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Fixing Eyelid Surgery - Blepharoplasty Revision

Eyelid Surgery | Eyelid Surgery Case Studies

Fixing Eyelid Surgery, Revision BlepharoplastyEyelid surgery is one of the most commonly performed cosmetic surgeries. Well performed, eyelid surgery has amazing power to refresh one’s look. A number of specialists offer eyelid surgery including ophthalmologists, eye plastic surgeons (ophthalmologists with fellowship training in eyelid plastic surgery), facial plastic surgeons, general plastic surgeons, dermatologists, and other cosmetic surgeons (physicians with various backgrounds including family practice, emergency medicine, gynecology, radiology, and general surgery). Thanks to the power of the Internet, anyone can proclaim that they are expert in eyelid surgery. However, when it goes wrong, the consequences can be devastating. Therefore, it is essential to look past the hype when it comes to fixing eyelid surgery or blepharoplasty revision.

Dr. Steinsapir is board certified in Ophthalmology and has completed numerous fellowships including three years of Orbit and Eyelid fellowships at the prestigious Jules Stein Eye Institute at the David Geffen School of Medicine at UCLA and a separate two year cosmetic surgery fellowship under the auspices of the American Board of Cosmetic Surgery. He is widely respected for his work and has published over thirty scientific papers and eight book chapters. He is much sought after as a teacher and lecturer. He is a true innovator having developed Microdroplet Lift® BOTOX®, a unique patent pending method for injecting BOTOX®, Deepfill™ under eye Restylane® treatment to non-surgically address the dark circle and under eye hollow for up to a year without the need for retreatment. Dr. Steinsapir is one of the foremost eyelid surgeon’s in the world. He is on staff at the UCLA Hospital and Medical Center where he is an Associate Clinical Professor of Ophthalmology at the Jules Stein Eye Institute. He is also on staff at Harbor/UCLA Medical Center where he serves as an attending surgeon. He is in practice in West Los Angeles and he is in high demand by discerning individuals from Los Angeles, Beverly Hills, and Southern California. Many of his patients also come to see him from around the country and the world. Very few doctors offer the level of skill and expertise he brings to cosmetic surgery and aesthetic restorative surgery to address prior unsatisfactory eyelid surgery.

Dr. Steinsapir has developed and advocates conservative surgical methods that help to preserve the integrity of the eyelids and spare eyelid tissue whenever possible. By combining this approach with the most innovative thinking and techniques, dramatic yet highly natural eyelid surgery results are possible with a minimum of down time.

In Dr. Steinsapir’s boutique practice in West Los Angeles, he sees several new consults a day with people who have concerns about prior eyelid surgery. Most of these people had eyelid surgery in the distant past and initially were very satisfied with the results of their original surgery. A small number of individuals seek Dr. Steinsapir out because they are having an immediate problem after a recent surgery and feel the issue warrants a second opinion. Dr. Steinsapir welcomes second opinion consultations. Often the primary issue is a lack of open communication between the surgeon and their patient. A call from Dr. Steinsapir can at times reestablish the doctor patient relationship and allow the patient to continue with their original surgeon secure in the knowledge that they are getting appropriate care and primarily need tincture of time. In a rare case, it will be clear that an individual is having an issue that is beyond the capabilities of the original surgeon to manage and acute operative intervention by Dr. Steinsapir is needed. Again these types of situations are very rare.

Post-operative issues often come down to a lack of appropriate post-operative follow-up and communication. As a Cosmetic and Eye Plastic Surgeon trained initially as a Board Certified Ophthalmologist, Dr. Steinsapir is acutely aware of the importance of eye comfort after surgery and what steps are needed to make the eye as comfortable as possible. No matter how technically superb the surgeon, lack of attention to eye comfort can undermine patient confidence. Unfortunately, specialists lacking the training in Ophthalmology can underestimate the impact of these easily addressed issues. For this reason, Dr. Steinsapir closely follows his patients after surgery. Some patients are seen every day for the first week. The majority is seen the day following surgery and then on a frequency that is appropriate for the state of healing noted on that visit. It is not Dr. Steinsapir’s goal to make follow-up care overly burdensome. On the other hand it is his philosophy not to miss anything important and close follow-up care and 24 hour availability is an essential ingredient.

Common post-operative issues can be thought of in two broad categories: Immediate and long term. Arbitrarily Dr. Steinsapir defines immediate as post-operative issues and complications that present anytime from moments after surgery to up to six months. Long-term complications are issues that present after six months. The six month time frame is useful because a number of concerns related to upper eyelid crease height, difficulty closing the eye, mild lower eyelid retraction or alterations in eyelid shape often resolve spontaneously in this time frame. In contrast, it is Dr. Steinsapir’s experience that when these types of problems are present 6 months after surgery and continue to be a concern, then they may need to be addressed with a corrective surgery.

