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Woman: What causes this complication of eyelid surgery? Do you think it is the mark of an inexperienced surgeon? I had incisional bleph plus ptosis repair. Whose fault was it for the bleph or ptosis? I read the doctor's operation report and it had no mention of fat removal. There was skin excised and a mullerectomy was performed, and eight millimeters of skin or muscle was excised. I don't remember what the report said but it was one of those two.
Dr. Prasad: Thank you for your question. You've submitted a set of photos and you expressed in your question that you're concerned about the quality of surgery and the level of experience of your surgeon after you underwent Asian eyelid surgery combined with ptosis surgery.
Let's start by just reviewing what appears to be on your photos that is of concern. When we look at your right eye, there appears to be several folds of skin on the right upper eyelid. It appears that the right eye was the eye that had the ptosis surgery. There is a slight difference in the type of exposure that I'm seeing in the first and second photo but it appears to be a change. It looks like the right eye is more elevated compared to the previous photo.
The question that you now are asking is about level of experience and the quality of the surgery. Well, you described in your question that the procedure performed was a Muller's muscle resection. As well as the removal of 8 millimeters of skin. So let's understand a little bit about what the purpose of ptosis surgery is, and this approach, and what can be options that you can discuss with your surgeon.
First of all, elevation of the eyelid using a Muller's muscle resection surgery is a standard operation done for eyelid ptosis. It has several advantages which includes avoiding the approach anteriorally from the front to elevate the eyelid approximately two millimeters. Removal of a thin strip of skin may have been adequate at the time of surgery, but sometimes the reality is the connection between the eyelid skin and the levator muscle which is necessary in order to create an eyelid crease can loosen or separate resulting in this multiple folded appearance.
As far as the height is concerned of the eyelid, this is something that every oculofacial plastic surgeon deals with. That is the predictability of ptosis surgery. Ptosis surgery is very sensitive to factors that occur intraoperatively and post-operatively. Unfortunately that results in some variability. Although best efforts are made to try to maximize the predictability. For example, in our practice when I do ptosis surgery, I actually have my patient open and close their eyes during the surgery. They don't feel anything but they're actually able to cooperate so I can try to maneuver and adjust the eyelid height and contour as well as I can. In fact, we actually sit the patient up during surgery to see, to make sure that we can get maximum symmetry.
As a general rule of thumb if the eyelid height is within two millimeters of symmetry between the two eyes, usually aesthetically it doesn't make much of a difference. Depending on the time frame since your surgery, you may want to consider just observation because sometimes swelling can have an impact on the eyelid height.
As far as the multiple eyelid creases are concerned, when I am faced with this type of issue, I have successfully been able to create a restoration of the crease using an non-incisional method. This being based on the report that you had some skin already removed. The multiple folds is not likely due to excess skin. If your eyes are closed, you can actually assess if there is excess skin but chances are there isn't.
How do we re-create a crease? Well using the non-incisional technique by making some fixed entry points from the outside and connecting the skin and orbicularis muscle to the levator muscle. We have been able to help a lot of our patients just get their ideal crease. Even after an incisional surgery where the crease wasn't as well defined.
I think you need to maintains some faith in your doctor. And communicate with your doctor about these results. I think that if you made the decision to choose this doctor based on your research prior then there's a good chances as long as this doctor is being open and communicating with you that revision procedure may be ultimately best performed by your prior surgeon. If of course you want to get additional opinions, then certainly you can do that. But in general it's always good to have the first surgeon, especially who's a specialist in this area who knows your anatomy and knows what they were dealing with during your surgery, very often a small revision can go a long way.
Again to recap our discussion, the ptosis procedure may still be close to where you want depending on how far out you are in terms of swelling and the correction of the multiple creases can possibly done by a non-incisional Asian eyelid fixation suture technique.
I hope that is ...
Dr. Prasad: Thank you for your question. You've submitted a set of photos and you expressed in your question that you're concerned about the quality of surgery and the level of experience of your surgeon after you underwent Asian eyelid surgery combined with ptosis surgery.
Let's start by just reviewing what appears to be on your photos that is of concern. When we look at your right eye, there appears to be several folds of skin on the right upper eyelid. It appears that the right eye was the eye that had the ptosis surgery. There is a slight difference in the type of exposure that I'm seeing in the first and second photo but it appears to be a change. It looks like the right eye is more elevated compared to the previous photo.
The question that you now are asking is about level of experience and the quality of the surgery. Well, you described in your question that the procedure performed was a Muller's muscle resection. As well as the removal of 8 millimeters of skin. So let's understand a little bit about what the purpose of ptosis surgery is, and this approach, and what can be options that you can discuss with your surgeon.
First of all, elevation of the eyelid using a Muller's muscle resection surgery is a standard operation done for eyelid ptosis. It has several advantages which includes avoiding the approach anteriorally from the front to elevate the eyelid approximately two millimeters. Removal of a thin strip of skin may have been adequate at the time of surgery, but sometimes the reality is the connection between the eyelid skin and the levator muscle which is necessary in order to create an eyelid crease can loosen or separate resulting in this multiple folded appearance.
As far as the height is concerned of the eyelid, this is something that every oculofacial plastic surgeon deals with. That is the predictability of ptosis surgery. Ptosis surgery is very sensitive to factors that occur intraoperatively and post-operatively. Unfortunately that results in some variability. Although best efforts are made to try to maximize the predictability. For example, in our practice when I do ptosis surgery, I actually have my patient open and close their eyes during the surgery. They don't feel anything but they're actually able to cooperate so I can try to maneuver and adjust the eyelid height and contour as well as I can. In fact, we actually sit the patient up during surgery to see, to make sure that we can get maximum symmetry.
As a general rule of thumb if the eyelid height is within two millimeters of symmetry between the two eyes, usually aesthetically it doesn't make much of a difference. Depending on the time frame since your surgery, you may want to consider just observation because sometimes swelling can have an impact on the eyelid height.
As far as the multiple eyelid creases are concerned, when I am faced with this type of issue, I have successfully been able to create a restoration of the crease using an non-incisional method. This being based on the report that you had some skin already removed. The multiple folds is not likely due to excess skin. If your eyes are closed, you can actually assess if there is excess skin but chances are there isn't.
How do we re-create a crease? Well using the non-incisional technique by making some fixed entry points from the outside and connecting the skin and orbicularis muscle to the levator muscle. We have been able to help a lot of our patients just get their ideal crease. Even after an incisional surgery where the crease wasn't as well defined.
I think you need to maintains some faith in your doctor. And communicate with your doctor about these results. I think that if you made the decision to choose this doctor based on your research prior then there's a good chances as long as this doctor is being open and communicating with you that revision procedure may be ultimately best performed by your prior surgeon. If of course you want to get additional opinions, then certainly you can do that. But in general it's always good to have the first surgeon, especially who's a specialist in this area who knows your anatomy and knows what they were dealing with during your surgery, very often a small revision can go a long way.
Again to recap our discussion, the ptosis procedure may still be close to where you want depending on how far out you are in terms of swelling and the correction of the multiple creases can possibly done by a non-incisional Asian eyelid fixation suture technique.
I hope that is ...
Complications From Asian Double Eyelid Surgery Combined with Ptosis Repair
Dr. Amiya Prasad discusses the possible complications of Asian eyelid surgery coupled with ptosis correction and a revision procedure to create a more defined eyelid crease without further incisions.
