Case 7: Doctor, Why Are My Double Eyelids Unequal?

Fat in the upper eyelid contributes to fullness of the lids. During double eyelid surgery, some of these fat are usually removed to allow better adhesion between the skin and the underlying tissue. However, if too much of this fat were removed, the upper eyelid may appear hollow and worse still some patients may develop multiple skin creases above the double eyelid. Therefore, experienced surgeon knows the importance of not aggressively removing the fat.

 

Sunken and hollow upper eyelid caused by excessive fat excision.

Also note the extra lines above the double eyelids.

Diagrams showing what happens when too much fat is removed.

a. Normal contour of double eyelid after procedure

b. Too much fat removed (red arrow) causing depression (hollow) upper eyelid

c. To overcome this problem the fat compartment needs to be pumped up (blue areas)

with either fat or substitutes such as hyaluronic acid.

 

 

The way to treat an eye that have too much fat removed is to replace the volume. This can either be fat transfer from other part of the body or using substitue such as fillers. The best filler with good safety record is hyaluronic acid.

 

Picture showing left sunken socket and extra lines due to fat depletion.

Hyaluronic acid was injected into the depressed area (arrows)

to pump up the sunken area and removed the extra lines.

(the last picture was taken immediately after injection)

 

Another patient with too much fat removal causing left sunken lid.

The lower picture was taken a few days after hyaluronic acid injection.

 

 

Case 6: Doctor, Why Are My Double Eyelids Equal?

Amongst East Asians (Chinese, Japanese and Korean), unequal double eyelids appear to be common in the normal population. Most cases are caused by poor attachment between the skin and the levator muscle in one of the eye. A study performed in Korea showed a prevalence of unequal double eyelids (in which one eye had double eyelid and the other without) is about 10.9%.

 

Song WC; Kim SJ et al. Asymmetry of the palpebral fissure and upper eyelid crease in Koreans. Journal of Plastic, Reconstructive & Aesthetic Surgery (2007); 60, 251-255

The eye without the double eyelid tends to appear smaller because of the eyelid skin hanging over the lid margin. This may sometimes be misdiagnosed as droopy eyelid. Treatment is to create a double eyelid similar in height to the eye with the double eyelid.

 

This patient was born with absent right upper skin crease. Over the year, she had been using glue and tape to create a double eyelid but find it time-consuming. She wanted a right double eyelid with minimal down time. I performed a DST (double suture twisting technique), the result appears satisfactory at one week follow-up without noticeable swelling.

 

Right double eyelid creation using DST.

 

Case 5: Doctor, Why Are My Double Eyelids Unequal?

To prevent the loss of double eyelids (skin creases) or ones that are shallow, it is important to create good adhesion between the levator muscle and the orbicular muscle and skin (photos showing the procedure). However, several factors may prevent this from happening and these factors may be divided into surgeon and patient factors.

 

Surgeon factors:

• Failure to clear adequate amount of tissue between the skin and the levator muscle.  This can interfer with correct adhesion between the structures.
• Inadquate anchoring of tissue between the orbicularis/skin and the levator muscle. There should be adequate area of contact between these tissues or the skin creases can easily disappear with time.

 
Patient factors:

• Excessive postoperative swelling. Prolonged swelling will affect the adhesion between theskin and the levator muscle.

• Failure to take care of the lids. Excessive rubbing of the eyelids can loosen the adhesion.

This patient presented with asymmetrical double eyelids. The left double eyelid is well-formed but that of the right one is shallow. This is due to inadequate adhesion between the levator and the skin.

 

Shallow right double eyelid.

 

There are several ways of recreating the adhesion: either by incision or suture technique. With the incision technique, the skin crease need to be incised along its length and the tissues resutured, however, this can create significant post-operative swelling in lid that had had surgery before. I opted for the suture technique and the post-operative result appeared satisfactory at two weeks.
 

Steps in suture technique to deepen

the double eyelid.

 

Postoperative appearance.

 

 

Case 4: Doctor, Why Are My Double Eyelids Unequal?

Postopertive swelling is a common cause of asymmetrical double eyelids (skin creases). This occurs especially in patients who needed more tissues (skin, muscle or fat) removed from one eye than the other. The swelling is usually worst on the first post-operative day. Cold compress to the upper eyelids  every 2 to 3 hour (each time for about 10 minutes) can significantly reduced the swelling. Depending on the extent of the procedure, the swellings may take one week to a few weeks to subside.

 

This patient (see pictures below) had excess upper eyelid skin and eyebags. She had excision of the excesss upper eyelid skin and fat and extended lower eyelid surgery. Because of the extent of the procedure, there was significant swellings the next day causing asymmetry of the eyelids. With cold compress, the swellings and hence the asymmetry improved after one week and continued to do so with time.

 

a. Before the operation;

b. 24 hours post-operation;

c. one week post-operation and

d. two weeks post-operation.

 

Case 3: Doctor, Why Are My Double Eyelids Unequal?

