long it takes, all steps must be checked carefully and carried out with care to achieve a good result.​

■ Two goals of the surgery

The goals of correcting a thick line and ptosis can be broadly divided into two points.

① To reduce a thick and unattractive double eyelid line and make it into a natural, thinner infold crease

② To make sleepy-looking, drowsy eyes open more widely and clearly

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

1. The planned incision line is designed to include the existing scar tissue.

Preoperative design is used to create a new double eyelid line below the scar line and determine the width of skin to be excised up to the scar line.

The excision width is measured 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 will be 3 mm.

The standard is determined based on the midpoint width.

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

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

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 the tissue is then removed with surgical scissors.

The lower edge of the excised area becomes the new double eyelid line, and the upper edge must be dissected and brought down naturally for closure.

3. The levator palpebrae superioris, orbicularis oculi muscle, orbital fat, and skin adherent to each other are dissected.

Because the skin above the incision line must be pulled downward, the hardened scar tissue that has adhered to it must be dissected.

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

Through this dissection process, the tissue can be advanced and repositioned downward, which is important as preparation for obtaining 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 scar tissue adhesion is too severe, in rare cases a 1–2 mm vertical incision is made in the orbicularis oculi muscle to release the contracture.

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

Advancing the orbital fat is part of preventing the tissue from adhering again.

If the fat is not repositioned, the tissue will adhere again, which can cause ptosis and make the eyes look sleepy.

In some cases, this can also lead to triple eyelid formation and become a cause of a damaged double eyelid line.

Another effect of repositioning the orbital fat is that if the eyelid is sunken, the depression can be corrected to some extent. In cases where fat grafting would otherwise be needed later, the surgery itself may provide some improvement, sometimes eliminating the need for fat grafting.

6. The levator palpebrae superioris is shortened to strengthen its function.

Levator palpebrae superioris shortening is one method for correcting ptosis.

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

This method does not cut out the levator palpebrae superioris; instead, it is simply advanced and tied to the tarsal plate (cartilaginous plate).

During revision surgery, the effect of levator shortening is to open the eyes more widely so they can be corrected more clearly, and by opening the eyes wider, the double eyelid line also becomes smaller, serving two purposes.

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 to prevent adhesion of the orbicularis oculi muscle.

The inner side of the eye is the area where scar adhesion is most likely to occur, and adhesion in this area can make the eyes look sleepy and prevent them from opening well, causing 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 secured with sutures.

8. During closure, layered suturing keeps the repositioned structures from shifting.

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 this, the skin below the incision line must be firmly fixed to the tarsal plate, and the repositioned fat must also be secured so that it does not ride upward.

In addition, the orbicularis oculi muscle and skin above the incision line must all be passed through with sutures and firmly closed in layers to obtain the desired double eyelid line.

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

The swelling-reducing agent, hyaluronidase, is a medicine that disperses fluid and can quickly reduce swelling as soon as it is administered.

However, excessive use can instead cause more bruising, so it is used selectively only to reduce swelling.

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

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

The reason for late removal is that in revision surgery, most cases do not have enough excess skin, and because the surgery involves advancing all tissues forward, there is 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, resulting in a larger scar, and the tissue may gradually ride upward, causing the double eyelid line to become larger as well.

Thus, until the tissue stabilizes, the stitches should remain in place to hold the tissue, so it is better to keep them in longer.

Many clinics remove stitches early for fear of leaving stitch marks, but that applies only to the first double eyelid surgery.

It does not apply to revision surgery.

To minimize stitch marks, most of the stitches are removed on day 4, leaving only about 3–4 stitches, and these are removed on day 7. This helps minimize stitch marks, prevent scar widening, and reduce distortion of the double eyelid line.

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

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

■ Double eyelid revision surgery process when the eyelid is sunken

A sunken eyelid causes the double eyelid line to ride upward and become distorted.

This often occurs as people age and crease lines form.

In this condition, the first step is to correct the sunken eyelid with fat grafting.

When the eyelid is sunken, double eyelid revision surgery alone usually does not produce a beautiful crease.

After micro fat grafting using microneedles, the sunken eyelid is corrected.

The line width has become smaller than before, but fine wrinkles remain along the line and the inner line is thick, so it does not look natural.

Revision surgery is needed to make the line natural, and surgery is planned 3 months later, after the fat graft has fully taken.

Three months after fat grafting, double eyelid revision surgery is performed to restore a natural line.

A natural double eyelid is one that is narrow on the inner side and gradually widens toward the outer side.