The most common problems after surgery relate to one of the most common problems adults experience with their eyes: dry eye. Many of us have dry eye or experience chronic eye irritation related to a deficiency of tear production. Swelling and temporary, expected lid dysfunction after surgery does not make things better. The eyelids are like the windshield wipers of the eye. When the eyelids are swollen after surgery, they do not move the tears around very well and this can cause drying and irritation. This type of swelling can typically affect eye comfort for ten days or so when there is normal tear production. When the eyes are dry, eye comfort may be affected by post-operative eyelid swelling for many weeks before resolving. When the surgery damages the nerve fibers that supply the muscle that closes the eye (orbicularis oculi muscle), the blink mechanism may be permanently affected causing long-term eye surface drying and dry eye symptoms (irritation, sensation of burning, grittiness, redness). Fortunately, many of these closure issues get better over time. Prevention with more conservative eyelid surgery is the best approach. When this is not an option, dry eye treatment with artificial tears and bland ophthalmic ointment are first line measures. This can be supplemented as needed with plugging the tear drainage system, and taping the eyes closed if the first line approaches are unsatisfactory. Long-term approaches can include surgery to improve eyelid closure.

Post-operative hemorrhage leading to large bruises is another source of issues and complications. Hemorrhage occurs because small and medium size vessels are cut or damaged during the surgical process. Bleeding from these vessels may be minimal or absent during surgery due the presence of adrenaline that is used in the local anesthetic for the purposes of controlling bleeding. Bleeding after surgery can occur from straining, coughing or other activities following surgery that disrupt the clots that normally form from the surgical wounds. A degree of bruising is expected following surgery and is a normal part of recovery after eyelid surgery. However, on rare occasions, a much more significant bruise can occur. If this happens deep behind the eye, which is reported following eyelid surgery when fat is removed in about one in 300,000 cases, the bruise can cause blindness. This type of bleeding is called a retro-orbital hemorrhage. While these cases are very rare, it is this very significant risk that prompts the eyelid surgeon to advise potential patients to avoid medications and herbal products that can thin the blood and predispose to bruises in the first place. For this reason, it is essential for your potential eyelid surgeon to know if you are taking a blood thinner such as aspirin, coumadin®, or Plavix® prescribed by another physician to reduce the risk of stroke or heart attack. In these circumstances, Dr. Steinsapir will advise against elective or optional eyelid surgery.

More superficial bruising may not threaten vision but these bruises can affect the outcome of surgery. Severe bruises cause swelling that can stretch a healing eyelid. In the upper eyelid, this can produce heaviness in the upper eyelid that might need to be corrected surgically if there is no resolution after 6 months. Similarly, in the lower eyelid, the bruise can stimulate the formation of extra collagen and scar tissue that can affect the vertical height or shape of the eyelid. When the resulting eyelid malposition does not satisfactorily resolve by 6 months after surgery, revisional surgery may be necessary to address the issue. Dr. Steinsapir is often asked if Arnica, an herbal product thought to reduce bruising should be taken. Generally, Dr. Steinsapir has not found this herbal remedy to be either helpful or harmful. Therefore, his advice is that it is not necessary to take Arnica. Other published studies tend to confirm this impression.

Infection following eyelid surgery is much less common than bruising. Antibiotics are often prescribed following eyelid surgery. However, some believe that they are not necessary because infection following eyelid surgery is so rare. Generally, Dr. Steinsapir thinks that while post-operative infections are quite rare, the small risk is not worth taking. Of course one can develop an allergic reaction to the antibiotics, so nothing is without some risk. Infection can still occur even when a post-operative antibiotic has been used. This necessitates a change of antibiotic. If the infection is serious, consultation with an infectious disease expert and intravenous antibiotics are options. The incidence of these types of infections is on the order of one in 5000. Once the infection has cleared, there may be loss of eyelid function or unanticipated scaring. When reconstruction is needed in these circumstances, it is often reasonable to wait a full year before making a revision because in that time the tissue may relax sufficiently that revisional surgery will be unnecessary.

Occasionally, stitches closing the surgical incision come apart before the skin edges are healed together. This is called a wound dehiscence. This most commonly occurs in the upper eyelid where an incision is made to remove excess skin. The raw edges of skin separate and the wound gapes open. This can be unsightly and it is tempting to sew the raw edges back together. This course may be the right thing to do. However, there may be a low-grade infection causing the wound separation in which case the best course of action is to simply observe the area, and keep it moist with extra antibiotic ointment. Perhaps the most surprising thing about wound dehiscence is how well it heals on its own. It has been Dr. Steinsapir’s experience that given time to fully heal, the body pulls the skin edges back together so well that no further intervention is needed.

Chemosis is a specific type of tissue swelling. The white of the eye that we see is a specialized tissue called the conjunctiva. Just like the eyelids can swell following surgery, the conjunctiva can also swell. It looks like jelly along the edge of the eyelid. Mild chemosis is self-limited meaning that it will resolve on its own. More severe chemosis is fortunately very rare and is almost never seen with standard blepharoplasty. It is more common with procedures to tighten the lower eyelid like canthopexy and canthoplasty. In this circumstance, the swollen conjunctival tissues balloon to the point where they are not covered by the closed eyelids. When this happens, the conjunctiva is subject to drying that causes more swelling. This becomes a cycle. The best treatment is aggressive lubrication with an ophthalmic ointment and when necessary occlusion with plastic wrap to prevent drying. Surgical treatments are available for the rare instances when these measures are insufficient.

