홍진주성형외과

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Eyelid Revision

  • 홈으로
  • Ophthalmo plasty
  • Eyelid Revision
[ Cause of depressed scar and eyelash eversion ]

Excessive removal of muscle and soft tissue just below the double eyelid line
There is abundant soft tissue in the outer layer of tarsus in Oriental eyelids, which separates the levator muscle and tarsus from the covering skin. Although an adequate amount of tissue should be removed, excessive, irregular removal can make a deep depressed scar on the double eyelid line.

If the muscles and tissues are excessively removed, the multi-layered structure is distorted resulting disruption of the normal structure underneath the skin. The irregularity of the surface with interrupted shadow makes the scar depressed.

The skin surface smoothness could be restored by scar excision and realignment of the layered structure along the normal skin crease.
Excessive removal of muscle and soft tissue just below the double eyelid line
After soft tissue reduction, the marginal skin should be fixed firmly to the deeper structure (tarsus, levator muscle or aponeurosis) to form an adhesion. At that time, the dissected skin can be fixed in various manner.
If it is fixed in method 1(fixed to the higher position), the skin would be stretched and thinner than upper skin. The step deformity occurs on the line due to the skin thickness difference between upper and lower side. It creates a depressed scar and deep fold. The eyelashes are lifted than the normal position and then hidden white mucosa might be exposed unnaturally.

If it is fixed to a lower point like method 3, the skin under the double eyelid line is loosely sagging over the eyelashes, and the fold becomes shallow or easy to relapse
If the depressed scar is combined with the eyelashes eversion, the skin below the line should be fully dissected and fixed in a neural relaxed line (Method 3)
Not parallel to the natural skin crease
If the line is not parallel to the natural skin crease. The skin folds unnaturally with irregular unwanted wrinkles. Irregular multi-folds make discontinuous shadows which are more prominent than a wide scar tissue. This irregular discontinuous silhouette makes unnatural “Plastic Surgery” look

=> It is necessary to align the irregular shadow of the unnatural skin folds by correcting the line parallel to the natural skin crease.

The skin edge alignment of the suture should be even to each side
Wrong edge alignment Correct edge alignment


[ Pretarsal fullness “Sausage deformity” ]
(Too High fold)

The thickness of the double eyelid is proportional to the height of the double eyelid. Because the higher the double eyelid, the thicker it can look, in designing the double eyelid, the appropriate height should be chosen to avoid “sausage like deformity” even if the skin is thick.

From low to higher line, there is a height that becomes thick sausage like fold, which is called the "upper limit of the height". If you get a double line below this upper limit, it will not be a sausage.

On the other hand, when the line is set too low, it becomes a so-called "hidden double eyelid fold" in which the eyelash and skin lower than a line is hidden when the eyes open wide. Therefore, if the height of the double eyelids should be designed in the range between 'sausage' line and 'hidden double eyelid' line to get a proper result.
Sausage deformity due to the excessively high line.
The only solution is lowering the line by reducing the skin between the high line and the target low line, then the pretarsal fullness is relieved.
Sausage deformity with normal line
In the case of ptosis, the double eyelid looks bigger even if the line is not that high. Eye-opening is insufficient to remain most part of lid unfolded. The levator modification for eye-opening enhancement is the procedure of choice.
Sunken Eye, Insufficient fat in upper eyelid
In sunken eye deformity, the middle portion of the eyelid is depressed due to insufficient fat tissue. Then, the skin over the line cannot overlap the lower side. Unfolded lower portion looks like a high fold double eyelid.

If the sunken eye is corrected with fat injection or filler, the normal fold can be created to become a normal double eyelid fold.
The eyelid skin overlaps with the lower part. Volume deficiency
Insufficient overlap of the skin each other—looks like a high fold line


[ Triple folds ]
(Multifolds)
Unwanted extra skin folds in the eyelid

Insufficient fat or soft tissue in the eyelid
The structure of the eyelids is the outermost skin, beneath which is muscle, soft tissue, and fat
Sufficient volume of fat and soft tissue :: The skin above the double eyelid overlaps enough each other. Also, the upper side of the double eyelid has enough volume so that the extra folds are not created.
Insufficient volume of fat and soft tissue :: The skin above the eyelid is folded separately and extra folds are formed(Triple folds).
Sufficient volume of fat and soft tissue
The skin above the double eyelids sufficiently covers the skin below the double eyelids
Insufficient Volume
Triple fold occurs on the upper eyelid
Improvement of triple folds by compensating the fat in the upper eyelid.
Adhesion due to excessive dissection
After the revision operation of a high double fold height, adhesion may occur at the previous line, which may cause triple fold.
Loosening the adhesion and place some fat and muscle to prevent recurrence.
Interpositional fat and muscles also form a volume to prevent triple folds. In addition, eye-opening enhancement procedure (levator modification procedure) is more effective.


[ Shape of double eyelid ]

designing double eyelid line
Skin crease lines are the result of a complex interaction between internal and external factors involving the skin. Generally, they are perpendicular to the underlying muscles of the face. In the upper eyelid, the eye-opening moves in vertical dimension, the crease lines are created horizontally.

A natural double eyelid line is folded along the natural skin crease. Therefore, when designing the double eyelid line, it should follow this skin crease or those parallel to the crease.
design along the natural skin crease
Two important points in making double eyelids naturally.

:: Proper height of the double eyelid line
:: Design along natural skin crease
It is the most natural line when designing according to proper height of the skin crease at an adequate height.
Irregular lines due to scarring
Occasionally, the uneven location of depressed scarring can cause a line irregularity. It is because the muscles and soft tissues removal or the depth of the skin fixation is not consistent along the incision.
In this case, it can be resolved by removing the scarred skin like a normal scar revision and fixing the depth consistently
Inside and Outside Folds
Three types of double fold. The lid margin may be closed (“inside” fold) or open (“outside” fold) at the medial end according to whether or not the two upper outlines of the eye, the edge of the skin fold and the true lid margin with the eyelashes, join together medially. (c) In the “in/out” or “neutral” fold, the medial side is open with a small gap, but the height of the lid margin is gradually increasing laterally
In-fold out-fold in/out-fold
Three types of double fold. The lid margin may be closed (“inside” fold) or open (“outside” fold) at the medial end according to whether or not the two upper outlines of the eye, the edge of the skin fold and the true lid margin with the eyelashes, join together medially. (c) In the “in/out” or “neutral” fold, the medial side is open with a small gap, but the height of the lid margin is gradually increasing laterally

'Appropriate line height' is more important than in/out shape'

Too vertical and strong Epicanthal fold
Inout-fold impossible, In-fold operation is recommended
However, even in the in-fold shape, the double eyelid fold should begin as early as possible from the innermost side. If the inner line is too low, it looks narrow and smaller palpebral aperture.


[ Epicanthoplasty revision ]

Excessive opening

※ *Lacrimal Lake : "the pond where the tears are poured." The red part on the inside of eyes
The ideal exposure for Lacrimal Lake is about 1/3 to 2/3.

More than 2/3 of the exposure is likely to give an unnatural and ferocious impression
If Lacrimal Lake is exposed to too much, Epicanthoplasty revision should be done.
The incision is made along epicanthoplasty scar, the skin is dissected to be moved, the opening should be closed in the manner of the zipper closure. (V-Y advancement)
Ineffective previous epicanthoplasty
The shape of the inner corner is more important than the degree of lacrimal lake exposure.
Round unnatural shape should be transformed into ideal triangular shape by simple trimming without further exposure of Lacrimal Lake.

Resect and trim the skin adequately


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