Don't forget to fasten your seat belt!

Before seat belt was made compulsory, eyelids lacerations were common injuries resulting from head collison against the windscreen. As an oculoplastic surgeon, I often get patients referred for reconstruction as a result of poorly reconstructed eyelids from windscreen injuries. These poor patients usually lost their eyelid skins during the laceration and the attending doctor was unable to replace the lost skin.Consequently, the remaining skins were sutured together resulting in eyelid contraction and problem closing the eyes. The treatment is to replace the skin shortage with skin grafts or flaps.

Poorly reconstructed eyelid with skin shortage.

Patient was unable to close eye.

 Reconstructed eyelid using skin from behind the ear.

Patient was able to close the eye fully.

To avoid the problem seen above it is essential to meticulously close the wounds and replace the lost skin when the patient is first seen. If the skin could not be found, the defect should be covered with skin flaps instead of just suturing the remaining skin which is a sure way of causig eyelid contraction. Unfortunatly, most of the primary doctors are not trained to perform reconstructionn in eyelid with large skin defect. The following patient was referred to me recently with a significant eyelid skin defect from windscreen injury. I performed two skin flaps to close the central defets.

Full thickness eyelid skin lost. Although the eye could close

well, when the skin grows back contraction will happen

resulting in problem with lid closure.

Areas of defect was located at the mobile part of the eyelid and

unless the skin is replaced, eyelid movement and closure

will be impaired.

The white line outlined the area of skin defect.

 Diagram showing creation of skin flaps which

were rotated to cover the defects.

Diagram showing the closure of the defect

with rotated flaps.

Closure of the skin defects with flaps.

Closure of the skin defect with skin flaps.



My Beautician Told Me I Got Funny Eyelid

This woman went to a hair saloon for a hair wash and the beautician told her that she can fixed her left droopy eyelid which she had had since birth (congenital ptosis). The beautician apparently believed that the problem was caused by the lack of skin crease and that the creation of a double eyelid would solve the problem and made her good looking.

However, what this woman had was a weak muscle resulting in failure to lift the left eye. As her muscle function was poor the only way to get it working would be to create a connection between the forehead muscle (frontalis) and the muscle that lift the eyelid (levator muscle) using a procedure called frontalis suspension as shown in the picture which I performed on a 10 year-old boy.

Unfortunately, the woman could not resist the temptation of appearing good and paid 2000 ringits to have sutures put into her left upper eyelid. Not only was the double eyelid failed to appear (as a result of the weak muscle) but the eyelid was not lifted (which was not surprising as the problem was not the lack of double eyelid). She went back to the beautician two weeks later and complained about the failed procedure. Instead of admitting her failed surgery due to her ignorance of the eyelid anatomy, the beautician scolded the patient:” I have done hundreds of this operation, and they all work wonderfully. You are the only one that fails to work. It must be something wrong with your eyelid! So don’t come back and complain to me!”

The poor woman readily believed the beautician until she met one of my patients who told her that the eyelid could be lifted by an eye surgeon. I performed the procedure using 2/0 prolene suture to connect the eyelid to the forehead muscle. Postoperatively, the patient was happy with her appearance.

Lesson of the story: “ If you want to have invasive procedure done to your eyelid by unqualified personnel, be prepared to be scolded if thing does not go well”.

The First Recorded Double Eyelid Surgery.

The first double eyelid surgery was recorded in Mikamo K. A technique in the double eyelid operation. J Chugaishinpo 1896. Mikamo was a Japanese surgeon who thought his patients with single eyelids appeared dull and unable to reveal their emotions, whereas those with double eyelids appear energetic and expressive. He observed that double eyelid can be formed through scar formation from procedures performed for entropion of the upper eyelid (inturning of the eyelid resulting in eyelashes rubbing on the cornea). He used 4/0 silk to make 3 ligations as shown in the pictures below to induce the formation of the double eyelid. Many suture techniques used nowaday are a variant of his technique.

