Double eyelid revision surgery: when it is needed and what to consider

Why people consider revision surgery

The ideal shape and height of a double eyelid vary greatly between individuals and cultures ^[1]. The same result can leave different people with different levels of satisfaction, and the reasons for dissatisfaction after surgery are varied ^[1].

How the crease was secured in the first surgery also affects the result. Most double eyelid surgeries form a crease by creating an adhesion between the tissue of the muscle that lifts the eyelid (levator) and the skin. The incisional method creates a well-defined crease, but a noted drawback is that a depression or scar may be visible when the eyes are closed and looking downward ^[5]. In a study of 522 cases using a new fixation method, there were still 7 cases of crease loss and 12 cases of asymmetry, and all 12 asymmetric cases were corrected with revision surgery ^[5].

The most common reasons for considering revision surgery are listed below ^[1].

• A noticeable scar
• A crease that is too low or too high
• A crease that is too shallow or too deep
• A triple crease
• Fullness at the front of the eyelid
• A droopy eyelid (blepharoptosis)
• Asymmetry between the two eyes

Correcting a double eyelid that does not move

People seeking revision commonly have a static fold, in which the skin below the crease does not move and the crease area looks sunken ^[2]. In one study of revision surgery in 203 patients with a static fold, the surgeons fully released the adhesions in the lower skin, and where the gap in the muscle around the eye (orbicularis oculi) in front of the tarsal plate was wider than 2 mm, they moved tissue in to fill it ^[2].

Of 105 patients with a severe static fold, 67 received a fat graft behind the orbicularis oculi muscle and 38 received an orbicularis oculi muscle flap, and satisfaction with the surgery was 86.7% ^[2]. Reported complications were partial crease loss in 7 patients (3.4%), complete crease loss in 3 (1.5%), a hollow upper eyelid in 5 (2.5%), multiple creases in 3 (1.5%), an unnatural crease curve in 5 (2.5%), and asymmetry in 4 (2.0%) ^[2].

Because these results come from a single research team, it is hard to assume that other patients and surgeons would see the same outcomes.

Correcting multiple creases

Unwanted multiple creases can appear after many types of double eyelid surgery, and they are attributed to adhesions that form from improper handling of tissue during surgery ^[3]. In people who have had several revisions, the adhesions are severe and there is little tissue left for reconstruction, which makes correction difficult ^[3].

One study divided 62 patients into three groups: creases that appeared without any surgery, creases that appeared after a first surgery, and creases that appeared after revision surgery. The surgeons released the scar tissue and filled the space with eyelid tissue, such as the orbicularis oculi muscle and orbital fat, to keep the layers from sticking together again ^[3]. The unwanted creases disappeared completely in 57 patients (92%). In 5 patients (8%) they recurred and were corrected with another surgery, and all recurrences occurred in the post-surgery groups, where the adhesions had been very severe ^[3].

The authors named precise release of adhesions, preserving enough tissue, and using other soft tissue to keep the skin and the levator from reattaching as the most important factors ^[3].

Correcting a double eyelid that is too high

In East Asian patients, a double eyelid crease that is too high is described as leading to unsatisfying results and as being difficult to correct ^[4]. One research team analyzed 213 revision surgeries performed over 4 years to lower a high crease ^[4].

Crease height was reduced in nearly all cases (98.59%), and 3 cases (1.41%) were classified as poor results ^[4]. The authors identified the key steps of the surgery as advancing the levator muscle and fixing it in place, and placing surrounding tissue or fat between the levator tendon (aponeurosis) and the skin over it ^[4].

However, the level of evidence for this study is relatively low, at level V, and the authors themselves stressed that it is a demanding operation that requires a deep understanding of eyelid anatomy and movement to avoid further damage to the levator ^[4].

Why revision surgery is difficult

Revision surgery can be more complex than the first surgery because it has to deal with adhesions and scar tissue from previous surgery as well as a reduced amount of tissue ^[3]. When the levator muscle is involved, as in correcting a high crease, care must be taken not to cause further damage to the muscle ^[4].

Problems such as crease loss, hollowing, and asymmetry can still occur after revision surgery ^[2]. Correction can become harder with each additional surgery, so it is best to decide only after carefully considering whether the next surgery can actually solve the problem ^[3].

What to ask during your consultation

A review of double eyelid surgery in East Asian patients addressed preoperative planning and consultation, the course of recovery, and complications and revision surgery as key concerns before and after surgery ^[6]. A revision consultation should start with an accurate diagnosis of where your current dissatisfaction comes from.

• The cause of the current problem (adhesions, a shortage of tissue, the fixation position, a droopy eyelid, and so on)
• The method used in your previous surgeries and how many you have had
• How it would be corrected, and whether tissue reinforcement is needed
• Complications that can occur after revision surgery, and how often they occur
• The realistic range of change you can expect