Double vision is another rare complication following cosmetic eyelid surgery. The most common cause of double vision immediately after eyelid surgery is the local anesthetic that can numb the muscles that move the eye. Generally, the vision is quite blurry after eyelid surgery because soothing ointment has been placed on the corneas. Also frequently cold compresses are placed over the closed eyelids. These measures prevent many from realizing that they are experiencing double vision. In one or two hours after surgery, the double vision has resolved. It is unexpected for double vision to persist after the first post-operative day. Six muscles are responsible for eye movements. The inferior oblique muscle is the most vulnerable of the extraocular muscles. The next most commonly injured muscle is the inferior rectus muscle. These are very unusual injuries. Double vision that persists beyond the first day should be carefully measured and observed. The most likely injury is a bruise to the inferior oblique muscle, in which case, the double vision should rapidly resolve spontaneously. Double vision that does not rapidly improve or gets progressively worse may represent an injury to an extraocular muscle. The most likely injury is due to scaring that can follow post surgical bruising. This type of damage is expected to gradually improve over a period of months. Direct injury to the extraocular muscle has been reported and these require surgery to correct. These are very rare, so rare the possibility is generally not even specifically mentioned in surgical consents.

Now lets consider long-term problems after eyelid surgery. Obviously some of these issues may be noted shortly after surgery. What characterizes them is that they will not improve with time and need to be addressed by surgery if the issue is sufficiently bothersome.

One of the most common issues is ineffective surgery. There can be a variety of reasons for this. Essentially the complaint is that I went to all this trouble and I don’t see any result or I was hoping for a more dramatic result and I am disappointed. On occasion, what is really being reported is that the individual who underwent surgery is not experiencing the positive feedback from loved ones and friends they were hoping for with the surgery and they are disappointed. A smart plastic surgeon once said that “a difference to be a difference has to make a difference.”. It is important to understand that a surgical result that is disappointing because it was not as dramatic as hoped for is not considered a complication of surgery. It is still an issue that prompts people to get revisional surgery.

The most common situation this occurs in is upper blepharoplasty in the setting of eyebrow ptosis. The brain compensates for the heavy eyebrow by activating the frontalis muscle, the forehead elevator. The forehead lifts the eyebrow until the skin in the upper eyelid no longer rests on the upper eyelashes. Clinically, this situation can be detected by looking for lines in the forehead and an abnormally elevated eyebrow. When upper blepharoplasty is performed in this setting, the excess skin in the upper eyelid is removed. This reduces the amount of forehead muscle activation that is needed to keep the upper eyelid skin off the upper eyelashes. The forehead relaxes and the eyebrows come down. The net result is that it appears that almost nothing was done surgically. Of course the forehead is smoother but if the objective was to make the eyes brighter by clearing space above the eyelashes, the net effect can be disappointing. Under these circumstances the best option is to perform a forehead lift in conjunction with the eyelid surgery.

Other circumstances that give rise to a disappointing surgical outcome due to an insufficient effect include, insufficient removal of upper eyelid skin, insufficient removal of lower eyelid skin or fat, and persistent lower eyelid lines after lower eyelid surgery. Again these are not considered to be complications. Yet in each case additional surgery may be needed to achieve the desired outcome. It is far better to be in this situation where the solution is to remove additional tissue than to be in a circumstance where too much surgery was done and tissue needs to be put back into the eyelid. The fix when there is not enough effect is usually straightforward; remove a little more tissue. However, as note above, occasionally a different approach is necessary as well.

 Fixing Eyelid Surgery, Blepharoplasty Revision



Frequently Asked Questions

Eyelid Malposition: Ptosis, Entropion, and Ectropion

There are several common types of eyelid malpositions. This is a general medical term for eyelids that don’t sit and do what they are supposed to do. Normally the eyelids are firmly held against the eye. Tears lubricate the eyelid movements and the eyelids themselves function like the windshield wipers of the eyes. This is the result of a delicate balancing act between the eyelid position and tension of the eyelid ligaments. In the lower eyelid the muscle that helps close the eyelids functions like a muscular hammock to hold the lower eyelid against the globe.

In the upper eyelid the levator palpebra superioris muscle is responsible for opening the eyes by elevating the upper eyelids. The action of this muscle is transmitted to the upper eyelid by a broad fan like tissue called the levator aponeurosis. Individuals may be born with a droopy eyelid and the levator muscle may not work as effectively as a normal muscle. Under the microscope, the muscle may look incompletely developed with fat and connective tissue replacing the muscle that should be present. Crowell Beard, M.D, has referred to this as “developmental dystrophy”. As the levator muscle does not effectively lift the lid, there may also be insufficient traction on the skin by the same muscle to generate a crease in the affected upper eyelid. It is not uncommon to see a heavy eyelid and an absent eyelid crease. Occasionally the heavy eyelid is associated with other eyelid abnormalities such as the blepharophimosis syndrome. This syndrome has a heredity basis and can run in families. A less common form of congenital ptosis called Marcus-Gunn jaw-winking ptosis: movement of the jaw causes a fall in the position of one of the eyelids. Treatment of these conditions is based on the degree the levator muscle is able to lift the eyelid. This measure is called the levator function.

In adults, congenital ptosis is seen but the most common cause of upper eyelid ptosis in the adult is acquired ptosis. There are several causes of acquired ptosis. The most common cause appears to be attenuation of the levator aponeurosis, which becomes stretched out over time. This is also referred to as levator dehiscence ptosis but it is controversial if the levator actually “dehisces,” a medical term for separates, or if the attenuated tendon gets cut in the process of performing the surgical repair. Other causes of acquired ptosis include four broad categories: neurogenic, myogenic, traumatic, and mechanical. It is helpful to classify and properly diagnosis the basis of the droopy eyelid because this has a bearing on the choice for repairing the upper eyelid ptosis.