Another cause of unequal double eyelids is unrecognized ptosis (droopy eyelid as a result of weak muscle) before surgery. Therefore, it is important for surgeons to make sure that the two eyes are the same size before double eyelid surgery to avoid any post-operative surprises.

 

This young woman underwent double eyelid surgery three months ago but had been trouble by unequal heights of the double eyelids being significant higher on the right. Examination revealed mild right ptosis with good eyelid function.

 

Right double eyelid higher due to ptosis.

 

Good function of the muscle moving the eyelid.

 

The treatment of choice in this case is to advance the muscle that moves the eyelid (levator muscle) so that right double eyelid is the same height as that of the left. I used the posterior approach method of advancing the levator muscle. This technique has the advantage of not cutting through the skin so that the down time is shorter.

 

Posterior approach ptosis repair.

Pre (I) and post (II) operative repair of

the right ptosis.

 

Case 2: Doctor, Why Are My Double Eyelids Unequal?

In case 1, I discussed asymmetrical double eyelids (skin creases) caused by unequal markings. In this case, the patient has equal markings but the amount of skin removed were unequal.

 

A 60 year-old woman complained that her double eyelids were uneven and wanted  revision. Examinion revealed the skin creases are of equal heights but there was loose skin of the upper eyelids.  The cause in this case was unequal removal of the upper eyelid skin with more being taken from the left than the right.  The excess skin on the right eye then covered part of the double eyelids making it look lower. The problem was easily rectified by removing the excess skin in the right eye as shown below.

Asymmetrical double eyelids.

The right one appeared lower.

The double eyelids (skin creases) were more or less

the same height but the right double eyelid is

covered by excess skin (arrows).

Two weeks after revision. The excess skin on the right

eyelid was removed and the double eyelids now

appear even.

 

The right way to prevent unequal double eyelids (skin creases) is to mark the double eyelid the same height and then removing the same amount of excess skin. The height of the double eyelids should be checked from time to time during the operation so that any uneveness can be addressed perioperatively (see pictures below).

 

Equal markings of the height of the double eyelids and

the amount of skin are keys to preventing

uneven double eyelids.

 

 

Case 1: Doctor, Why Are My Double Eyelids Unequal?

Nothing causes more distress to patients who underwent upper eyelid surgery than unequal double eyelids (skin creases). Granted most double eyelids are unlikely to be exactly the same height even in the best hands but gross asymmetry are unacceptable to the patients.

This woman underwent upper eyelid blepharoplasty for excess upper eyelid two months ago. She came to see me and asked for revision. Examination revealed gross asymmetry of the double eyelids (being noticeable on the left eye but almost absent in the right eye because it was covered by the excess skin). Examination revealed that the double eyelids have been created unequally.

This problem usually occurred preoperatively because the surgeon failed to make proper measurement and marking before the surgery. The solution is to redraw new lines of equal heights and excise the excess skin especially on the right eye.

 

Asymmetrical double eyelids.

Asymmetrical double eyelids with the eyes closed.

Unequal height of the double eyelids with the eyes

looking down and the eyebrows lifted.

Symmetrical double eyelids after surgery

for comparison.

 

Skin Cancer Around the Eyes

Althought I am an eye doctor who subspecailizes in eyelid surgery, I am often referred cases involving areas outside the eyelids. This patient has a non-healing ulcer on his nose which has increased gradually over the past 6 months. The biopsy reveals this to be a basal cell carcinoma. If left untreated this cancer can destroy the tissues and even death. The treatment of choice is excision of the skin with good margin to ensure complete clearance of the tumour. The defect is then reconstructed using nearby skin such as the face or the forehead. In this case, the defect was covered using a glabellar flap.

A non-healing ulcer of the nasal area.

 

Destruction of the nose if the tumour were left

untreated.

 

The tumour is marked with free margin to ensure

adequate excision of the tumour.

A glabellar flap is fashioned to covered the defect.

The forehead wound is closed directly with silk.

The flap is thinned before used to cover the defect.

The defect is covered and the flap is trimmed

to ensure  a good covering.

 

At the end of the surgery, the stitches are left

for two weeks.

 

 

Not All Double Eyelid Surgery is for Aesthetic Reason

This young boy came to my clinic because of a long-standing history of right ocular irritation. The vision was also slightly reduced (6/12). On examination, he was noted to have absent right double eyelid (skin crease) and a left well-formed double eyelid (skin crease). The eyelashes in the right eye are pushed downward by the skin causing them to rub against the eye and hence the irritation. The irritation was abolished when the eyelid was lifted.

 

Right absent skin crease causing misdirection of the eyelashes.

 

 

To lift the eyelashes, I create a double eyelid (skin crease) using the interrupted suture technique. The procedure concentrated mainly on the nasal aspect of the eyelid (where eyelash misdirection was the most severe).

 

 



 

The ocular irritation improved instantly after the procedure. The post-operative picture was taken at 3 months showing well-formed double eyelids and the eyelashes are now pointing outward instead of inward and downward.