Complications of Double Eyelid Surgery

Statistics show that in the USA the most common cosmetic surgery is breast implant whereas in East Asian countries double eyelid surgery (Asian blepharoplasty) tops the list. However, poor results from double eyelid surgery are often more difficult to disguise than breast implants as it would be impractal to wear dark glasses constantly to hide the imperfections than wearing bra. It is estimated that 10% of patients who underwent the procedures have complications resulting from the procedure. Fortunately, the majority of these can be easily corrected. A good article (Strategies for a Successful Corrective Asian Blepharoplasty after Previously Failed Revisions. Chen et al. Plast. Reconstr. Surg. 114: 1270, 2004.) published a few years ago looked at patients who presented to their plastic centres with complications relating to double eyelid surgery and their management.

In the series of patients the authors encountered, most of the complications are disappearance of the double eyelids and upper eyelid asymmetry with unequal crease height, length, and shape. Other less common complications are blepharoptosis (droopy eyelids due to damage to the muscles that open the eye), supratarsal depressions (sunken upper eyelids from too much fat removal), lagophthalmos (problem with eyelid closure caused by too much skin being removed). The following pictures show some of these complications.

Disappearance of the double eyelids. This is a common complication of suture

technique but may occur with the incision technique. It is caused by lossening

 of the adhesions between the skin creases and the levator

muscle. The treatment is reoperation.

Eversion of the eyelashes or lash ectropion. This is caused by inappropriate

suturing of the skin and levator muscle. Usually with time

or massage, the eyelid will return to normal.

Another common complication is asymmetry of the skin creases. Sometimes the differences

may be caused by swellings in which case the asymmetry will resolve with time.

However, if it is caused by poor markings at the starting of the surgery,

 the treatment of choice is to reoperate usually on

 the eye with higher skin crease.

High skin creases and sunken upper eyelids. This resulted from marking

the double eyelids too high and removing too much fat. The treatment is

to lower the skin creases and replace the lost fat either by moving the fat

downward from the upper eyelid or by fat grafting.

Ptosis or droopy eyelid, this resulted from accidental damage to the levator muscle.

Usually operation by resuturing the cut levator muscle is required.

Lagophthalmos or problem with complete eye closure is a less common

complication and usually occurs with new surgeons who excise too

much skin. Applying lubricant to the eyelid skin together with

massage, the lagopthalmos may reduce or disappear

but in severe cases, skin graft may be needed.

Could you do DST for me?

Nowaday, a lot of patients appear to obtain their cosmetic information from plastic surgery websites and want to have certain procedures because of the wonderful results some of these sites claim. I recently received an oversea email asking me to perform DST as he reads on the internet that it is a fail-safe technique for double eyelids and have little down time. DST (double sutures and twists) is a variant of the suture technique for double eyelid surgery and was described by Katsuhiro Kure and Akihiro Minami (steps as shown below). They claimed to have perform this technique for 1108 eyes over 10 years with no loss of double-eyelid line in a mean follow-up time of 32 months. However, their patients must have been very carefully selected because I have seen two cases of DST performed oversea with breakdown of the double eyelids. Some plastic surgeons claim DST stand for Durable Suture Technique to entice the patients. This technique like all suture technique only work well in patients who have thin upper eyelid without excess upper eyelid skin and fat. 

Unfortunately, this patient did not meet the criteria as he had excess upper eyelid skin and fat so the best result was achieved with incision technique that removes the skin and some fat. 

 Preoperative appearance. Note the excess skin 

and thick upper eyelid.

Immediate postoperative appearance.

Total Face Transplant

I came across this remarkable story about this American man who underwent total face transplant last week. the previous face transplants were only partial.

A MAN who had his face wiped off by an electric shock while working as a cherry picker has successfully received the United States' first full face transplant.

Dallas Wiens, 25, can look forward to a new life with a donated face attached last week by a 30-strong team at Boston's Brigham and Women's Hospital, which said it was "the first full face transplant" performed in the country.
Although plastic surgeons could not restore Mr Wiens's sight, he is otherwise on the road to recovery and already chatting, leading doctor, Bohdan Pomahac, told a press conference.
"He's awake and talking on a cell phone," he said.

"Today's tremendous news marks a new milestone in Brigham and Women's legacy in transplant surgery," hospital president Betsy Nable said.
"The pioneering achievement by the entire transplant team is a gift made possible by the most selfless act one human being can do for another, organ donation."

Before the injury.

Mr Wiens, from Texas, was injured in November 2008 when his head touched a high voltage electrical wire. The burns literally erased his face.

Dr Pomahac led the team of physicians, nurses and anesthesiologists for more than 15 hours to replace Mr Wiens's "nose, lips, facial skin, muscles of facial animation and the nerves that power them to provide sensation", a statement said.
The $302,660 cost of the operation was met by the US Department of Defense as part of research into aiding severely wounded service personnel.
Mr Wiens's grandfather, Del Peterson, thanked doctors effusively for their surgical marathon.
"You have made this day an amazing journey. And you have blessed Dallas's life and we thank you," he said.
"Dallas always said after the injury that he now had a choice: he could just choose to get bitter, or choose to get better.
"His choice was to get better. Thank God today he's better."
This was the second face transplant the hospital has done in the last four years.
A partial transplant was performed on James Maki, who fell on the electrified rail in a Boston subway station and severely burned most of his face.
Dr Pomahac, flanked by the rest of his team, said the prognosis for patients in such ground-breaking operations was good.
"I am happy to report that Jim Maki, our first face transplant recipient, is doing great and we're confident that Dallas is on a similar course," he said.