There are two principle approaches to repairing acquired upper eyelid ptosis. For small amounts of ptosis (1-2 mm) a simple test is performed during the preoperative assessment. An eye drop is instilled into the eyes and the response to the drops is measured. If the drop raises the eyelids to the desired height, the lid position is very likely to respond to a surgery referred to as a Conjunctival Muellerectomy. This surgery is performed from behind the upper eyelid using a special clamp called a Putterman ptosis clamp. If the eyelid does not respond to the eye drops or if the degree of ptosis is too large a second type of ptosis surgery is indicated. This type of surgery is called an anterior levator resection ptosis surgery. This surgery is performed through an incision at the eyelid crease on the outside of the eyelid. The levator aponeurosis is dissected and sutures are tied to effectively shorten the aponeurosis. Surgery is performed under local anesthesia. This facilitates repositioning of the eyelid. The patient is asked to open and close the eye. The sutures can be repositioned to adjust the eyelid position. Once this is satisfactory, the sutures are permanently tied and the eyelid is closed. Skin sutures are removed within a week. Swelling and bruising usually resolves in 10-14 days. A personal consultation with Dr. Steinsapir will determine if you are a candidate for upper eyelid ptosis surgery.

Laxity of the lower eyelid can present as either a turning in or turning out of the lower eyelid. These malpositions usually occur in older individuals. The type of lower eyelid malposition is determined by the nature of which structure have become weak in the eyelid. When the lower eyelid retractors become attenuated, the forces on the eyelid tend to favor an inward rotation of the lower eyelid. This is called entropion. This causes the eyelashes to rub against the eye and cause severe irritation. There are various approaches to address these issues. Typically the lower eyelid retractors are reattached and the lower eyelid is shortened. When the lower eyelid is lax and there is contraction of the lower eyelid skin or weakening of the orbicularis oculi muscle as occurs with Bell’s palsy, the lower eyelid rotates away from the eye. This is called ectropion. In this situation, the lower eyelid does not rub against the eye. However, the lid does not protect the eye and this can also cause irritation. Surgery is directed at lengthening the lower eyelid and resuspending the lid back against the globe. In both cases, an assessment of the midface support is essential. With entropion and ectropion, failure to address midface ptosis can lead to an unsatisfactory result. Swelling and bruising usually resolves in 10-14 days. A personal consultation with Dr. Steinsapir will determine if you are a candidate for repair of entropion or ectropion.

Lacrimal Surgery

Abnormal tearing is a common problem. This is seen in newborns who have incomplete opening of the tear duct system and in older adults. However individuals of all ages can present with this problem. In adults, tears well up in the eye on an all too regular basis. This necessitates constant wiping of the eye with tissue. The tears can blur vision and the perpetual tears running down the cheek is a source of embarrassment. Even loved ones have difficulty grasping the debilitating nature of this problem.

In the inner corner of the eyelid are small openings called puncta that are the openings to the tear drainage system. Below the skin the puncta continue as the canalicui, small lined tubes that are stiffened with elastin and drain the tears into a sac that lies deep in the bone on the side of the nose. This sac drains into the nose. At birth, some of the valves that help direct the tears to drain to the nose may not be open and functional. Many babies rapidly out grow this problem. When the problem does not resolve Dr. Steinsapir will recommend massage of the tear system. If this fails to improve the situation, a probing of the tear ducts by 12 months of age is generally recommended. Some pediatric ophthalmologists will perform this procedure without anesthesia in the office. Dr. Steinsapir feels that this is traumatic and recommends a brief general anesthesia to permit a more optimal probing of the tear ducts with a higher likelihood of success. For some infants, the tearing will persist and placement of tubes and additional procedures may be needed.

In adults, probing of a blocked tear duct is unlikely to improve the tearing. A different approach is needed. A diagnostic irrigation of the tear duct system leads to a working diagnosis of the anatomic blockage and a recommendation for the appropriate surgery. For many adults with tearing the surgery recommended is called a dacryocystorhinostomy. This surgery involves bypassing the blockage in the lacrimal sac. Bone between the lacrimal canal that contains the lacrimal sac and the nose is removed. The lacrimal sac above the blockage is opened, as is the corresponding nasal mucosa, which lines the other side where the bone was removed. These edges are sewn together creating a new passageway for tears to drain from the eye to the nose. The surgery can be performed on an outpatient basis under sedation. Recovery takes about 7-10 days. Typically when tubes are placed, these are removed 6 months after surgery. A personal consultation with Dr. Steinsapir will determine if a dacryocystorhinostomy is right for your tear problem.

Orbital Surgery

Dr. Steinsapir is highly trained in orbital skull based surgery. Care of the eye changes associated with thyroid eye disease benefit from this range of skills. The management of this condition is discussed in the section on thyroid eye disease. Other orbital conditions include orbital tumors such as cavernous hemangiomas, mucoceles, lacrimal gland tumors, and the repair of orbital fractures. These conditions require careful assessment and detailed imaging to determine the optimal treatment plan. Many of the incisions used to address these conditions are inconspicuous and hide in the eyelid crease, or are approached from behind the eyelids. Orbital fractures can occur from mild or severe facial trauma. Orbital fractures should be repaired promptly to prevent the eye from healing with compromised function or appearance. A personal consultation with Dr. Steinsapir is necessary to determine the best approach to address the orbital changes you are experiencing. You are encouraged to bring copies of any imaging studies that have been performed to your initial consultation.

