Asymmetry of skin creases are common amongst attractive faces.

One of the most common cause of dissatisfaction after double eyelid surgery (Asian blepharoplasty) is unequal height of the double eyelids (skin creases). However, even in the best of hands, the lines created are likely to be slightly unequal in height and provided the difference is slight most patients can be persuaded to accept the results. In fact, it is worth noting that amongst models and film stars who are perceived as attractive, asymmetry of skin creases are common (see pictures above).

In the next article, I will discuss the causes for unequal double eyelids after surgery and ways to restore the symmetry.

Unequal double eyelids may be mistaken for droopy eyelids.

An eyelid without double eyelid may appear smaller because of the overhanging eyelid. (see why double eyelid makes the eye bigger?) If one eye has double eyelid and the other absent double eyelid, the later may be mistaken for droopy eyelid. I have come across a few patients who were referred to me for droopy eyelid when in fact the problem is absent of double eyelid in the smaller eye and the treatment of choice is to create a double eyelid. There are several ways of doing these either with non-surgical method (glue or tape) or surgery (both suture technique or incision technique).

Right eye appears to have droopy eyelid due to poorly

formed double eyelid. Creation of double eyelid balances

both eyelids.

Right eye appears droopy due to absent double eyelid.

When the double eyelid is created with tape the two

eyes appear the same size.

Below is the article which I recently published in Malaysian Journal of Medicine highlighting this condition:

Challenges in Diagnosis and Management of Pseudoptosis Secondary to Asymmetrical Skin Creases

Result of eyelid lowering procedure.

The lady with the staring look and uncomfortable eyes returned to the clinic 7 days after the lid lowering procedure. Her eyes are now not staring and the eyes are comfortable.

"People say I always stare at them and my eyes are uncomfortable"

This woman suffered from hyperthyroidism as a result of Grave's disease a year ago. While she was under treatment, she noticed her eyes became prorgressively more protruding and the upper eyelids began to retract. About 30% of sufferers of Graves' disease will also suffer from Graves' ophthalmopathy that's what this patient had. Her friends and family members were uncomfortable talking to her face to face as she always appears to be staring at them. The retraction of the upper eyelids is giving her a lot of discomfort because of rapid evaporation of the tears. She was forced to use artificial tears hourly.

To improve her appearance and reduce the discomfort, I decided to perform eyelid lowering procedure on her after making sure that her thyroid status and the eyelid retraction were stable. The procedure I used is called müllerectomy which means the removal of Müller's muscle. This is a small muscle of the upper eyelid used to open the eyelid (the other muscle is called levator). Special thanks to Dr. Ting Siew Leng for taking these photos.

Thyroid eye disease with staring eyes due to protrusion

and upper eyelid retractions.

Injection with lignocaine and epinephrine given to

the conjunctiva before operation.

The conjunctiva is cut above the tarsal plate.

The conjunctiva is exposed to reveal the underlying

Muller's muscle.

The Muller's muscle is grasped and dissected from

the conjunctiva and the levator aponeurosis.

More dissection was performed to make sure all Muller's muscle

 was included in the removal.

The Muller's muscle is clamped to reduce bleeding

before it was excised.

After removing the Muller's muscle, the conjunctiva is

closed with buried 6/0 vicryl.

The retracted eyelids were lowered at the end

of the operation.

Doctor, Can You Restore my Double Eyelids?

Revisional Asian blepharoplasty is the term used if a second operation is needed after the initial double eyelid surgery. There are many reasons for revisional Asian blepharoplasty and one of the most common reasons is to restore a double eyelid that disappears. As I mentioned in the previous blog, the disappearance of double eyelid is usually caused by loosening of attachment of the skin to the underlying levator (the muscle that open the eye) so the revision involves restoring this attachment. Depending on the presence of scar tissue, excess skin or puffiness (from inadequate fat removal), the revision can be performed with either a suture technique or incision technique. If there were no excess skin or puffiness of the eyelid, I usually use the suture technique to restore the double eyelid as it has shorter down time. Otherwise, an incision technique is needed to either remove the excess skin to give a more youthful appearance or underlying fatty tissue to allow a better adhesion between the skin and the underlying muscle.

A double eyelid restored with suture technique. There was

no puffiness or excess skin in this eye.

Another double eyelid restored with suture technique. Again,

the eye is suitable for suture technique as there is no excess

skin or puffiness.

This patient had scar tissue, excess skin and multiple folds.

An incision technique was used to restore the double eyelid.

The picutre on the right shows the result second day

 post-operative.

This patient had had suture technique done for double eyelids twice

in a beauty saloon. Examination revealed excess skin and puffiness,

she underwent revisional Asian blepharoplasty using

the incision technique.

Doctor, why does (do) my double eyelid(s) disappear?

Most patients are happy with the results of double eyelid surgery which make their eyes bigger and more animated. Unfortunately, in a significant proportion of patients these double eyelid may disappear with time causing them to seek help for restoring the double eyelid. 

Some patients whose surgically created double eyelids

disappear, loosen or fade.

Diagrams showing two main ways of creating double eyelids.

The main reason for the disappearance of the double eyelid is the loss of the attachment between the levator muscle (or tarsal plate in the suture technique) and the skin. The factors for this loss may be divided into surgeon factor and patient factor. In the case of the surgeon factor, the main one include:

a. Failure to choose the appropriate method for double eyelid creation. Essentially, double eyelid can be created by the suture technique or the incision technique. Suture technique is suitable for eyes with thin skin without puffiness (resulting from fat) and if this technique were used in eyes with puffy eyelids, the failure is high.

b. Failure to clear the appropriate amount of tissue between the skin and the levator muscle. In the incision technique, the tissues (orbicularis muscle and fatty tissue) between the skin and the levator muscle should be adequately cleared to allow proper adhesion between the structures. Failure to do this will result in loosening of the adhesion.

Diagrams showing loosening of the adhesion between the skin

and the muscle after the suture technique.



Diagrams showing detachment of the skin from the

 underlying muscle after incision technique.

In the case of the patient's factors, the main ones are:

a. Excessive postoperative swelling. The patient must follow the doctors' instruction to control the swelling by using medications and ice pack. In Failure to do can result in excessive and prolonged swelling that affect the adhesion between the skin and the levator muscle. This applies to both the suture and incision techniques.

b. Failure to take care of the lids. Excessive rubbing of the eyelids can also loosen the adhesion and this should be avoided.

In the next blog, I shall mention how I restore the double eyelids in these patients.

Kissing Naevus of the Eyelids

A kissing naevus is a type of congenital compound naevus that affects equal portions of the upper and lower eyelid. Because of its extension to the lid margins, the edges of the tumour touch or ‘‘kiss’’ during closure of the lidsAlthough not cancerous, it can cause considerable cosmetic disfigurement to the patient. This woman has had this kissing naevus for life and was very conscious of it. Whenever she went out she cover her left eye with her hair. To remove the blemish, the skin bearing the naevus was excised and reconstructed using a combination of graft and flap as shown below.

Pre-operative appearace of the left kissing naevus.

Pre-operative appearace of the left kissing naevus.

 

The initial plane of closure was marked and the skin

infiltrated with lignocaine and adrenaline.

The kissing naevus was removed leaving a raw area that

 needs to be closed. The lower eyelid defect was closed by

sliding flaps after excising a triangular area of skin.

The triangular skin (arrowed) was kept to be used as skin graft.

The lower eyelid was closed by sliding the skin on

either side of the defect. The triangular skin was

fashioned to closed the remaining raw area.

The appearance of the eye at the completion of

reconstruction.

The appearance of the eye at one-day

post-operative.