Lower Blepharoplasty Revision? (photo)

Question

8 months ago I had an upper and lower blepharoplasty. My surgeon also lifted the outer corners of my lower eyes as they hung below my pupil. He also did CO2 resurfacing below my eyes. My eyes look awful with bags. It is as if I never had surgery at all. I have an appointment coming up with my doctor and I wish to be more educated on revisions before I spend even more money. Is it reasonable to expect this repair to be done at at discounted charge or no charge. Thank you so much for your help!

Kenneth Hughes, MD · Answer

There seems to be a component of irritation and allergic reaction in the lower eyelid skin. This is hindering the result to some extent. I would get the irritation under control before removing a little more skin with resuspension procedure of the eyelid.

Mehryar (Ray) Taban, MD, FACS · Answer

You appear to have combination of edema/fluid and excess skin, at the least. Expecting 100% improvement with perfectly smooth lower eyelid area may be not be practical but there are options available for improvement. See an oculoplastic surgeon for evaluation.

A.J. Amadi, MD · Answer

Obviously with a photo, it is more difficult than an exam in person, but it seems to me that in addition to the redundancy of the skin, and a downward tilt to the corner of the eye,  there is also thickening of the skin as well as some redness. I wonder if you have an allergic component  [allergic or atopic dermatitis].

	This would definitely need to be treated before a revision is attempted. I would recommend a consultation with a dermatologist as well as a second opinion with an Oculoplastic surgeon.

Kenneth D. Steinsapir, MD · Answer

Not all lower eyelid surgeons are created equal. We don't have the benefit of having your before photos. It is likely that you needed more than CO2 resurfacing. Lower eyelids burn a lot of very experienced surgeons. You need a better repair of your lateral canthal angle, excision of the extra lower eyelid skin and support of the orbicularis oculi muscle at the orbital rim to reconstruct the orbitomalar ligament. Additional opinions are warranted here.

Darryl J. Blinski, MD · Answer

Your result demonstrates the need for a lateral canthoplasty, redrawing of the excess skin. Best to obtain a few in person opinions.

Sam Goldberger, MD · Answer

It does look like you need further surgery.  Unfortunatey, surgeons policies regarding revisions are different, and there is no standard.    If you are uncomfortable, get a second opinion.

Roger Bassin, MD · Answer

It would certainly be helpful to see your before photos, but your 8 month post-operative photos appear to show that you still have quite an abundance of lower eyelid skin. I also see the corner of your eye appears to be lowered, which may leave you susceptible to chronically dry, scratchy, and irritated eyes (if it hasn't already). I do recommend you seek a second opinoin as corrective surgery may be necessary.

	Hope this helps!

Amiya Prasad, MD - Account Suspended · Answer

As an oculofacial cosmetic surgeon, 20% of my practice is revision and eyelid surgery and they rank highest in the hierarchy of plastic surgery procedures. Part of what we do in cosmetic surgery, is the reality that a certain percent or patients need revisions and no surgeon has never had to do revisions. One of our mentors in our field said, “A surgeon who claims never have to do revisions is doing one of the two things: either they’re not doing surgery or they’re just plain lying.”  It is also understandable that a certain percentage of people don’t have the ideal outcome and there are many reasons for that.

	Looking at your photos, I can tell that your skin quality almost has a certain appearance consistent with photo aging which is caused by sun exposure and/or smoking, whether it’s primarily as a smoker or as a secondhand smoker. I can also asses from your photo that the lower eyelid is sagging on the outer aspect and coming down. 

	Without doing a physical exam, it is important to at least assess on your own by picking up the corner of the eyelid up and see if it looks better. That’s the benefit that I don’t have just by looking at your photos. But when I look at your photos, I want to pull that lower eyelid up and give it a little tightening.

	There’s a structure of the eyelid called the lateral canthal tendon which is an important part of the anatomy and support of the eyelid as it's the tendon that actually attaches the eyelid to the bone. In our practice, it is typical to do some type of tendon supporting procedure particularly when someone’s going to have several procedures that could affect the position of the eyelid. In your case, I think you need to have a procedure like a lateral canthal plasty, canthopexy or a lateral tarsal strip which all involve the reconstruction or reinforcement of the lateral canthal tendon. Unfortunately, lifting up the skin and attaching it doesn’t give it the stability and it eventually tends to pull down. We see a lot of patients whose upper lids were tethered to their lower lids because their previous surgeon has pulled the eyelid up and stitched it in a way that pulled the upper eyelid down in attempt to stabilize the position of the lower eyelid.

	I don’t think that you have to start exploring questions about cost of revisions without first communicating with your doctor. You should get from your doctor a sense of comfort that this is a procedure that they feel qualified or experienced to do. Often, really good surgeons will have relationships with other surgeons who have more experience in specific areas. It’s very difficult for one surgeon to be brilliant and exceptional in every area.  There’s nothing wrong with you having another specialist do some work if there is a clear communication and understanding with you and your original surgeon and the referring specialist.

	To summarize, you need some type of support procedure in order to get the lower eyelid into a proper position. You also need to address the draping of the skin that has come down. That procedure is to attach the lower eyelid back to the bone or the orbital rim, and to stabilize the position of the lower eyelid called a lateral canthoplasty or canthopexy.   I hope that was helpful, and thank you for your question.

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