▷ As in the example above, the sunken eyelid should first be corrected with fat grafting, and only after 3 months, once it has fully settled and its final appearance can be confirmed, should a plan be made and revision surgery performed accordingly. Only then can the surgery be accurate and produce a good result.

Double eyelid revision surgery - partial incisional method

The partial incisional method is a surgical technique used to restore the crease to its original clear line when the line becomes smaller, unfolds, or becomes blurred.

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

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 may determine the most suitable line.

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

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

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

3. After sedation, local anesthetic is injected into the three marked areas while the patient sleeps for about 5 minutes.

The local anesthetic is used in minimal amounts so swelling is reduced as much as possible.

4. Very small incisions of about 2 mm are made at the three marked sites.

If the incision is made too large, a lot of scar tissue remains, so surgery is performed with the minimum incision possible 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 is a tissue that interferes with double eyelid formation, so it must be removed to prevent the double eyelid line from unfolding.

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

6. If there is a large amount of orbital fat, the fat is pulled out through the outer incision site and exposed.

Fat removal is mainly performed from the outer side.

7. The fat is held with a hemostatic forceps, and the base of the protruding fat is cut off with a scalpel.

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

8. After fat removal, bleeding is controlled with electrocautery to prevent bleeding.

If hemostasis is not performed properly, orbital bleeding can occur and bruising and swelling will become severe, so good hemostasis is important.

9. Through the three incision sites, a very fine dissolvable suture is used to connect the levator palpebrae superioris and the skin to create the double eyelid line.

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

Washing your face and wearing makeup are possible from the next day.

Use the cool pack provided by the clinic 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 best to do them for exactly 3 days.

Double eyelid revision surgery - levator palpebrae superioris shortening

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

Since the surgery must be performed through an incision, a double eyelid line will form during the process, so people without a double eyelid will inevitably have to create at least a faint crease.

▷ Surgical process for levator palpebrae superioris shortening

1. Design is made and local anesthesia is administered.​

2. An incision is made along the design line.

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

4. The levator palpebrae superioris is exposed, marked for the amount to be shortened, and the marked area and the upper border of the tarsal plate are tied together with sutures.

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

6. The outer skin is sutured.

Double eyelid revision surgery - levator palpebrae superioris resection

This method reduces the length of the eyelid-lifting muscle (levator palpebrae superioris) by 5–10 mm and sutures the cut end of the levator palpebrae superioris to the tarsal plate.

It is mainly used in cases of moderate ptosis.

Double eyelid revision surgery - micro fat grafting

If the upper eyelid is sunken and the double eyelid line looks awkward, there are cases where correction is possible with micro fat grafting alone without incision.

If surgery is performed while the double eyelid is sunken, the crease cannot be made properly and unsatisfactory results are likely due to the sunken contour.

When there is a sunken eyelid, it is best to first perform fat grafting to correct the depression while also adjusting the shape of the double eyelid.

■ Effects of correcting the double eyelid line with micro fat grafting of the upper eyelid

① Correction of a thick double eyelid line
② Correction of an unfolded double eyelid line
③ Correction of an asymmetrical double eyelid line
④ Correction of a triple double eyelid line
⑤ Correction of multiple crease lines
⑥ Restoration of a disappeared double eyelid line

■ Anatomy diagram of the orbital fat in the upper eyelid

■ Effects obtained through micro fat grafting of the upper eyelid

Aesthetic aspect ① Correction of sunken areas to restore a softer, younger-looking eye appearance ② Correction of an awkward double eyelid line
Functional aspectIt smooths the movement of the levator palpebrae superioris that opens the eyes, helping reduce eyelid fatigue.​

■ Procedure for attractive-looking upper eyelid micro fat grafting

The goal of upper eyelid fat grafting should satisfy both aesthetic and functional purposes.

For this, it is very important to graft the proper amount of fat into the correct location.

The most accurate location for fat grafting is where the orbital fat is located, and good results are achieved when the newly grafted fat blends with the existing fat in this area.

However, if the fat is mistakenly grafted into the orbicularis oculi muscle layer, the eyelid can become lumpy and heavier, making it even more uncomfortable to open the eyes.

Therefore, upper eyelid fat grafting must be performed with precise anatomical knowledge and careful technique to achieve the desired result.

1. Fat is harvested from areas where a lot of body fat is stored, such as the lower abdomen, waist, or thighs.

For wrinkle correction, a large amount of fat is not needed, so harvesting from the lower abdomen is preferable.

• Because local anesthesia (painless sedation) is used, there is no pain at all.

• A thin liposuction cannula is used to collect fat into a syringe.​

2. The harvested fat is placed in a centrifuge to remove impurities (local anesthetic, serum, red blood cells, etc.).

The purpose of centrifugation is to remove impurities contained in the fat, increase its concentration, and improve the graft survival rate.