Anophthalmic Socket

Trauma and disease can necessitate the removal of an eye. Often this is recommended when the eye has lost all useful vision and has become a blind, painful eye. This may follow soon after a sudden trauma, the discovery of an intraocular tumor, or after a long fight to preserve a diseased eye. The removal of an eye is the option of last resort. A second opinion is advisable if there are any questions about the best course of action. Generally, it is not recommended to remove a blind eye that is otherwise comfortable. In this circumstance, if there are cosmetic issues, a custom contact lens or scleral shell can be fabricated by an ocularist with good cosmetic results. When a blind eye becomes painful, removal by enucleation or evisceration is generally recommended. Enucleation means the removal of the entire eye. The extraocular muscles may be reattached to the intraconal implant that is placed in the orbit to make up the volume lost when the damaged eye is removed. Once the socket has healed, an ocularist then fabricates an acrylic prosthetic piece to fit behind the eyelids, referred to as a “glass eye.” An evisceration involves the removal of the cornea and the contents of the eye, but leaves most of the eye wall or sclera intact. The advantage of this procedure is that it is less disruptive to the orbital tissues and leads to more natural movement of the acrylic prosthetic. Generally, an evisceration is preferred if there are no reasons that might favor an enucleation in a particular circumstance. There has been a push toward integrated intraconal implants made of hydroxyapatite. Unfortunately, these implants are often not well tolerated resulting in exposure of the implant and the need for revisional surgery. The anophthalmic socket (socket without an eye) often requires revisional surgery due to a number of factors. One of the common issues is related to inadequate replacement of orbital volume because too small of an implant was chosen at the time the eye was removed. The ocularist attempts to compensate for this by making a larger prosthesis. However, over many years, the weight of the oversized prosthesis can stretch the eyelids leading to secondary issues, including chronic discharge and difficulty retaining the prosthesis. A consultation with Dr. Steinsapir is needed to determine the best options for rehabilitation of the anophthalmic socket.

Cancer Reconstruction

Skin cancer can affect the eyelids. Basal cell carcinoma is the most common of the skin cancers that affect the eyelids. Others include squamous cell carcinoma, sebaceous cell carcinoma, and melanoma. All skin cancers have the potential to damage eyelid structures. The lower eyelids are more commonly involved but all portions of the eyelids can be affected. Lesions typically present as a slowly growing mass. Other signs include break down of the skin with raw and crusting areas, and bleeding. Basal cell carcinoma tends to have a heaped and pearly edge with central ulceration. Squamous cell carcinomas can present as a rough red patch of skin that slowly expands. Sebaceous cell carcinoma can grow insidiously along the eyelid and even experienced doctors sometimes confuse this with chronic inflammation of the eyelid margin. Melanomas are often pigmented, grow irregularly and may demonstrate a range of color or even be without pigment. In addition to local behavior, several of these skin cancers have the potential to spread to other parts of the body and can be life threatening. This includes squamous cell carcinoma, melanoma, and sebaceous cell carcinoma. Basal cell carcinoma is unlikely to spread to other parts of the body but it causes local destruction if not surgically excised.

Treatment of these eyelid skin cancers starts with a formal diagnosis established by sampling the lesion. This is done as a biopsy performed by your dermatologist, general ophthalmologist, or by Dr. Steinsapir. This is comfortably done with a little local anesthesia and the removal of a small punch of tissue. Generally the biopsy site, which is quite small, is left to heal on its own. If the biopsy does prove that the lesion is a skin cancer, the next steps for managing the lesion very much depend on the type of skin cancer. In virtually all cases, surgical excision is indicated to cure the cancer or maintain local control if there is evidence that the lesion has spread. Early diagnosis and treatment greatly increases the likelihood of a cure.

The key with managing eyelid cancers is their complete surgical excision. Their removal must be the primary concern over the aesthetic and functional consequences of removing the skin cancer. However, how the excision is performed can make a big difference both for the ultimate success of treating the skin cancer and preserving eyelid aesthetics and function. Traditionally, eyelid skin cancers were removed by the reconstructing eye plastic surgeon. A pathologist then examines the edges of the tissue removed using frozen sections. This method is still used today and has a relatively high rate of success. However, there is a more optimal method of excising eyelid skin cancers. This involves a team approach where a dermatologist surgeon trained in Mohs’ cancer surgery excises the tumor and the eyelids are reconstructed by Dr. Steinsapir. There are numerous advantages to this approach. First, the rate of success in excising the cancer is much higher than frozen section control. In some published series success approaches a 99% cure rate. This is because the method lets the Mohs’ surgeon map and sample 100% of the surgical margin. Secondly, the method is very economical in preserving normal surrounding tissue. Since the eyelids and tear duct system represent very precious real estate, preserving this tissue means a better aesthetic and functional result without compromising the goal of removing the skin cancer. Recovery is also faster. Once the Mohs’ surgeon has completed removal of the lesions, a dressing is placed over the area and Dr. Steinsapir then examines the area. The closure may be performed in the office if the defect is small or on an outpatient basis at UCLA that day or the next day based on the circumstances. A personal consultation with Dr. Steinsapir will determine which approach is right for you.

