Doc, can you extend my double eyelid?

This girl with puffy eyelids underwent small incision double eyelid surgery two months ago. The result appeared satisfactory, however, she wanted the double eyelid to extend out further.

Right eyelid before and after small incision 

double eyelid surgery. 

What the patient wished. The desired extension of 

the double eyelid was created by using a paper clip.

I performed a small incision fat removal combined with suturing of the orbicularis to the levator aponeurosis to give the desired result.

a. Marking was made along the desired double eyelid; 

b. Incision was made through the skin, orbicularis and orbital septum; 

c. The preaponeurotic fat was prolapsed and removed; 

d. sutures of the orbicularis and levator were made 

followed by skin to skin lid closure. 

Pre and postoperative pictures (immediately postsurgery). 

The double eyelid had been extended and 

the outer eyelid less puffy due to fat removal. 

Doc, Can You Perform Suture Technique on My Puffy Eyelids?

Suture technique for creating double eyelid is useful in thin upper eyelids. However, in  puffy eyelids the failure rate is high because the fatty tissue in front of the levator muscle will prevent adequate adhesion between the muscle and the skin. Small incision technique in which some fat is removed is the recommended technique as it has the advantage over the full incision technique in having a shorter downtime. However, some patients are adamant in having any incision done to the eyelids for fear people would know they have had double eyelid surgery. In such patients, I modify my suture technique to increase the longevity of the double eyelids by removing fat through the mini-incisions. 

A patient with puffy eyelids but didn't want any incision technique.

Modified suture technique. a. Three markings were made 7 mm above the eyelid 

margins; b. 3 stab incisions were made through the markings and the orbicularis 

and orbital septum were removed using forceps and Vanner scissors; c. fat was

 prolapsed through the small incisions; d and e. the fat was clamped and excised; 

f, g and h. 6/0 vicryl sutures were used to form the double eyelid.

The picture below was taken two weeks after the operation.

Another patient with the modified suture technique. 

The picture below was taken four months later. 

Another patient with the modified suture technique. 

The picture below was taken 6 months later.

Doc, could you balance my double eyelids?

This patient wanted to even out his unequal double eyelids (skin creases) and had seen plastic surgeons who recommended creating a higher double eyelid for the left eye. However, the patient wanted the right double eyelid to be lowered. Examination revealed that his right eyebrow is higher than the left. Further history revealed that the double eyelids was equal in height until he developed a right eyelid infection from stye 7 years ago.

Right double eyelid (skin crease) and 

the eyebrow were higher than the left.

Eyelid examination (see below) showed he actually had a right droopy eyelid and this was masked by the compensatory lifting of the right eyebrow. If surgery were done to make the left double eyelid higher, the difference in the eyebrow height will become more marked and the patient was unlikely to be happy. 

Patient lifted both eyebrows widely. 

The right eye appeared smaller than the left eye.

The right eyebrow was stopped from lifting 

and the right eye became smaller.

The correct diagnosis was right droopy eyelid (ptosis). This was  most likely to result from dehiscence of the muscle (levator muscle that opened the eye) from the eye infection that he had 7 years ago. The treatment of choice was right ptosis operation. However, he was sceptical about the diagnosis as the two plastic surgeons he consulted both recommended left double eyelid surgery. To convince the patient,  two jabs of botox were injected into the forehead to lower the eyelid.

2 X 4 units of botox were injected into the frontalis 

just above the eyebrow (red spots).

When seen two weeks later, there was an obvious right mild ptosis. The patient was now happy with the diagnosis and agreed to a right posterior approach ptosis operation.

Right eyebrow was lowered with botox. 

The right eye became smaller due to ptosis.

Double Eyelids and Fat: Case 1

The anatomy of the Chinese eyelids (also that of the Korean and Japanese) is different from that of the other races in that the orbital fat descends more inferiorly due to lower insertion of the orbital septum. This is the main reason why the Chinese has absent or lower double eyelids (skin creases) and a fuller eyelid. An understanding of this anatomical difference is essential for surgeon who perform double eyelid surgery (Asian blepharoplasty). The following cases illustrate the importance of this this anatomical difference.

This 34 year-old woman underwent double eyelid surgery 5 months earlier. She was unhappy because of the presence of extra lines radiating from the central double eyelid. This was caused by incomplete removal of the fat so that the skin and the levator (the muscle that moves the eyelid ) can not form good adhesions.

Extra lines radiating laterally from the main double eyelid.

To remove the excess line, the residual fat and the levator muscle was resutured to the skin and the overlying muscle called orbicularis oculi.