Results of Reconstructing a Poorly Repaired Eyelid Trauma

This patient underwent eyelid reconstruction 2 weeks ago to repair the eyelid defect and allow him to close his eye better. The following pictures show the preoperative and postoperative results at 1- week and 2-week.

Before the reconstruction, large defect with skin shortage

and ocular exposure on closure.

Postoperativer result at one week. Significantly improved closure.

Postoperative result at two week. Improved lid appearance despite

slight contracture.

3 Must Know Steps before Eyelid Surgery - Step 3

Here is the final step you need to know before eyelid surgery.

Double eyelid surgery: Pre and postoperative pictures.

 Double eyelid surgery: Pre and postoperative pictures.

Double eyelid surgery: Pre and postoperative pictures.

 Removal of excess upper eyelid skin: Pre and postoperative pictures.

Removal of excess upper eyelid skin: Pre and postoperative pictures.

Eyebag surgery: Pre and postoperative pictures.

 

Droopy eyelid (ptosis): Pre and postoperative pictures.

Droopy eyelid (ptosis): Pre and postoperative pictures.



3 Must Know Steps before Eyelid Surgery - Step 2

The second step is to make sure that the person who is operating on you is a registered doctor otherwise he or she is operating illegally in Malaysia. Should anything occur you will not be covered.

 If the person who operate on you is not registered to practice 

you are not covered should anything goes wrong.

All practicing doctors must register with the Malaysian Medical 

Council or they are practicing illegally in Malaysia and liable to 

persecution under the Malaysian laws. If you want to verify the person 

who is going to operate on you, you can visit the Malaysian Medical

Council website to find out if he or she is really a doctor. 

 As an example, I type my name and the site will show the

medical school I graduated from and where I practice.

All eyelid surgery are invasive procedures and should be performed 

under hygienic conditions to avoid infection. The top picture shows 

a sterile theatre where the procedure should be done. The lower 

picture shows a beauty saloon which should not be used to 

perform invasive eyelid surgery. In addition, centres without 

proper hygienic environment run the risk to transferring 

infections such as hepatitis B or AIDS between patients.

 The above patients had had poor double eyelid surgery performed 

by illegal personnel. The persons who perform the procedures 

deny responsiblities or could not be contacted.

Fillers are gaining popularity in Malaysian. Unfortunately, instead 

of injecting tested and harmless fillers, some unscrupulous centres 

inject their patients with silicone resulting in facial distortion. 

Injected silicone enlarge progressively resulting in firm masses. 

They are often difficult and expensive to remove (see arrows).

3 Must Know Steps before Eyelid Surgery - Step 1

Continuation of the lecture of "3 Must Know Steps before Eyelid Surgery"

The slide summarizes the first step before embarking on eyelid

surgery.

Some patients bring their favourite film stars and wanting to look

 exactly like them. While it may be possible to achieve some

resemblance of eye shapes, an exact copy is not always 

possible. Beware of doctors who over promise as

they often under deliver.

Pictures of film stars and celebrities before and after eyelid surgery

may mislead patients to believe eyelid surgery can make them appear

 glamorous and may be disappointed when the operations only

enhance their appearance.

Western magazine featuring glamourous female Caucasians make some

Malaysian readers wanting to achieve the same deep-set looking

eyes. Unfortunately, the results can be a facial mismatch because

of ethnic differences in the facial features (bone structures,mouth

and nose). 

This girl wanted to appear like her idol. I promises to give her good

looking double eyelids but advise against having deep set eyes as

she would appear odd and may lose her ethnic identity which

she may regret.

After eyelid surgery, there would be a period of recovery and patients

have to be aware of these and avoid being over anxious. Although

eyelid surgery can drastically appear the appearance of some

patients, most would be enhancement.

Some patients are insistent of achieving a certain look and after careful

counselling to ascertain they don't have any psychological problems,

it is safe to produce the desired results. However, it is important

 to warn the patients the resutls may be difficult to reverse.

Will continue the lecture in my next blog.

3 Must Known Steps before Eyelid Surgery - Introduction

I gave this presentation last Sunday in Jalan Yap Kuan Seng, Kuala Lumpur. For the benefit of those who could not attend the lecture, I have chosen the main points of the presentation for this and the next 3 blogs. This is the introduction bit to the presentation.

 

 The above are some of the patients I had operated on. As can be seen, 

not all eyelid operations are cosmetic surgery, some conditions can 

interferes with the vision and some may be life-threatening.

 If you show these photos to the public and ask them to rate

the persons according to intelligence, friendliness, health, 

trustworthiness,  attractiveness and whom you would are 

more llikely to employ.

The majority of the public, based on the appearance alone, 

will give positive attributes to the above photos as 

shown (tips) and more likely to employ these people.

However, what the public was unaware of were that some 

of the pictures belong to the same persons before and

post eyelid surgery. Although we want to believe that look 

or beauty is only skin deep, but most people based

their perceptions based solely on the person's appearance. 

Those who have ageing changes or abnormal eyelid

shapes are being disadvantaged in their social life.

The lecture will continue tomorrow.