What is revision blepharoplasty?
Revision blepharoplasty, also known as eyelid revision surgery, is a secondary surgical procedure which is performed to correct any complications that have arisen or to improve the results of a previous eyelid surgery. When a patient finds that they are not happy with the outcome of a past blepharoplasty procedure, perhaps due to a resulting defect or disfiguration which causes them distress, then a revision procedure may be recommended.
Revision blepharoplasty is more complex than the first procedure and can be carried out in several ways, depending on the complexity of the problem. Revision blepharoplasty covers a range of problems, the most common of which are: Lower lid retraction, scarring, rounding of the corners of the eye, hollowing of the upper of lower eyelids or residual bags and bulges.
The images opposite demonstrate very typical complications from blepharoplasty with sagging of the eyelid laterally, and in more severe cases, loss of intercanthal tilt and ectropion. These changes can be aesthetically devastating and cause significant eye pain, discomfort, and vision loss.
Why undergo blepharoplasty revision?
There are many reasons why a patient may need to undergo blepharoplasty revision surgery, but, in most cases, patients are unhappy with the results of a previous eyelid surgery. As blepharoplasty deals with a very delicate area of the face, if the procedure is not carried out by a high-skilled oculoplastic surgeon, complications can occur.
The complexity of the problem can vary significantly from person to person, including minor degrees of scarring to severe eyelid malposition, which affects the integrity of the eye and its ability to function correctly.
The most common reasons for undergoing blepharoplasty revision are as follows:
While eyelid skin typically heals very well, it can, on occasions, be too vigorous. This can lead to noticeable scars and bumps around the incision areas, which may be more visible than some patients had anticipated before undergoing eyelid surgery. If scarring is the reason for wanting to undergo eyelid revision surgery, it can usually be effectively managed with scar revision procedures.
Under corrected eye surgery
Another problem can arise when the original eyelid surgery under-corrected the initial concerns or issues. In this instance, not enough skin was removed and/or the muscle that lifts the eyelid was not sufficiently tightened during an initial blepharoplasty procedure or ptosis surgery. When this occurs, the face appears older and heavier looking. Often, the eyelids appear puffy and tired, and the upper field of vision can be impaired.
Over removal of skin or fat
Excess removal of skin in an initial eyelid procedure can cause severe issues for the patient. The most severe complications arise from changes in the lower eyelid contour, which lead to retraction and greater exposure of the eye. For example, the removal of too much soft tissue and skin from the lower eyelid can result in an increased amount of the white sclera (i.e. the white, outer layer of the eyeball) to show, while the lower eyelid hangs below the coloured iris.
Lower lid retraction changes are complex. They can cause severe soreness and dryness, as well as devastating aesthetic results for the individual. The lower eyelids sag, revealing more of the white of your eye than normal (sclera show). Although this type of problem is probably the most difficult to address, A lower blepharoplasty revision can correct the eye contour and giving it a more natural shape.
Another common complaint when too much skin or fat is removed is the poor positioning of the eyelids. An asymmetrical, unbalanced and somewhat unnatural appearance can result. Blepharoplasty revision can be performed to realign everything so that the previous symmetry can be restored.
A hollow, sunken look under the eyes may also occur if excessive fat has been removed from the area. By injecting fillers or fat transfer, the lower and/or upper eyelids can achieve volume for a more youthful appearance.
How is eyelid revision surgery carried out?
The way the revision surgery is performed will depend on the individual patient, their specific concerns, and the results of the initial eyelid procedure. Generally, corrective eyelid surgery to remove excess skin or muscle will be more straightforward than a revision procedure to remedy the results of an aggressive over correction, where the skin or fat will need to be put back in the area.
Typically, a retractor release and canthal suspension can be enough to restore eyelid position in mild cases where eyelid revision surgery is needed. However, In the most severe cases, where excess skin and fat have been removed, different layers of the eyelid will need to be built up. This is done by applying a range of materials, such as hard palate grafts, to the internal lining of the lid.
