Are Oculoplastic Patients Vain?

Most people assume oculoplastic surgeons deal mainly with patients who are vain as shown by this humourous poem below (from Survey of Ophthalmology).

A Resident's Lament (Akshay Gopinathan Nair MBBS, Michael F. Marmor MD)

As I study now to be an eye MD,
I ask what kind of doc I want to be.
It is a rather daunting question
That raises fear and apprehension,

As each eye part has its own specialty!
Should retina be the field in which I train
To find a tear or subtle new membrane?
But I seem to give my patients aches
When I indent to find their breaks
And that just makes for too much mental strain.

Perhaps it should be neuro-ophthalmology:
The optic nerve, its path, and its pathology.
But when there’s pallor, one asks Why?
With CT, PET, and MRI …
So why not just go into radiology?

My surgery could be limited to refractive.
I’d soon build up a practice, very active.
Though YAGs and excimers do magic
The odd myopic surprise is tragic:
On balance this may not be so attractive.

Then how about procedures oculoplastic
On skin that is no longer so elastic?
But operative hours are long (a pain),
And patients they are, oh, so vain.
It’s hard not to say something too sarcastic.
Perhaps glaucoma is the field to choose,
Though pressures, fields, and angles do confuse:
Does pressure cause the nerves to die,
Or sick nerves yield when pressure’s high?
I’d like a field where fewer patients lose.

Strabismus is another possibility,
To repair defects in the eye’s motility.
But waiting rooms with children crying
Would, in time, become quite trying
(From residency right through to my senility).

With so much then to learn, is it reality
To limit oneself to only one modality?
The eye is wondrous and diverse!
I think I’ll embrace, for better or worse,
The field of ophthalmology in totality.

Although most of my private patients are concerned with double eyelids and eyebags; a large proportion of my patients seen in the Sarawak General Hospital are concerned with non-cosmetic eyelid conditions such as eyelid tumours and eyelid malpositions referred from all over Sarawak. A recent example is this patient who developed a right cicatricial ectropion (retraction of the eyelid as a result of scarring) after facial infection.

Retraction of the left lower eyelid as a result

of facial scarring.

Steps used to correct the retraction.

Appearance of the eyelids at second week

post-operative.

Doctor, Why are My Double Eyelids Unequal? Part III

Another important cause of unequal double eyelid height is due to unequal removal of the eyelid skin. This is especially common in older patients with excess skin, the eye where less skin is removed will result in the eyelid hanging over the double eyelid making the double eyelid appears lower.

The picture on the left shows equal amount of skin to be removed is marked whereas the picture on the left shows that the left upper eyelid has more skin being marked for removal.

This woman underwent a double eyelid surgery in a beauty saloon. Unfortunately, the left double eyelid appeared lower than the right (right picture). She went back to look for the "surgeon" but was told that she had returned to China without forwarding address or telephone. Examination showed that more skin had been removed in the right than the left eye. Revision was carried out by removing the excess left upper eyelid skin.

Doctor, Why Are My Double Eyelids Unequal? Part II

Case 1. A patient who had double eyelid surgery done

elsewhere. Left skin crease higher than the right.

Case 2. Another patient with a higher left skin crease

performed elsewhere.

As mentioned in the previous blog double eyelid (skin crease) asymmetry is one of the most common complaints from the patients undergoing double eyelid surgery. Unequal skin markings before the operations is an important cause of the asymmetry and to avoid this:

a.  It is important to mark the skin prior to any anaesthetic injections to avoid distortion of the tissue.

b. In addition, double eyelid surgery should be postponed if there is any eyelid swelling which again can distort the tissue for symmetrical markings.

c. During the markings, the measurement should be precise and ideally a caliper (as shown in the picture) should be used rather than a ruler.

d. Another important thing to remember during markings is to ensure that the skin of the eyelids are under equal tension (see pictures below).

The marking is done with a caliper with the eyelid skin

under tension by pulling on the eyebrow.

Marking with a caliper with the eyelid relaxed. Note that the

marking, even though marked at 6mm as the picture above,  

produce a line higher than when the skin is under tension.

Doctor, why are my new double eyelids unequal?

Several studies looking into the complications and patient dissatisfaction of double eyelid surgery found that unequal double eyelids (asymmetry of the skin creases) is one of the most common complaints (see references below). While unequal double eyelids are common immediately after double eyelid surgery, their persistence beyond 4 weeks should be regarded as permanent. Patients who have significant unequal double eyelids (more than 1 mm different) often seek help to address the imbalance. 

This 38 year-old underwent double eyelid surgery in a beauty saloon using the suture technique. The procedure was performed by a "doctor" from China of dubious qualification. Post-operatively, she noticed significant unequal double eyelids. Despite repeated reassurance from the beauty saloon owner, the asymmetry remained 8-week post-operative. Unfortunately, the surgeon had since gone and could not be contacted.

The three possible causes of this deformity noted were:

a.       The difference in measuring and marking the skin for suturing or incision

b.      Different skin tension while doing supratarsal fixation and

c.        Differing widths of skin excision in upper eyelids.

References:

1. Strategies for a successful corrective Asian blepharoplasty after previously failed revisions. Chen SH, Mardini S, Chen HC, Chen LM, Cheng MH, Chen YR, Wei FC, Weng CJ. Plast Reconstr Surg. 2004 Oct;114(5):1270-7; discussion 1278-9.
2. Complications of Oriental blepharoplasty. Weng CJ, Noordhoff MS. Plast Reconstr Surg. 1989 Apr;83(4):622-8.
3. Unfavorable results in Oriental blepharoplasty. Hin LC. Ann Plast Surg. 1985 Jun;14(6):523-34. No abstract available.