Post-Cancer Surgery Reconstruction

It is the goal of the primary surgeon to make the best closure of the area after the removal of the skin cancer. However, for a number of reasons, the initial closure often represents the best compromise at the time. It is quite common that more than one stage of reconstruction will be necessary to obtain the best aesthetic and functional results. Dr. Steinsapir has found that for a variety of reasons, people do not always get the best advice regarding the value or need of having further reconstruction. The message can sometimes be that the patient is being vain, or ungrateful in asking for a better reconstructive result. In some cases, the reconstructive surgeon has made their best effort and really doesn’t have any idea how to make the compromised area functionally or aesthetically better. Dr. Steinsapir prides himself on providing innovative approaches to improve eyelids compromised by prior reconstruction. A personal consultation with Dr. Steinsapir will determine what options are available to improve your appearance and the function of your eyelids.

Bell’s Palsy and Facial Nerve Injury

Bell’s palsy causes facial weakness or frank paralysis. Typically people awake to find that they have a weakness on one side of the face. Symptoms may progress over several days. Facial weakness may be the only sign. A viral infection in the canal that transmits the facial nerve is thought to be the cause. Studies suggest that the most common virus that produces this syndrome is the Herpes Simplex Type 1 virus, which is also responsible for cold sores. Recovery of the facial nerve occurs partially or completely in over 80% of cases. Unfortunately, this means the eyelid function can be significantly impaired resulting in severe corneal exposure and drying. For a given individual it is impossible to know at the time that the weakness develops whether the symptoms will persist for a few months or a lifetime. Treatment is initially directed at supportive measures including frequent artificial tears and bland ophthalmic ointment. If needed temporary partial closure of the eyelid may be necessary. This procedure is called a tarsorraphy. Long-term solutions may also include the placement of a gold weight in the upper eyelid to facilitate eyelid closure, midface lift with placement of a hard palate graft, and permanent lateral tarsorraphy. Some advocate the placement of a spring closure of the upper eyelid. Unfortunately, these appliances are not stable in the eyelid, are prone to infection, and often require a commitment to multiple surgeries to maintain function. Surgery to address acoustic neuroma, a benign brain stem tumor, is another cause for facial nerve injury. Frequently the tumor is intimately involved with the facial nerve, which is injured in the process of removing the tumor. Weakness of eyelid closure is managed in a fashion similar to Bell’s palsy because in many cases function will recover in time. When recovery does not occur, definitive steps are needed to protect the cornea. A personal consultation with Dr. Steinsapir will determine the best options for your situation.

Reconstructive Midface Surgery

Many lower eyelid problems benefit from midface surgery. The lower eyelid is intimately related to the cheek mass that tends to fall over time. When lower eyelid abnormalities are the result of midface ptosis, failure to surgically address the midface ptosis will result in a compromised surgical outcome. Dr. Steinsapir is frequently called upon to correct these types of problems. How do you know if you need this type of help? Virtually any lower eyelid situation that has not responded to more traditional techniques needs to be carefully assessed to determine if midface ptosis or maxillary hypoplasia are contributing to the anatomic challenges. If you have had more than one revisional surgery on the lower eyelid without obtaining the surgical result you and your surgeon had hoped for, you will benefit from a consultation with Dr. Steinsapir. Contact the office to schedule you personal consultation.

Scar Revision

The initial repair of a facial laceration is often performed under less than ideal conditions. Tissue swelling can compromise the alignment of the tissues even when the repair was performed by a plastic surgeon, facial plastic surgeon or eye plastic surgeon. It is often possible to achieve a much more acceptable result after the initial repair. In many cases, the body can heal remarkably. For this reason, Dr. Steinsapir advises waiting 6 to 12 months before considering having an unacceptable scar revised. An exception to this rule is sometimes made if it is clear that for whatever reasons the reapproximation of the wound edges is clearly inaccurate. Scar revision involves excising the old scar tissue using a W-plasty tissue rearrangement. The fresh wound edges are carefully reapproximated using magnification. These procedures are generally performed under local anesthesia in the office procedure suite. The revised scar is always more visible while it is healing. The sutures are all removed within one week after the procedure. As the wound heals, the redness quiets and over the course of several months the wound matures. The technique is very effective for highly visible scars. A personal consultation with Dr. Steinsapir will determine if the scar you are concerned with will benefit from scar revision.

Too much of my upper eyelid folds were removed at the time of upper eyelid surgery leaving my upper eyelid sulcus hollow and the eye skeletonized. What can be done?

It was once taught to eyelid surgeons that it is impossible to take too much upper eyelid skin with the blepharoplasty. However, this is not the case. It is essential to consider the position of the eyebrows in assessing how much spare skin exists in the upper eyelid. A conservative approach is to position the eyebrow anatomically, and then determine how much excess skin exists in the upper eyelids. When too much skin and underlying tissue are removed from the upper eyelid, the upper eyelid fold is compromised. This results in a hollow space below the eyebrow where the upper eyelid fold once existed. The upper eyelid fold is an important anatomic feature. Failure to conserve the upper eyelid fold, as part of the upper blepharoplasty, is a major cause for an over operated appearance. It is also important to understand that it is virtually impossible to create more upper eyelid fold with secondary surgery.

I think my upper eyelid creases were made too high. Is there anything that can be done to help this?