Where excess skin removal is the underlying issue, every possible avenue is explored to prevent skin grafting. Our consultants recommend multiplane midface lifting in order to move more skin into the eyelid area.
In many cases, blepharoplasty revision procedures are more challenging and more complicated than the initial procedure. Daniel Ezra uses a range of reconstructive techniques to restore the position and functionality of the eyelid. With his wealth of experience, he will operate in cases where he feels he can achieve a substantial improvement that is within the patient’s expectations. If he cannot, then he will advise against further surgery.
What happens during a revision blepharoplasty consultation?
During the initial consultation, the patient’s concerns will be carefully listened to, and a discussion will be had about the goals of the revision eyelid surgery. A comprehensive examination of the eye area will be carried out, along with the facial skin and underlying tissues, to ensure that the surgery will not compromise the health and integrity of the eyes. A detailed medical history will also be taken.
All of this will enable Dr Ezra to come up with an individual treatment plan, which is designed to address the patient’s needs. Patients will also be counselled on what the expected outcome of the surgery will be, ensuring their expectations are realistic and achievable.
In preparation for this consultation, patients will be asked to bring with them a clear timeline of the history of previous operations and also a range of photographs from before and after the initial surgery was undertaken.
How should I prepare for revision blepharoplasty surgery?
During the initial consultation, a medical history will be taken, which includes asking about current medications, allergies, previous surgeries, and smoking habits. Patients should stop smoking several weeks before surgery and should avoid taking any non-steroidal anti-inflammatory drugs, such as Aspirin, Ibuprofen or Voltarol two weeks before the surgery.
All patients having local anaesthesia with sedation or general anaesthesia will be required to consume no food or drink for at least 7 hours before surgery. Patients should also not wear make-up or apply any creams to the eye area on the day of the procedure.
Driving after surgery is not safe, so patients are strongly advised to arrange to be picked up from the hospital by a friend or family member.
What happens during the post-operative recovery period?
As with the original blepharoplasty procedure, when you awake from surgery, your vision will be blurred due to the thick antibiotic ointment that is applied to prevent your eyes from drying. This, along with prescribed eye drops, should be applied several times a day for a specified time after the procedure. Over-the-counter painkillers can be taken to relieve any discomfort.
Patients must prevent the eyes from getting wet for the first 48 hours, after which they should clean the eyes gently with soap and water and dab dry while the area still heals.
Dissolvable stitches may be applied to close the surgical area, which requires no removal. However, if removable sutures are used, then they will need to be removed after 5-10 days. The surgeon will discuss your individual treatment plan, including post-operative care, before and after the procedure.
As blepharoplasty revision is an outpatient procedure, you will be allowed to go home on the same day but should arrange for someone to pick you up from the hospital. Most people will be able to get up and walk around on the evening of or the following morning after the procedure if they feel up to it.
Swelling, bruising and puffiness is normal and common for between 1-4 weeks, varying between the type of procedure carried out and the individual patient. To help reduce swelling, ice packs can be gently applied to the area and sleeping in an upright position can also help. If any crusts or scabs appear, do not pick them off, they will fall off on their own.
Strenuous activity, such as vigorous exercise or heavy lifting, is not advised for the first week post-surgery. Walking at a gentle pace is encouraged so that patients remain mobile and can return to normal activities.
Make-up and contact lenses can be worn after two weeks. You should continue to wear sunglasses outside to protect the eyes.
How long will I need off work?
Patients will typically need between 14-21 days off from work to recover, depending on the severity of the case. Depending on the nature of the job, most people will be okay to work from home using a laptop from 48 hours after the surgery.
Is eyelid revision surgery safe?