3. After centrifugation, the fat undergoes a second concentration process to remove water and oil.

By removing water and oil, nearly 100% concentrated fat is obtained.

4. The purified fat is transferred into a fine 1 cc syringe and grafted into the desired area.

The fat is again transferred into a fine 1 cc syringe and grafted into the desired area.

The clinic uses its own micro needle (micro grafting cannula) developed in-house.

The micro needle is a special grafting cannula used only by this clinic, enabling ultra-precise grafting.

For grafting, subcutaneous tunneling is performed first so that the fat can be placed accurately into the wrinkle area, which helps correct wrinkles effectively.

The micro fat grafting cannula is inserted into the planned eyelid line and grafted precisely.

The graft must be placed into the orbital fat layer to create a smooth contour and a high survival rate.

After fat grafting, daily life is possible immediately, and washing the face and applying makeup are possible from the next day.

■ Correction of a thick line with micro fat grafting

This is applied only when the upper eyelid is sunken. Micro fat grafting requires highly skilled technique and know-how, and the eyelid anatomy must be understood accurately.

Only those with extensive experience in double eyelid revision surgery can perform eyelid fat grafting properly.

Because this is a very advanced procedure that also considers correction of the sunken eyelid and the awkward double eyelid line, it is better not to undergo the procedure at a clinic with insufficient experience or from someone who is not a board-certified plastic surgeon.

■ Correction of an asymmetrical line with micro fat grafting

When the eyelid becomes sunken due to insufficient orbital fat, the line may ride upward and become larger.

In such cases, it can be corrected simply with micro fat grafting without revision surgery.

Micro fat grafting is a simple procedure in which fat is injected with a syringe.

■ Correction of an unfolded line with micro fat grafting

When the eyelid becomes sunken and the line rides upward and unfolds, the sunken eyelid and the unfolded line can be corrected with micro fat grafting.

However, this applies only when the cause of the unfolding is solely the sunken eyelid.

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

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

■ Correction of a triple line with micro fat grafting

When the eyelid becomes sunken, the skin may ride upward, causing the line to become larger or a triple double eyelid to form.

Sometimes multiple layers of wrinkles may form.

Even in such cases, they can be easily corrected with micro fat grafting.

■ Two-dimensional planar fat grafting of the upper eyelid

Fat grafting for the upper eyelid should be performed as a two-dimensional planar fat graft.

If fat is grafted under the skin, the eyelid becomes heavy and the skin can become lumpy.

To avoid these side effects, fat must be grafted precisely between the orbicularis oculi muscle and the levator palpebrae superioris, which requires accurate anatomical knowledge and extensive experience.

Fat grafting only produces complete results functionally and aesthetically when it is performed at the correct location.

■ Recovery period after upper eyelid fat grafting

Usually, daily activities are possible immediately.

Some swelling and bruising may occur, but they are usually mild enough to be covered with makeup, so there is generally no major disruption to social life.

However, swelling and bruising vary from person to person, so not all cases are the same. On average, severe swelling and bruising do not occur, and it is common for the area to look natural after about a week.

■ Number of upper eyelid fat grafting sessions

Eyelid fat grafting has a relatively high survival rate compared to other areas.

A satisfactory effect can usually be achieved with one session, or at most two.

The interval between procedures is 3 to 10 months, and when repeating the procedure, the fat that was previously harvested is thawed and used again.

However, many people are satisfied after just one procedure and do not need a second one.

Because fat survival varies by person, the decision about a second procedure should be made after at least 3 months.

■ Side effects of upper eyelid fat grafting

The side effects are limited to some swelling and bruising.

Other side effects can be considered virtually nonexistent.

Because the procedure uses the patient’s own fat rather than a foreign material, there is no immune rejection or inflammation.

Also, once the fat takes, it is no longer absorbed and becomes part of the patient’s own tissue.

In some cases, people experience side effects after undergoing the procedure at a clinic with limited fat grafting experience, but that is a matter of the practitioner’s skill.

Problems can occur if the fat is grafted into the orbicularis oculi muscle layer rather than the orbital fat layer, making the eyelid heavier and lumpy, if too much fat is injected and the eyelid becomes so swollen that daily life is difficult, if excessive fat injection causes ptosis and difficulty opening the eyes, or if a large amount of the fat is absorbed and the effect is not noticeable.

Results can differ from one clinic to another, so it is better not to undergo the procedure from someone who is not a board-certified plastic surgeon and has limited experience in fat grafting.

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