The surgeon sets the height of the upper eyelid crease. Unfortunately, many surgeons fail to understand that they are making their incision too high above the eyelashes, often 10 or more millimeters above the eyelashes. As the incision heals, it tends to creep up another one or two millimeters. This means that ultimately the upper eyelid crease will heal at 11-14 millimeters above the eyelashes. This creates a very high crease and contributes to the hollow appearance in the upper eyelid. Before we criticize other surgeons, please understand that many text books of plastic surgery and journal articles on this subject also pass on the erroneous information that the surgical crease should be made this high. Dr. Steinsapir advocates making creases much lower and typically marks the upper eyelid incision about 6.5 to 7.5 millimeters above an eyelid margin. It is relatively straightforward to raise a crease but very difficult (almost impossible) to predictably lower an upper eyelid crease. The best cure is avoiding the surgeon who plans on placing the blepharoplasty crease incision too high. You can discern this by looking at the before and after pictures. If every one of the after pictures demonstrates that the upper eyelid fold is gone, you should seriously consider finding a different office.

The skin on my upper eyelid platform is wrinkled and loose. I can’t seem to keep makeup on without it smudging. Is there anything that can be done to help this?

When upper blepharoplasty is performed, simply removing extra skin is not enough to create a great result. Beautiful blepharoplasty results require what Dr. Steinsapir calls a structured blepharoplasty. For the eyelid platform skin this means making the eyelid crease at just the right height and anchoring the eyelid platform skin to the levator tendon, which raises the upper eyelid. This places the upper eyelid skin on a slight stretch resulting in a smooth platform for makeup. Crepe-like upper eyelid skin can be addressed after unsatisfactory upper blepharoplasty by a carefully planned re-excision of the excess skin left on the eyelid platform. With the eyelid open, the upper eyelid skin is anchored to the levator tendon to create a long lasting adhesion to the eyelid elevator. Recovery is usually shorter than standard upper blepharoplasty. Generally, this type of revisional procedure can be performed in an office procedure setting with local anesthesia.

My upper eyelashes point down. It bothers my vision and makes my eyes look dull. Is there any thing that can be done about this?

This condition is called eyelash ptosis and it is related to poor levator fixation of the upper eyelid platform skin. Again, a structured blepharoplasty will address lash ptosis. When this is not performed, it can be corrected with a revisional procedure. Typically a carefully planned re-excision of the upper eyelid platform is carried out so that the platform skin will be on slight stretch when the platform is reattached to the levator tendon. This puts slight traction on the skin of the eyelid platform and this gently rotates the eyelashes upward to a more youthful position. Recovery is usually shorter than standard upper blepharoplasty. Generally, this type of revisional procedure can be performed in an office procedure setting with local anesthesia.

Since my upper eyelid surgery, the inner corners of my eyes look heavy. What causes this and what can be done?

When upper eyelid surgery is performed, it is inevitable that the eyebrows will relax downward to some degree. Dr. Steinsapir carefully evaluates potential candidates for eyelid surgery during the consultation. He is specifically looking to assess the degree of brow ptosis present. When it is significant, there is usually compensatory activity of the forehead lifting muscles. When blepharoplasty is performed alone, relaxation in the position of the eyebrows after blepharoplasty can crowd the upper eyelid space and this is sometimes described as the inner corners of the upper eyelid as looking heavy or full. The solution is to perform a forehead lift or a forehead lift in combination with upper blepharoplasty to stabilize this situation. Not every one with a degree of brow heaviness needs a forehead lift. Often the upper blepharoplasty can be performed alone with great results. However, when the heaviness of the forehead is bothersome after eyelid surgery, the fix is a forehead lift.

My eyelids seem very heavy since my blepharoplasty. What causes this and what can be done?

This is actually quite common. It is the result slippage or disinsertion of the upper eyelid tendon. This tendon connects the upper eyelid edge with a muscle that raises the upper eyelid. This results in a condition that is referred to as ptosis or blepharoptosis. It can be caused if the tendon is cut during surgery but it can also slip on its own and this can be made much worse with the swelling of the eyelid that occurs with the blepharoplasty. Correcting this first entails determining if one or both of the eyelids is drooping. One may be worse than the other but if both sides are not fixed at the same time, the side that was not repaired will end up looking heavy. The exact procedure needed to fix the droopy lid is determined by how heavy the eyelid is and its response to the instillation of neosynepherine eye drops. Based on the effect of this test and several other measurements Dr. Steinsapir will determine the most appropriate surgery for correcting the ptosis.

Since my eyelid surgery my eyes seem very dry and at night I don’t think I close my eyes. What can be done about this?

Dry eye commonly occurs in adults even without eyelid surgery. Typically, an existing dry eye condition returns to its presurgical status after about 6 weeks. It takes about this long because persistent swelling of the eyelid tissues after surgery can make dry eye symptoms worse. However, overaggressive surgery can produce long-term damage to the function of the eyelids worsening the dry eye symptoms. If too much upper eyelid skin was removed, the eyes may not fully close at night causing dry spots to develop on the cornea accounting for the increase symptoms. Depending of the design of the blepharoplasty, the nerves that supply the muscle that help close the eye can be damaged weakening the blink reflex. This means that during a blink there may not be sufficient speed or force to cause the upper and lower eyelids to meet during the blink. This is a problem because the eyelids move tears on the eye surface around. The net result is surface drying and symptoms. The first line of approach to treating these issues is to increase the frequency of eye drops and, when indicated, ophthalmic ointment at bedtime. When needed, the tear drains in the eyelids can be closed temporarily with plugs to see if symptoms improve. When these measures fail, consideration may be given to reconstructive surgery. The nature of what is needed is very much directed by the severity of the symptoms and the degree of drying seen on the surface of the cornea. A range of options is available. However the key objective is to make the eyelids meet and to create sufficient force of eyelid closure to help spread the tears over the corneal surface.

