Complex Revision of Unsatisfactory Double Eyelid Surgery
Following Multiple Previous Operations,
Photographed Start to Finish
(Surgery by Dr. Frank Meronk)
To bypass surgery photos, click 
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(image cropped for privacy)
This patient had undergone previous incisional double eyelid surgery with an unsatisfactory result. Following attempted revision elsewhere, both lids were worse. When first seen in our office, each upper eyelid demonstrated:
• no crease with very noticeable asymmetry
• multiple incomplete lines, folds, and scars over the full expanse of skin
• hollowed eyelids with the deepest depression extending up to and under the rim of bone
• ptosis (lid droopiness covering too much of the eyeball)
• lashes pointed downward into the field of vision
• inability to close fully when asleep
• slight skin shortage
Without adequate orbital fat extending forward from the socket, the lids cannot form a natural crease and will instead crumple into mulitple uneven folds. The depression resulting from volume loss can be distressing since "ages" the lids and face.
Ptosis is common in the setting of hollowness but may also indicate damage to the tendon (levator aponeurosis) that connects the lids's opening muscle to the eyelid edge.
In patients who have undergone multiple previous operations, the extent of scarring and damage to internal tissues is unknown until actual surgical exploration. Unfortunately, this general constellation of findings is not uncommon in patients seeking revision in our practice.
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(To follow the description, open this pop-up window on pertinent anatomy.)
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1. Upon opening the lid along the site of the intended future crease, dissection and excision of scar tissue was accomplished until the levator muscle and aponeurosis were freed of adhesions. As seen in the photo to the right, the tendon had been disinserted from its normal attachment during previous operations and its edge had retracted upward (area colored in light green).
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2. (Same photo as on left) Normally, orbital fat from the socket extends forward and covers most of the levator aponeurosis (as drawn in light orange). In this case, a severe shortage of orbital fat was encountered (shown further in the photo directly below). Without adequate fat, the more exterior tissues of the lid can collapse onto the levator complex, prevent formation of a crease, tether movement of the lid when opening and closing, and bunch up into irregular external folds.
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3. The free edge of the levator aponeurosis was freed from scar, advanced downward, and reattached to its normal anatomic position (ptosis repair). The blue arrows point to three sutures that have already been placed in this repair, while the green dots outline an area not yet repaired.
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4. Following completion of the ptosis repair, the highest part of the levator was retracted downward by forceps to expose the full magnitude of missing fat. The purple arrows point to the edge of bone covered only by a thin layer of brow fat. Deep inside the cratered area, only a few globules of normal orbital fat can be seen.
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5. To address an orbital volume deficiency requires grafting of structurally-intact fat from another source. Donor fat was obtained as small particles ("pearl fat") and introduced over the top of the eyeball and into the emptied socket. Care was taken to avoid injuring the eye muscles, nerves, blood vessels, and eye itself.
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6. The donor fat was distrbuted and layered throughout the area of hollowness. The skin has been lifted in this photo to show the outermost layer of fat pearls extending beyond the levator muscle and covering the top half of its aponeurosis.
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7. Remaining remnants of previously-damaged orbital septum were draped over the fat. The skin and closing muscle were draped over the septum.
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8. A new crease was constructed utilizing deep fixation between the skin edges and the previously disinserted but now reattached levator aponeurosis. Because the grafted fat now inflates the lid above this area of fixation and helps prevent reformation of previous scar as well as collape of overlying tissue, a defined crease will be able to form during healing.
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9. The wound was closed in several layers. Notice full reinflation of the hollowed area shown in the "Before" photo at the top of this page.
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(Note: This patient is still healing.
Results will be posted when available.
To view before-and-after photos of other patients who have undergone
similar surgery, visit the Hollowed Eyelid section of this website.
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More Examples of Complex Asian Eyelid Revision
Caution: Actual Surgery Photos
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No crease after two operations
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