Fixing Eyelid Surgery
Eyelid 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.
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™ 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.
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