The patient shown here was taken from his original article and she had asymmetrical skin creases with absent double eyelid in the right eye (arrowed). After the procedure, she developed double eyelid as shown. The pre and postoperative pictures were presented in a right to left fashion because the Japanese wrote from right to left.

Losing Small Part of the Lower Eyelid is the Least of His Problems

Horrible facial disfigurments are common in war. However, most leaders who launch the war would not like these pictures to be seen as it would affect the morale of the army as well as reducing the support from the general public.

This unfortunate soldier had his mid-face blown off and reconstruction involved the use of forehead flap and bones taken from the ribs. Large number of disfigured soldiers allowed the surgeons (especially the plastic surgeon) to advance their knowledge and skills in wound reconstruction, that is why progress in surgery often occurred during large scale wars.

Superb Drawings Showing How Eyelid Defects are Covered.

Techniques which we always thought were invented recently had actually been around for hundred of years.  While looking for ways to repair a large eyelid defect a few years ago, I came across this superb drawings in the UNIMAS library by a German surgeon showing how upper and lower eyelid defects could be covered. The author was Hermann Eduard Fritze (1811 - 1866) and as far as I know he had no names attached to any diseases or instruments ie. eponym. However, the techniques he described have been copied in all major plastic surgery books dealing with eyelid defects.

The Double Eyelids My Friend Gave Me

It never ceases to amaze me the number of gullible people who are willing to let unlicensed or unqualified personnels (usually beauticians) to perform invasive procedures on their faces. Many of these people will haggle from dawn to dusk over some faked cheap LV bags but will never think twice of handling over a few thousands ringgits to some quacks to have their faces butchered. Not only are these centres unqualified, they do not have the necessary hygiene standard as demanded by the Health Department. Further more, if anything went wrong these personnels usually deny any responsibilities and they don't any means of rectifying the problems. As an oculoplastic surgeon, I have come across a number of botched jobs by these unqualified personnels. When asked why they went to these dubious centres, these unfortunate souls usually said their friends or their friends’ friends say so and so can guarantee to make them beautiful. Some of these botched jobs are beyond repairs like those with distorted facial features from silicone or paraffin injection.
This woman came to see me two months ago as she had had botched double eyelid performed by her beautician friend two years ago. Apparently, her friend acquired the techniques of performing double eyelid using sutures (more on the techniques of double eyelid surgery later) from a visiting doctor from China (also not licensed to practise in Malaysia). As a friendly gesture, the beautician offered her half price to have the procedure performed in the beauty saloon. The result was the lopsided double eyelids seen here.

Asymmetrical double eyelids with multiple skin creases.

Her friend reassured her that time will heal everything but time only left her the scars that she lived to regret. I performed revisional blepharoplasty on her and cut out all the scarred tissues caused by the sutures. The excised skin showed numerous sutures which were placed in a haphazard manner indicating the operator was not skilled to perform the procedure. Postoperatively, the two eyelids appear symmetrical and for the first time in two years that she would go into the public without sunglasses.

The skin removed from the eyelids showing multiple

poorly placed sutures (arrowed).

Sutures pulled out from the excised skin.

Symmetrical skin creases at the conclusion of the revision.

The appearance of the eyes at 4 weeks.

Eyelashes with a Difference - Somehow I don't think it will Catch on.

I remembered watching a horror movie called "The Fly" as a medical student in the 1980s in which Jeff Goldberg accidentally got fly genes in him while testing his complicated "telepod" machine which turned him into half fly half human.

Now fast forward 25 years, some "clever" fashion designer had succeeded in incooperating the fly DNA into human eyelids - "Eyelashes made of dead fly legs" !

The designer may have got the idea from this child with flies on his face. This is a common sight in Sahara regions where hygiene is poor. The fly is a common vector of an eye condition called trachoma which is potentially blinding.

Just hope the girl with the new eyelahses does not get either trachoma or diarrhoea from cholera :).