Lost my crease 1 month after mullerectomy. What are my options now? (Photo)

Question

It's been over a month and my eyelid crease hasn't come back in my right eye after mullerectomy. It actually created a second crease a few millimeters above. I got it for medical reasons since it was covering my upper vision at night and now I'm worried insurance won't cover a revision since it would be cosmetic. My surgeon said he'll check in a few weeks from now but I think at this point I should look elsewhere. Is it will swollen maybe?

Kenneth D. Steinsapir, MD · Answer

It was the wrong ptosis surgery and the wrong eyelid surgery for someone who needs both a ptosis correction and a double fold surgery.  The Mullerectomy is beloved by oculoplastic surgoens.  However, it has a significant and under appreciated failure rate in the setting of anterior levator aponeurosis disinsertion.  Basically the tendon is out of position for the surgery to be effective in lifting the eyelid.  What you need is an anterior levator aponeurosis resection ptosis surgery with an anchor blepharoplasty to correct the ptosis and make a permanent double fold. You should let the eyelid heal 6 to 12 months before having this revised and you need to find someone with true expertise for this.

Mehryar (Ray) Taban, MD, FACS · Answer

It is possible to add eyelid crease. Consultation is necessary to examine your eyes and determine the best approach. Discuss with your surgeon too.

Amiya Prasad, MD · Answer

Thank you for your question.You are requesting further explanation of a situation where you underwent ptosis surgery using a method called Mueller’s muscle resection. You are one month out after that surgery, and you’re concerned because you lost your eyelid crease. You have also noticed a development of a slightly higher crease. You’re concerned that any further surgery will not be covered by insurance because any revision surgery related to the crease may be considered cosmetic. You’ve met with your doctor who is planning to see you in a few weeks, and you’re concerned that it may be better for you to go elsewhere.
I can share with you a perspective based on this information you provided. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. Cosmetic surgery is a core of my practice, as well as medical surgery such as ptosis surgery. Unique to your situation is the Asian eyelid anatomy that is relevant to this type of healing process. 
You are well aware that Muellerectomy or Mueller’s muscle resection is a shortening procedure from behind the eyelids to help people with drooping eyelids. This allows for a certain general predictable level of eyelid height improvement, and the front of the eye is untouched. 
To review some of the anatomical principles of Asian eyelids, the crease is present naturally in about 50% of Asian people. The crease is due to the presence of attachments of fibers from the skin to the levator muscle, which is responsible for most of the eyelid movement. When you do Asian eyelid surgery, whether it’s a non-incisional or incisional procedure, the goal is to create a connection between the skin and that muscle. 
Given you are one month out since the surgery, I think a reasonable explanation is there is still some swelling. Swelling can affect crease presence, and the variability in crease formation. As long as your doctor is following you, this situation can be appropriately monitored. Often people get concerned about missing an opportunity to do something relatively early, so they get anxious and look elsewhere. 
From my perspective as someone who does a lot of Asian eyelid surgery, for a situation like yours, I would wait several months to allow for swelling to resolve. In addition, given that this type of surgery is done from the inside of the eyelid, I would be concerned about putting stress on any of the tissue while healing is ongoing. For example, when you do a non-incisional Asian eyelid surgery, we’re making little openings on the skin. We want to create a crease because you don't have extra skin, so you want to create an infolding, or a double fold, or double eyelid. When you make little openings on the outside of the skin, you pass a stitch from the inside out to try to create this connection. Part of that procedure is to actually flip the eyelid, which can put stress on it, and potentially separate some of the tissue that was so meticulously connected when you had the Mueller’s muscle resection procedure. 
It is possible that swelling can resolve and your natural crease may come back, or it might be the crease became less defined or separated because of the natural healing process. Sometimes, swelling can cause this type of effect, and it takes several months to wait and see what happens. Further, any type of surgery to recreate a crease would be based on the surgeon’s preference, maybe from an approach in the outside to remove skin, or from the skin’s side directly to the levator muscle, or to do the non-incisional. I think at one month, it’s a little early to make those kinds of decisions. I think that if you’re satisfied with the eyelid height, appearance, and symmetry, allow time to transpire until you are in a better position to ensure that no further complication to the original surgery occurs by doing an intervention that’s too early. I hope that was helpful, I wish you the best of luck, and thank you for your question.

Lost my crease 1 month after mullerectomy. What are my options now? (Photo)

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Lost my crease 1 month after mullerectomy. What are my options now? (Photo)

Answers (3)

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Everything you need to know about Eyelid Surgery

Our mission is to create a world where every investment in modern beauty is Worth It.