Female Voice: Can a second upper blepharoplasty rectify a high irregular crease with some scar tissues? My upper and lower blepharoplasty was done nine years ago. The incisions on the upper eyelids are too high. My Asian, almond-shaped eyes were turned into rounded ones. The creases are also irregular, and there are some indented scars in them. Now that my eyelid skin is looser, with some hooding and wrinkles, can a second blepharoplasty be done? Will this remove the irregular crease lines, scars, and the wrinkles, some lateral? Can the eyelid crease be lowered? My eyebrows are at the orbital bones. Thanks.

Dr. Amiya Prasad: Thank you for your question. You submitted a question with some concerns about revision eyelid surgery, and you mentioned in your question that you feel like you have some extra skin over the eyes, as well as that your almond-shaped Asian eyes were turned into more rounded eyes.

So as a cosmetic oculofacial plastic surgeon for 20 years and a specialist in revision eyelid surgery, I certainly can share with you a lot about this particular issue. I'm going to focus more on the lower eyelid situation because we see this problem a lot. We have patients who come from all over the world. The common issue is that the lower eyelid is retracted. The term is lower eyelid retraction. In other words, what was before the surgery, a natural almond shape where the lower eyelid was at the same level as the color part of the eye, called the iris, after surgery, you get rounded. It's called scleral show lower eyelid retraction.

Unfortunately, enhancements are typically not that successful unless proper anatomy is restored. So let me help you learn a little bit about this. The lower eyelid is actually a very complex structure. Its position is a balance of several factors. One factor is the lateral canthal tendon, which is what attaches the lower eyelid to the inner aspect of the bone. The other factor is the vertical support of the lower eyelid. In other words, there is anatomy underneath that is like a suspension bridge in a way, where there are pillars below that are keeping that area up.

Then, of course, is the integrity of the skin and the orbicularis muscle. The orbicularis muscle is like a support muscle. It's like a hammock, and it holds the eyelid in position. Very commonly, well-meaning plastic surgeons will do this procedure from the outside, take away the fat, and then place the skin back and then trim off skin, without doing anything to restore the integrity of the lateral canthal tendon and appreciating that there may not have been as much skin excess as they initially believed.

Because what happens during surgery is when the person is lying down, there's a shifting of everything upwards. So it can appear like there's more skin than there actually is. So what ends up happening, there's a skin shortage. There is a loss of the pillars that I described earlier. That causes the lower eyelid to sink. Then because the lateral canthal tendon is not properly reenforced, everything sags.

So your revision procedure for your lower eyelid is likely to be more involved than just doing a simple tuck-up type of procedure or a limited procedure. A lot of our patients have had multiple revisions before they came to see us. Very often, they end up with more skin shortage. They end up with wider scars, and we have to do a lot more surgery. This includes a combination of grafting of tissue on the inside of the eyelid, grafting of skin on the outside of the eyelid, and even doing something called a drill hole canthopexy, where we make little holes in the bone in order to restore the integrity of the tendon.

Now, I'm not saying that you will need all those things, but it is important to understand that these three elements of balance are very important for lower eyelid position and restoring of that anatomy. So I think you have a lot to discuss with your doctor. It is very important that you and your doctor have a meeting of the minds.

One of the things that I also describe, in terms of tempering this concern about post-operative results, is that a lot of people actually like that rounded look. In the upper east side of Manhattan, that type of look is walking around all over the place. So it is . . . The people who have that look feel that they look really good. So it's a meeting of the aesthetic values of the patient and the doctor that ultimately defines the success of a procedure.

But when it comes to eyelid surgery, it also is a critical factor that the health and integrity of the eye itself be maintained and protected. So I think that once you have an understanding of what your doctor is recommending, if you feel comfortable and confident that things will work out with any type of revision surgery your doctor is suggesting, then you can certainly move forward with having that done.


Can Pulled Lower Eyelids Be Corrected After Surgery?

Dr. Amiya Prasad details the importance of restoring the anatomy of the eyelid after a previous surgery caused lower eyelids to pull down.