• Primary goal: The same as with "primary" blepharoplasty– that is, an improvement in the appearance of the upper and/or lower eyelids. The distinction here is that the patient has undergone previous unremarkable (uncomplicated) blepharoplasty surgery some years earlier and now desires a repeat operation. As a group, the patients are more elderly than the average blepharoplasty candidate.
• Secondary goals: In patients who have undergone previous blepharoplasty, seldom is there enough new overhanging skin to interfere with vision. Thus, functional (non-cosmetic) concerns are generally minimal.
• Special anatomy: The unknown degree and location of internal scarring from older techniques may significantly alter the anatomy and predispose to less predictable results.
• Anesthesia: Because of unknown or unexpected alterations of normal anatomy, it is extremely helpful if the patient can cooperate during surgery by opening and closing the eyes upon request. Local anesthesia with oral or light intravenous sedation is thus highly desirable.
• Operative technique: The same as for "primary" blepharoplasty, but undertaken with a much more conservative bent. Adjunctive procedures are often indicated (see next paragraph).
• Variations: Since most patients old enough to be requesting secondary blepharoplasty have likely undergone lower eyelid surgery by a transcutaneous (skin) approach, any lower eyelid fat removal is best undertaken via a transconjunctival (posterior) approach to lessen the chance of excessive scarring in the middle layers of the eyelid leading to lower eyelid retraction. Almost all patients will benefit from lateral canthus reinforcement and a SOOF lift and attempts at orbital fat conservation). Skin excision in the upper eyelid should be very conservative, and care should be taken to ascertain whether the patient would, in fact, best benefit from brow - forehead elevation instead of further upper eyelid surgery.
• Advantages: As with "primary" blepharoplasty
• Limitations: The incidence of complications is increased because of (1) scarring from previous surgery and (2) the sometimes inappropriate selection of standard surgical techniques when, in fact, the addition of more advanced adjunctive measures noted above are indicated.
• Care and recovery: As noted in Section Four. In addition, swelling and bruising may be somewhat increased, resulting in a slower recovery. Scars made "over" other scars may take longer to mature and soften.
• Risks and complications: As noted in Chapter 28: Eyelid Surgery Risks, except that the incidence of almost all complications is moderately increased.
• Comments: The use of modern techniques by today's more specialized cosmetic surgeons makes secondary blepharoplasty a less likely future operation for patients of today. Most patients requesting secondary surgery either (a) had surgery at a very young age for minimal problems and have since aged, or (b) had older surgical methods performed by less experienced and less specialized practitioners of years past.