Since my lower eyelid surgery the area under my eyes seems hollow. What causes this and what can be done about it?

Lower eyelid surgery is performed to address skin wrinkling and lower eyelid fullness due to orbital fat that over time bulges forward into the lower eyelid. By carefully sculpting lower eyelid fat, a balance can be struck leaving enough volume in the lower eyelid to eliminate the bulge but prevent deflating the lower eyelid which can contribute to the under eye circle. The under-eye circle is actually the result of a gradual fall in the cheek fat over time. There are several options at the time lower blepharoplasty is initially considered. For the right patient, a conservative lower blepharoplasty done transconjunctival (behind the lower eyelid) can be a fabulous choice. This is particularly good for a relatively young person with thick lower eyelid skin but lower eyelid fullness. Over the past few years, we recognize that it can be helpful to conserve the lower eyelid fat by positioning it into the top of the cheek to help fill in the under eye circle. Chemical peels can firm the skin of the lower eyelid masking the circle. Restylane® can be used to fill in the under eye circle. Where appropriate a vertical midface lift over an orbital rim implant can also address the under-eye circle. Many of these approaches can be used to address the under eye circle that becomes more obvious once the lower eyelid fat creating the bulge has been removed. Because the treatment is relatively easy and can last a year or more, many patients faced with this issue elected to have Deepfill™ Restylane® to fill the under eye circle. A personal consultation with Dr. Steinsapir is the best way to learn what is the best approach for you situation.

Since my lower eyelid surgery my lower eyelids look pulled down. What’s up with this?

The gentle almond shaped curve of the lower eyelid is created by a delicate balance of forces including the ligaments of the lower eyelid, the force generated by the orbicularis oculi muscle, the prominence of the eye itself, the projection of the cheek, and the weight of the cheek. Essentially, the lower eyelid position defies gravity. It is little wonder that lower eyelid surgery can permanently alter this balance and cause the lower eyelid to become pulled down after surgery. Surgery also causes scar tissue to form in the lower eyelid, weakens the ligaments of the lower eyelid, and damages the muscle that helps hold the lower eyelid against the eye. these issues is challenging because of the careful analysis needed to determine the best options for a given individual. Restoring the lower eyelid contour requires that all of the contributing factors be taken under consideration. It is not unusual to address only one side at a time surgically because the correction often requires that placement of graft material to support the lower eyelid. To obtain the best possible result, the eyelids are sewn closed for about a week. When necessary, this type of reconstruction can be combined with orbital rim augmentation and vertical elevation of the cheek to further support the lower eyelid. This approach has the power to address lower eyelid contour problems that have not responded to multiple prior approaches.

I had lower eyelid surgery and there seems to be residual fullness in the outer third of my lower eyelids. Is it possible that my doctor missed some eyelid fat?

There are three fat pockets described for the lower eyelids. The two central pockets are easily accessed during lower eyelid surgery. The outer fat pocket is less easily accessed during eyelid surgery. The experienced eyelid surgeon anticipates this and with a little effort, the needed fat sculpting can be accomplished. Residual lower eyelid fullness responds well to revisional lower eyelid surgery.

I had a fat transfer to my lower eyelid to fix my under eye circles and now I have lumps and my circles are still there. What is going on and what options do I have?

The under eye circle is a very common issue caused by a fall in the top of the cheek fat which in youth blends with fullness from the lower eyelid to create cheek fullness up to the lower eyelid crease. Transferring fat to the face has become an increasingly popular treatment. Generally, this treatment is very good at restoring volume in the face. The treatment is generally very good when the transferred fat is placed in locations that possess a reasonable layer of fat to hide any irregularities created by the volume of the transferred fat. The lower eyelid in the area of the lower eyelid circle contains almost no fat compared to the adjacent cheek. This means that there is no place for the volume of the fat transfer to hide. This results in visible lumps and bumps. Correcting these has proven to be very difficult. The fat tends to be found in planes that do not correspond to standard surgical approaches. Melting the fat with steroids can lead to unpredictable fat loss. The best approach is to remove the worst of the visible fat deposits and filling around the others with the hyaluronic acid fillers like Restylane®. This approach evens out the lower eyelid irregularities and in some cases this can be effectively performed without the need to surgically remove the fat.

Since my midface surgery, the skin in my lower eyelid bunches up when I smile. What is going on and what can I do about this?

The midface anatomy is highly complex. Several of the midface tissue planes act as glide planes. Certain midface and lower eyelid treatments seem to change the nature of how these tissues glide over each other. CO2 laser resurfacing can be associated with aggressive contraction of the glide planes of the lower eyelid resulting in bunching of the lower eyelid skin with smiling. Interestingly, this type of effect is not typically seen with a chemical peel that produces a comparable degree of tightening. This type of skin heaping can be seen following midface lifting which may stimulate an inflammatory response in these same glide planes. The best cure of this issue is to avoid overly aggressive skin and midface lift procedures.

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