What is this consultation about?
The eyelid is less forgiving than any other part of the face. It has the thinnest skin on the body, moves thousands of times a day and functions within millimeters. A difference that would go unnoticed elsewhere can change your expression here.
Revision eyelid surgery therefore begins with an important distinction: leaving some of the original problem uncorrected is very different from removing too much tissue. These are opposite problems, and the latter is much harder to address.
Common reasons for a second operation
On the upper eyelid
Remaining excess skin or uneven results between the two eyes.
An eyelid crease that is too high, too low or different on each side.
An untreated drooping brow, which can leave the eyelid looking heavy even when the surgery itself was technically correct.
Too much tissue removed, causing difficulty closing the eye or persistent dryness.
On the lower eyelid
A lower eyelid that has pulled down, exposing more of the white of the eye below the iris.
Rounding of the outer corner of the eye, changing its shape.
Hollowing caused by removing too much fat.
Persistent dryness, irritation or tearing.
Lower eyelid malposition is the most common late complication of lower blepharoplasty through an external approach. It is also particularly uncomfortable because it causes symptoms as well as visible changes.
Why lower eyelid revision is different
When a lower eyelid pulls down after surgery, a shortage of skin is rarely the only cause. Usually, three factors are involved: internal scarring that pulls downward, weak support at the outer corner, and cheek tissue that has descended and no longer supports the lid from below.
This has a practical consequence: treating only the visible problem — the skin — does not work. Unless the internal scarring is released and support is restored, the problem tends to return. Each additional operation makes the tissue more difficult to work with.
That is also why these corrections are less predictable than a first blepharoplasty. They can improve the result, often significantly, but they cannot restore the eyelid exactly as it was before the first operation. Anyone who promises that has not performed enough revision surgery.
How long to wait
Blepharoplasty results are considered final at three months. Many differences that cause concern at one month resolve on their own by then. Operating again too soon, while the eyelid is still inflamed, can make a problem worse when it would otherwise have settled.
The exception is difficulty closing the eye that leaves the cornea exposed. This needs immediate assessment and cannot wait.
What I do not do, and why
I do not perform transconjunctival blepharoplasty or use nanofat. It is important to know this from the outset in revision surgery: some corrections commonly use those approaches, and I either address them differently or refer the patient when appropriate.
What to Expect
Assessment of the tear film and eyelid laxity before recommending any procedure.
Review of photographs taken before the first operation, if available. These are the most valuable reference for the consultation.
Around two hours for more straightforward corrections. Operating time for complex repairs is determined case by case.
The final result is assessed at three months.
An honest conversation
With eyelids more than any other area, further surgery is not always the right choice. Repeated operations do not provide unlimited chances to improve a result: each leaves less tissue to work with. Part of this consultation is deciding when to stop.
References
- Patel MP, Shapiro MD, Spinelli HM. Combined hard palate spacer graft, midface suspension, and lateral canthoplasty for lower eyelid retraction: a tripartite approach. Plast Reconstr Surg. 2005;115(7):2105-14; discussion 2115-7.
- Patel BC, Patipa M, Anderson RL, McLeish W. Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip. Plast Reconstr Surg. 1997;99(5):1251-1260.
- Taban MR. Lower Eyelid Retraction Surgery Without Internal Spacer Graft. Aesthet Surg J. 2017;37(2):133–136.
- Bui H, Li D, Kim HJ. Preventing Retraction With Use of Primary Eyelid Spacer Grafts in Cosmetic Lower Lid Blepharoplasty. Aesthet Surg J. 2023;43(11):1226-1232.