Uneven Eyelids After Blepharoplasty

                  In
the immediate post-operative period it’s difficult to make judgments about
eyelid aesthetics when swelling is present. The first several months following
blepharoplasty are characterized by dynamic changes in the eye lids because of
wound healing. For these reasons, judgments regarding symmetry should be
delayed until swelling has resolved.

                  In
addition, it’s important to note that your pictures suggest baseline asymmetry
of the brows and orbital rims. In your case the right brow and orbital rim seem
lower than your opposite side.

                  This
asymmetry can affect the final result in a variety of ways. In some cases,
blepharoplasty can unmask baseline asymmetry making it more obvious. In other
cases, baseline asymmetry may require the surgeon to make compromises regarding
incision placement.

                  It’s
very difficult to evaluate asymmetry in the immediate post-operative period
because of swelling. This evaluation can be made even more difficult by
baseline asymmetry and the compromises that are necessary to address them. For
these reasons, it’s important that you have good communication with your
plastic surgeon. It’s important to be patient and make sure all your concerns
are addressed. 

I would see your surgeon for a physical exam and  visit. The eyes do swell markedly. Also things like which side you sleep on can affect the way the swelling settles over time. So likely the best idea is to be patient at this point. There is no considering revision until at the very least the 6 month mark. Hope this helps. DrC

Asymmetry is not unusual in eyelid surgery. Often, if one eyebrow is higher than the other, it will make the asymmetry more noticeable.  You should hold off on any revisions for at least three months.  More skin can than be removed from the lids that is still a little droopy.

Hi Daisy,

 

Early healing and Early Assymetries

It does appear that the eyelid incision on the left is higher than the right one by a few millimeters.  Since these are photos, and swelling and other factors can't be assessed in a face to face examination, I would give the surgeon some benefit of the doubt, and give yourself a minimum of 6-12 months to heal completely.  It may be that the assymmetry of the two sides will improve if the left eye with the higher crease happens to still have more bruising and swelling than the right side.  On the before photo, it appears than the left eyelid looked puffier, and on the after photo, it appears that much of that fat was removed, which can also account for a higher eyelid crease.

 

Leaving Equal amounts of skin

If a revision were to be performed for to even out the creases, my goal is to "leave" an equal amount of skin from below the eyebrow hairs to the eyelid crease, and the eyelid crease to the eyelash line.  If the skin below the eyebrow and the eyelid crease is equal  on both sides, then a tiny strip of skin should be removed from the existing crease toward the eyelash line.  When measuring the skin removal, some surgeons will try to remove an equal amount of skin, which makes sense, as long as the skin that is left on the patient is also equal on both above and below the eyelid crease.

 

I usually take 10-15 minutes before the procedure to measure with a fine caliper and a green forceps to "estimate the excess skin" and mark the incision location, as well as the amount of skin removed and the amount of skin left.  I rarely make the perfect line on the first try and need to go back and forth between the two eyelids to come to a "compromise" between the two sides.  I've seen on the television plastic surgery shows where they mark the upper eyelids "free hand" while making all of the other facial markings, but I don't feel I am able to do the same without using strict measurements at key areas.

 

Upper eyelid hollowing

Looking closely at the before photos, your eyes look puffier, with the left upper eyelid puffier than the right side.  On both after photos, the puffiness on both sides appear flatter, but in particular on the left side, it appears that the upper rim of the eye socket is visible.  People with naturally deep set eyes tend to have this type of upper eyelid hollowing.  This hollowing is also another reason for the higher eyelid crease.  The right eyelid looks puffier than the left, so it is also possible, that as the swelling comes down on the right side, the right crease will also become higher and match closer to the left side.  

 

Raising one eyebrow

Another observation that I have seen is that patients who have upper eyelid hollowing tend to raise their eyebrows more on the hollowed side.  You had a tendency to raise your left eyebrow before surgery as well as after surgery

 

Go to a mirror, and push your left eyebrow down a bit to match the height of your right side and see if the eyelid crease heights become more even.  If so, the surgeon can only do so much during surgery to perform an accurate surgery, but the surgeon can't control how a patient may hold their eyebrows assymetrically after surgery.

 

Potentially Botox to the forehead on both sides will help to "reset" or "retrain" your forehead muscles and relax the left forehead.  If the left forehead is more relaxed it may also help with the assymetry of the eyelid creases.  

 

Don't worry

Depending on how everything settles down with full upper eyelid recover, you will either  not need to do anything since the eyelids may even out.  Perhaps a small revision procedure to even out the skin remaining might be performed on one side.  Or non-surgical procedures can be done to lower the upper eyelid crease by adding back volume to the upper eyelid hollow.  Please check out the link below, which shows a patient of mine who had her upper eyelid crease lowered.

 

Best,

Dr. Yang

 

 

At 3 weeks post-op, swelling is definitely still playing a role.  It will be some time before your post-operative results can be carefully assessed for the need for any revision surgery. 

I suggest that you keep in close contact with your surgeon so that he/she can walk you through this expected recovery process and address any problems down the road should that become necessary.

I agree with those surgeons noting the asymmetry of your eyes preoperatively. This may affect incision placement.  As time goes by this should not be a big factor.
 

You have pre-existing asymmetries that are accentuating the post-surgical differences. However, in your eyes-closed post-op view, it appears that that is a distinct asymmetry in the distance between your upper eyelid margin and the incision. The distance is greater in your left eye (right side of the picture). At this point, I think it is best to wait and let all of the tissues settle and swelling resolve for several months before having additional surgery. Good luck with your recovery.

Dear Daisy,
We like to say that if you tell the patient before surgery it is an explanation but if you tell them after surgery, its sounds like an excuse.
Your photos are helpful but it would be even more interesting to also have the before pictures. I agree with Dr. Moellenken that you have facial asymmetry, almost every one does. In your case the left eye sits higher in the face than the right eye. This is a surprisingly common situation when one looks for this. This asymmetry existed before surgery. However, it is the surgeon's burden to point these issues out prior to surgery.
However, you seem to have difference between the two sides that go beyond this basic asymmetry. The crease height, where the upper eyelid incision is placed, seems to be higher on the left side than the right. This may account for more visibility or apparent length of the left upper eyelid platform. Also although the right canthal angle is lower on the right side than the left, the right lower eyelid seems to bow downward more that the left lower eyelid.
One thing that is definitely true is that things get better in time. While some of the issues may not change much over time, enough will that you may or may not feel that you would benefit from a revisional surgery. I would recommend and I think most surgeons would agree that you should heal from this initial surgery 6 to 12 months before considering a revisional procedure.

Of course you are quite early arfter surgery and should wait before making any decisions on the final outcome.
However, your eyes are asymmetric. Your left eye appears more prominent and higher. This is a result of the eyeball in the eye bone socket, and is not affected at all by surgery. So that asymmetry will always be there, and cannot be corrected by blepharoplasty of any type.
There are certain tricks that can be used to camouflage the appearance of orbital dystopia, however the relationship of the eyeball with the bony socket is not easily changeable.

Uneven eyelids after blepharoplasty can result from the transcutaneous eyelid surgery. The rounding of the lower eyelids is causing this problem. A lower lid tightening procedure with possible midface lift may correct the problem.