Steps taken to erase the extra lines. a and b. Marking was done to remove some 

of the skin. The lower marking corresponded to her double eyelid (skin crease).

 c. and d. The skin and ocularis muscles were removed from the marked area. 

e. The orbital spetum was open and the fat isolated and excised. 

f. and g. after the fat excision, the extra line disappeared. 

h. The levator was then sutured to the overlying muscle and skin. 

Appearance of the eyelid at 3 months.

A Boy who can't Shut His Eye

This boy was referred because of inability shutting his right eye leading to constant ocular irriation and tearing. He has had recurrent severe styes in the right upper eyelid for the past two years. Examination revealed contracture of the right upper eyelid from skin shortage. To correct the problem, the area of skin shortage was replaced with a flap from adjacent area as shown.

Everted right upper eyelid from recurrent styes (top). The everted 

upper eyelid affected problem with eye closure (bottom).

Steps of reconstruction. 

a. the intending rotation flap was marked; 

b. a horizontal  cut was made in the upper eyelid to release the contracture; 

c. Dissection was done to fully release the contracture and allow the eyelid to rest in normal position; 

d. the rotation flap was created;

 e. the flap and the surrounding tissues were underlined to allow mobilization of the tissue without tension; 

f. the flap was placed in position; 

g. the site where the flap was taken was closed with 4/0 silk and the flap was sutured with 6/0 ethilon; 

h. some trimmings was done to the flap to close better;

 i. at the end of the operation and

 j.  the temporal side of the eyelid was closed using 4/0 silk (tarsorrhapy) to immobilize the flap so that it may heal faster.

Doctor, Is this Cancer?

This man was alarmed by the appearance of a yellowish lump on the side of his left eye. He came to see me worrying that it might be a form of eye cancer. Examination showed the lump to be soft and arose from behind the globe. Its colour and location indicated this was fat that had came forward from behind the eye. The condition was more of aesthetic concern than one of functional. The fat was excised under local anaesthesia.

A yellowish lump in the upper outer corner of the left eye.

a. The lump came from behind the eyelid; b. The fat was gently pulled out after incising the

 eye white; c. The fat was clamped to prevent bleeding before cutting with scissors; 

d. After removal of the fat, the cut end was cauterized to prevent any bleeding; 

e. At the end of the surgery; f. The eye white was sutured using 8/0 ethilon.

Alternative to upper blepharoplasty: Infrabrow excision.

With age, the upper eyelid loosens and hangs over the double eyelids and if severe over the eyes giving patients a tired look. Upper blepharoplasty in which the excess skin is excised with or without simultaneous removal of the fat and muscles is a time-tested technique. However, there are some side effects associated with this technique. First, when too much is excised, the thicker upper eyelid will be sutured to the thinner eyelid at or near the junction of the double eyelids. This gives rise to an overhanging appearance (see Figure 1). Second, the removal of excess skin usually extends beyond the double eyelids which gives additional line on the sides of the eyes which may take sometimes to fade. One way of addressing this problem is to use infrabrow excision in selected patients. 

Figure 1. A patient who had had upper blepharoplasty. 

Note the overhanging thick skin (red arrows) over the skin

 creases (double eyelids) and the scars on the temporal 

side of the skin creases (black arrows)

This patient came for an eyelid consultation with the desire to lift her upper eyelids so that she looked less tired. She stressed that she did not want any extra lines beyond her double eyelids or the double eyelids to be higher than her existing ones. With upper blepharoplasty, this request could not be met (Fiture 2). However,  her eyebrows were high and the excess skin was moderate making her an ideal candidate for  infrabrow excision. After discussing the pros and cons of the procedure (the cons being additional scar below the eyebrows, change in shape of the eyebrows and lower eyebrows position), the patient opted for the procedure. 

Figure 2. The amount of skin that needs to be excised (red area) 

if upper blepharoplasty were performed in this patient.

Figure 3. Removing the skin below the eyebrow will lift 

the skin over the eyes and the skin creases.

Figure 4. Steps in infrabrow excision. a. The amount of skin to be 

excised is marked close to the inferior eyebrows; b. The skin is excised;

 c. The excised area should include both the skin and the orbicualris 

oculi (the muscle that closes the eyelid); d. The muscle is closed first 

with absorbable suture in this case 4/0 vicryl; e. The skin is closed with 

5/0 praline and f. At the end of the surgery, the skins are lifted off 

the eyes and skin creases (double eyelids). 

Infrabrow is ideal for patients without too much loose skin and who can camouflage the scars with make-up or brow embroidery. Therefore, the procedure is performed almost exclusively in females.