Revisions in Suboptimal Cases

This chapter illustrates various conditions that required revision (correction of suboptimal results), all with prior surgery that may have included buried sutures methods and/or incisional methods. The contrast between Asian eyelids and those of Caucasians, and the diversity even among Asians themselves, are what makes Asian eyelid surgery such an interesting and challenging art.

Case 1 (Figure 16-1)

Skin blanching following application of local anesthetic in a patient undergoing revision or touch-up correction. The previously operated skin here is tighter and shows less spreading of the injected solution.

Case 2 (Figure 16-2 A, B)

25 y.o. female who had previous surgery with high crease and shape asymmetry. (A) Before and (B) after revision.

Case 3 (Figure 16-3 A–C)

22 y.o. female who had crease procedure at age 10. (A) She has trichiasis (in-grown eyelash) of the upper lids.

(B, C) Postoperative view.

Case 4 (Figure 16-4 A, B)

32 y.o. male who had buried suture method procedure previously. (A) There is a shielded crease on the RUL and no crease on the LUL. During revision the crease was reset to 7 mm.

(B) Post-revision photograph.

Case 5 (Figure 16-5 A, B)

47 y.o. female who had incision method with skin removal. She sought a more noticeable crease height. (A) Before and (B) following revision.

Case 6 (Figure 16-6 A, B)

23 y.o. female who had four previous procedures. Absent crease in the LUL. Desired a NTC. (A) Before and (B) following revision.

Case 7 (Figure 16-7 A, B)

48 y.o. female has ptosis of LUL. (A) Before and (B) after crease revision, combined with ptosis correction of the left eye.

Case 8 (Figure 16-8 A, B)

22 y.o. female had incision method. Both sites show spreading of skin scar.

Case 9 (Figure 16-9 A, B)

45 y.o. female having had buried suture method showing shallowing and duplication of creases of LUL. (A) Before revision and (B) 7 days following revision bilaterally, with normal swelling.

Case 10 (Figure 16-10 A, B)

55 y.o. female with moderately high crease. (A) Before and (B) following revision to lower the crease on both sides.

Case 11 (Figure 16-11 A–C)

Young woman with absence of crease, or very low-set indented crease at the lower section of the pretarsal eyelid skin. Photographs show fullness of the lid, often seen despite having had buried sutures method 10 years previously.

Case 12 (Figure 16-12 A–D)

(A) 22 y.o. female with high crease, semilunar shape. There are redundant double crease lines, with scarce skin left.

(B, C) The ratio of pretarsal/preseptal is almost 1 : 1.

After revision (D) , with the crease reset to a lower position and transition to a parallel shape.

Case 13 (Figure 16-13 A, B)

55 y.o. female with high crease: RUL at 9 mm, LUL measured at 10 mm.

(A) Before and (B) following revision to 7 mm crease height. The crease is now less harsh and more natural.

Case 14 (Figure 16-14 A, B)

Young woman who had a high crease set. (A) Note the aspect ratio between the pretarsal (lower) segment and the preseptal (upper) segment is almost 1 : 1. There is some acquired ptosis and limitation on upgaze , as well as lagophthalmos.

(B) Two weeks after a revision attempt utilizing the author’s beveled approach and resetting of crease height. The ptosis is released and the crease height will continue to settle down over the next few months. The aspect ratio has improved between pretarsal segment and preseptal region. (The patient returned to her overseas residence shortly after.)

Case 15 (Figure 16-15 A, B)

This patient underwent a lid crease procedure. (A) Notice that the crease does not merge into the fold medially. The medial aspect of the crease overrides the supracanthal fold, resulting in an upper bifid crease.

( B ) Higher magnification of RUL.

Case 16 (Figure 16-16 A, B)

50 y.o. female with a left seventh nerve palsy who underwent a lid crease procedure. Note the poor closure of her left upper lid owing to facial paresis and probable mid-lamellar contracture.

Case 17 (Figure 16-17)

35 y.o. female who has had excessive fat removal high over her supratarsal sulcus. Note the inadequate formation of the lid crease and the hollow sulcus.

Case 18 (Figure 16-18 A–C)

Female university student who presented after lid crease placement. ( A ) She showed a high crease over the left upper lid and a segmented crease over the medial extent of the right upper lid and scar over the lateral half of the crease. I recommended enhancement and revision of the right upper crease, and repositioning to a lower level for the left upper crease. She elected to have only the right lid revised. A tarsal height-based Asian blepharoplasty was performed on the right upper lid, cicatrix was released from the lateral half ( B ).

( C ) One week postoperative appearance.

Case 19 (Figure 16-19)

Incomplete and ‘bifid’ crease: the upper crease did not extend to the medial one-third of the fissure width. The splitting of the crease is more noticeable over the right upper lid.

Case 20 (Figure 16-20 A, B)

A patient with asymmetric creases. The right upper lid crease was too close to the lid margin, and is scarred down to the anterior surface of the upper tarsus. The left upper lid crease is high, harsh and semilunar in shape.

Case 21 (Figure 16-21 A, B)

This patient had an asymmetric crease made more evident by the acquired ptosis of the right upper lid. This is an example of a static crease.

Case 22 (Figure 16-22 A–C)

( A ) 30 y.o. female with multiple creases over RUL (with one dominant and several less distinct creases over the medial half) and multiple indistinct high creases over LUL. ( B ) Note the enhanced supratarsal sulcus on the LUL, probably due to excessive fat removal. ( C ) Correction of the LUL consisted of crease enhancement with excision of the small strip of skin encompassing the multiple creases. No attempts were made to correct the supratarsal hollow because (a) this is a difficult procedure to perform, and placement of synthetic fillers frequently leads to complications; and (b) the conversion of several faint lines to a main crease often creates enough inward folding, especially on upgaze, to make the hollow less noticeable.

Case 23 (Figure 16-23)

50 y.o. female with high creases, some of which are bifid and multiple.

Case 24 (Figure 16-24 A–D)

( A ) 30 y.o. female who had two lid crease procedures in Asia. She complained that the crease tapered excessively towards the lateral canthi and of fullness in that area when she smiled. ( B ) Asian blepharoplasty was performed laterally. Intraoperatively, scar tissues were excised until the underlying aponeurosis was clearly seen.

( C ) Appearance immediately after the procedure.

( D ) Appearance 1 month postoperatively. Some residual pretarsal edema can still be seen.

Case 25 (Figure 16-25 A–E)

( A, B ) 25 y.o. female had undergone placement of a reddish tattoo line in an attempt to form a pseudo-crease over the RUL. She had minimal ptosis of the same lid.

( C ) The tattooed crease line, which measured less than 1 mm wide, was excised. ( D ) A new crease was formed based on the author’s technique.

( E ) Closure of the wound over the RUL.

Case 26 (Figure 16-26)

55 y.o. female with a high, harsh, incomplete crease. The crease spanned only 60% of the width of the fissure.

Case 27 (Figure 16-27 A–C)

( A ) This patient had a crease deformity of the RUL due to laceration by broken windshield glass during an automobile accident, with embedded glass fragments. The LUL had a ‘shielded’ crease. ( B, C ) Postoperative views after crease revision.

Jan 26, 2019 | Posted by in OPHTHALMOLOGY | Comments Off on Revisions in Suboptimal Cases
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