Yes, when performed by a highly-skilled oculoplastic surgeon, a revision blepharoplasty procedure is safe. Blepharoplasty (of any form) is a very delicate operation and mistakes are not easily corrected. Not all cosmetic eyelid surgeons have the skills necessary to carry out this delicate, complex surgery. As such, it is essential to seek out a highly skilled eyelid surgeon, like Mr Ezra, who has the correct skills or training to deliver the results that patients are looking for.
Does blepharoplasty revision leave scars?
Eyelid revision surgery is susceptible to some scarring. The degree of scarring after revision blepharoplasty is dependent upon several factors, including how the initial blepharoplasty operation went, the surgeon, the ethnicity of the patient and their individual genetics and healing predisposition. As such, we always welcome patients to meet our specialist consultant, Mr Daniel Ezra, and talk in-depth about the procedure and what the post-surgery results are typically going to be.
How long should I wait before having revision blepharoplasty?
It is strongly advised that patients wait at least six months before undergoing a revision blepharoplasty procedure. This will allow sufficient time for the area to heal correctly and for patients to assess results before considering whether another procedure is necessary.
The time it can take to heal after eyelid surgery can vary between patients, but generally, most people will still notice swelling and bruising for several weeks after blepharoplasty. It is only after the patient has healed completely that they will be able to see the final result and can, therefore, determine whether their desired outcome has been achieved.
Different types of revisions:
1. The hollow upper eyelid
The upper eyelid is a very complex structure. One of the most common reasons for patients consulting is that too much tissue has been removed. If the internal scaffolding of the eyelid has been removed, such as the fat pads, this can give a hollow and gaunt appearance. This type of problem is especially an issue for patients with naturally hooded lids where blepharopasty must be carefully planned to ensure that the natural look is maintained.
Addressing these issues is complex, but will often require volume augmentation of the upper eyelid. The images below demonstrate how a combination of filler, fat transfer and surgery can be effective in reversing problems arising from this.
This patient had the right upper lid rebuilt to restore the natural hooding and improve symmetry. A small amount of skin was excised from the left to improve the symmetry.The postoperative image was taken only a few days after the surgery, showing some residual swelling.
This patient underwent upper lid blepharoplasty which left the left upper lid with a double skin crease and hollowing. This was addressed with filler injection to the upper lid and surgical reformation of the skin crease.
This patient developed significant upper lid hollowing and a raised skin crease. This was treated with a combination of fat transfer from the abdomen and a skin-crease reformation procedure, demonstrating how a fuller lid can be recreated.
2. Lower lid ectropion
This patient developed severe lower lid retraction due to excessive skin removal. This has caused the lower lid to retract and expose the eye, leaving significant soreness and exposure.
This type of complication is extremely difficult to correct, but required a multiplane midface lift to bring up more skin tissue into the eyelid. The cheek elevation was fixed at multiple points and allowed he eyelid position to normalise. Canthal fixation with canthoplasty was sufficient to address the canthal tilt in this case.
3. Lower lid retraction
This patient also developed lower lid retraction, but less severe, with no ectropion. The preoperative examination determined that there was enough skin to allow for lid elevation, which meant that the posterior layers of the eyelid were elevated with a septoretractor recession and spacer graft in this instance with Alloderm.
Note the significant improvement in the lower lid position and the obliteration of the scleral show.
4. Rounded lateral canthus
This represents one of the most difficult areas to treat. This is often caused by shortening of the tarsal plate by further shortening the lower lid. This misguided form of treatment is often difficult to recover from.
By ensuring maximum tissue preservation and fixing the lateral canthis to the lateral wall of the eye socket with internal burr-holes, the canthus can be recreated to give a sharper and more defined angle.
The images show the patient 1 week after her surgery with residual swelling, but a crisp and sharp outer corner securely fixed to the bone of the eye socket.
This patient had previously undergone upper and lower eyelid blepharoplasty 12 months earlier but had residual bags. She required a revision procedure focussing on fat debulking and reorganisation/redraping to fill the underlying hollows. The results demonstrate a very significant improvement in the overall contours of the eyelids.