Repair of a Shortened Eye with Blinker Effect

This man sustained multiple laceration of the left outer eyelid 6 months ago in a motorcycle accident. The wound was poorly repaired giving rise to apparent shortening of the left eye and a blinker effect (see pictures 1 - 3).

Picture 1. The left outer corner is covered by the skin due to

 poor reconstruction making the eye looks smaller.

Picture 2. The covering of the left outer corner of the eye

gives rise to a blinker effect.

Picture 3. A blinker on a race horse to direct the vision forward.



There are several methods for correcting such defects. However, as this defect resembles epicanthal fold in the inner corner of the eye (see picture 4), I decided to correct the defect using skin redraping method. This has the advantage of minimal scaring. The steps of the procedure are as shown below (picture 5).

Picture 4. Epicanthal folds before and after epicanthoplasty

using the skin redraping method.



Picture 5. Steps of skin redraping. 

Special thanks to Dr Yew Yen Harn and Dr Lausanne Chua for assisting 

the operation and taking the photos.

Picture 6. Before and after the  reconstruction. 





Ptosis Surgery.

Happy Labour Day. Did three eyelid surgery today. All ptosis performed with posterior approach.

Some Patients Done Recently.

Three procedures cover most of my oculoplastic cases: Asian blepharoplasty; eyebag surgery and ptosis (droopy eyelids). Below are some selected patients from last months.  

Patient a is a male patient who has had small incision operation for double eyelids. the double eyelids should not be made too high or the eyes become feminized. Patient b had bilateral small incision double eyelid surgery coupled with non-surgical rhinoplasty. Patient c has had bilateral double eyelids done elsewhere by a plastic surgeon, shecomplains the eyes look sleepy, and examination reveals bilateral ptosis. Bilateral posterior conjunctivomullectomy was done to lift the eyes by 2mm.

Total Excision of the Upper Eyelid in a Patient with Sebaceous Cell Carcinoma

This 72 year-old woman from a remote village developed a rapidly growing lesion of the right upper eyelid. Examination showed the whole upper eyelid was invaded by the tumour. Biopsy revealed sebaceous cell carcinoma. This type of cancer is more common in Asians than other races and is not related to sun exposure like basal cell carcinoma or squamous cell carcinoma. I excised the whole upper eyelids and replaced it with the lower eyelid using a technique called Cutler-Beard's flap in August last year. 

A rapidly growing mass in the right upper lid 

destroying most of the eyelashes. 

The mass involved nearly all the upper eyelid and biopsy 

showed this to be sebaceous cell carcinoma. 

Steps of upper eyelid reconstruction in this patient. a-c. The upper eyelid

 was excised with normal looking tissue to ensure the margin is free 

of tumour. d-g. Full thickness lower eyelid was used to cover

 the defect. This was done in 3 layers: conjunctiva of lower lid 

to conjunctiva of upper lid; orbicularis muscle of lower lid 

to levator of the of the upper and skin to skin. 

h. End of the procedure. 

Appearance of the eye at one week post-operative. The patient was

discharged and given date for opening the flap in 2-month time. 

For various reasons the patient was unable to return for secondary surgery until February this year (6 months after the primary procedure). After opening the flap, she was able to move her eyelid normally and there was no recurrence of the tumour. 

a. Appearance of the right eyelid 6 months after the Cutler-Beard's procedure.

b, c, and d. Opening up of the flap. e. right eyelid at 3-week after lid opening. 

A Rapidly Enlarging Upper Eyelid Lesion

This European man, who has been living in Malaysia for the past decade, presents with a left upper eyelid mass which grows rapidly over a period of two months. The lesion bleeds easily when touch but otherwise painless. A biopsy shows this to be a squamous cell carcinoma. Skin cancer is relatively uncommon amongst native Malaysians because the presence of increased melanin offers protection against ultraviolet light which is the main cause of skin cancer such as basal cell carcinoma and squamous cell carcinoma. Europeans who live in sunny countries are at increased risk of skin cancers as their skins have less melanin. 

Preoperative appearance showing a large lesion 

involving one-third of the upper eyelid.

I excise the anterior lamellar with 5 mm clear margin. After getting clearance of the lesion from the pathologists, the raw surface is covered with bilobed flap. The patient has good result even at 3-week postoperative. The scar in white skin tends to heal better and less noticeable than patients with darker skin. 

Pictures showing stages of tumour excision and reconstruction.

3-week postoperative.

Doc, Can You Make My Double Eyelids Identical?

Skin creases (double eyelids) when present in East Asians (Chinese, Japanese and Koreans) are usually of the tapering type (see Figure 1a). Parallel skin creases are less common (See Figure 1b). Some people may have tapering skin crease in one eye and parallel in another (See Figure 1c). 

Figure 1a. Symmetrical tapering skin creases; 

Figure 1b. Symmetrical but low parallel skin creases. 

Figure 1c. Asymmetrical skin creases: right eye parallel and left tapering. 

During double eyelids surgery, it is easier to create tapering skin creases than parallel skin creases. However, sometimes despite the best effort of surgeon, the skin creases created may be asymmetrical with one eye having tapering skin crease and the other parallel. If the skin creases were not created too high, these differences are usually not noticeable on casual inspection. 

This woman underwent small incision double eyelid surgery two months ago. She had high skin creases created at 8mm. Postoperatively she developed different shape skin creases with the right tapering and left parallel. Examination showed the right medial upper eyelid is fuller than the fellow eye suggesting there was more fat on this side. This explained why parallel crease can not be formed. I performed a small incision medial to the previously created skin crease and removed fat and sutured the underlying levator aponeurosis (the muscle that open the eye) to the orbicularis muscle (the muscle that shut the eye). This successfully created the parallel crease. 

Figure 2. Asymmetrical skin crease. Right tapering and left parallel.

Figure 3. Examination show parallel crease can be created by extending 

the skin crease.

Figure 4. a. Marking was done medial to the existing skin crease; 

b. Incision was made along the marked line and fat removed; 

c. The underlying levator aponeurosis is sutured to the orbicularis; 

d. parallel crease was created.

Figure 5. One day after the surgery. 

All about the Eyes

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