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Eyelid Surgery – Revision Specialist

As an Oculofacial Surgeon, Dr. Amiya Prasad trained in eye surgery by completing his residency training in Ophthalmology. This super-specialized training in cosmetic eyelid surgery far exceeds the training in eyelid surgery of general Board-certified plastic surgeons.

Oculofacial Plastic Surgeons are recognized in the medical community as the super specialists of eyelid surgery, who specialize in cosmetic eyelid surgery, eyelid reconstruction and cosmetic surgery revision procedures.

Prasad Comsetic Office- New York

Blepharoplasty combined with Artistry with Precision

It can be argued that eyelid surgery is one of the most difficult areas of cosmetic surgery. Millimeters can spell the difference between successful surgery and a surgical complication. An artistic eye, a steady hand, and extensive knowledge of this area are critical to a successful procedure.

Eyelid skin is thinnest skin in the body at about half a millimeter in thickness, which makes surgery of this delicate area challenging.

The eyelid support structures and fine muscles, and how they affect the anatomy of the eye area adds another set of variables which can impact your cosmetic results. Eyelid surgery is performed very close to the eye which also adds a unique risk when compared to other cosmetic procedures.

before and after eyelid surgery revision or blepharoplasty revision - older female patient
before and after blepharoplasty revision - older female patient

How a surgeon should approach to eyelid surgery revision and complications?

Dr. Amiya Prasad has a unique style to eyelid complication and revision surgery that gives him a unique position amongst Oculoplastic Surgeons.

In addition to his training in Oculoplastic Surgery, Dr. Prasad trained in Facial Plastic Surgery as well as Body, Breast and Extremity Surgery, earning him Board Certification in Cosmetic Surgery from The American Board of Cosmetic Surgery.

Dr. Prasad brings to Oculoplastic Surgery a certain perspective and approach by applying principles from surgical procedures which 99% of Oculoplastic Surgeons do not perform.

For example, Dr. Prasad’s innovations in the use of stem cell-based regenerative technology, which he performs during facelift surgery and non-surgical hair restoration (TrichoStem® Hair Regeneration), is used routinely in his eyelid complication or revision surgery procedures to maximize the results.

lower eyelid retraction - revisions blepharoplasty before and after
before and after Lower Eyelid Retraction surgery - blepharoplasty revision before and after - female patient

What is the most common blepharoplasty revision?

Eye bag removal surgery (lower blepharoplasty) is one of the most common cosmetic surgery procedures performed by a wide range of cosmetic and plastic surgeons. The lower eyelid is a complex structure which protects the lower part of the eye and plays an important role in eye lubrication.

Lower eyelid retraction is more likely avoided in the hands of an eyelid specialist who understands the support structure when removing and sculpting the fat that causes eye bags, and can perform procedures to prevent this complication from happening.

What are the common errors that can lead to eyelid retraction?

  • Eyelid Skin Removal
  • Tranconjunctival Eye Bag Removal
  • Ectropion

What is eyelid skin removal?

A common procedure to treat puffy eye bags is called transcutaneous blepharoplasty wherein an incision is made below the eyelashes to remove and sculpt the fat.
This approach to lower eyelid surgery is preferred by many plastic and cosmetic surgeons who don’t specialize in eyelid surgery. As stated earlier, limited training in eyelid surgery leaves fewer options for the surgeon when performing lower eyelid surgery.

lower eyelid retraction example - older female

Eyelid skin is also often removed with this approach, which is where problems start. Wrinkled under eye skin is often mistaken by surgeons to be excess skin, which is not necessarily the case.

With successful eyelid surgery measured in millimeters, a tiny portion of eyelid skin removal can have a huge impact on the eyes. Too much skin removal can leave the eyes looking rounded and pulled down (lower eyelid retraction).

What is transconjunctival eye bag removal?

Transconjunctival blepharoplasty differs from transcutaneous blepharoplasty in such a way that no skin is removed and no external incision is made.

Non-specialized surgeons performing this procedure have been known to comprise the anatomical support of the lower eyelid and cause scarring which causes the eyelid to be pulled downward.

The entire procedure is done from the inside of the eyelid. The transconjunctival approach is generally superior to the transcutaneous approach because it preserves the support structures of the lower eyelid, keeping them intact.

What is ectropion?

Ectropion is related to lower eyelid retraction wherein the eyelids are pulled down due to surgery, but is taken a step further when lower eyelid actually becomes exposed by turning outward.

ectropion and eyelid retraction after lower eyelid surgery

What are the risks of lower eyelid surgery?

Cosmetic lower eyelid surgery lower eyelid blepharoplasty is amongst the most popular cosmetic surgical procedures performed throughout the world the appearance of puffy eye bags that are present all the time is due to bulging fat and is commonly genetic in origin as well as being associated with facial aging the genetic aspect of this condition is why many younger people have under-eye bags the most effective and longest lasting procedure for puffy eye bags is lower eyelid surgery to sculpt the fat responsible for the under eye bags

The popularity of lower eyelid surgery can make it appear to be a generic procedure in actuality it’s anything but generic many surgeons performing this category of surgery use a one method fits all approach resulting in many people needing corrective procedures by specialists like myself the lower eyelid is a complex structure and the art is in creating the optimal strategy to get the most satisfactory result with minimal risk for complications I’ll discuss how I assess my patients and how I customized the procedure to minimize the risks related to lower eyelid surgery

I’m Dr. Amiya Prasad I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon I’ve been in practice in Manhattan and Long Island for over 20 years as an oculoplastic surgeon who specializes in cosmetic eyelid surgery I routinely perform lower eyelid blepharoplasty as well as eyelid revision surgery for complications after surgery originally performed by other doctors I’ve observed throughout my career that a lot of complications after lower eyelid surgery occur because the surgeons performing this procedure are not fully aware of the ways to avoid compromising the support structures intrinsic to the lower eyelid anatomy one of the more common risks of lower eyelid blepharoplasty is lower eyelid retraction the degree of eyelid retraction can be such that the eyes look rounded after surgery and the patient loses the characteristic shape of their eyes I’ve seen patients who had this problem after surgery and their original surgeon denied that the patient had a rounded appearance of their lower eyelids it seems that there’s been a normalization of rounded lower eyelids similar to the normalization of high arched eyebrows and overfilled lips

This is why during consultations patients will often express their disdain for the look of some famous people who they feel look like they’re a deer in headlights so what is the cause for this eyelid retraction problem well the most commonly performed surgical technique to address fat under the eyes which causes puffy eye bags is called transcutaneous blepharoplasty this technique involves making an incision in the lower eyelid right below the eyelashes to access the fat pockets responsible for puffiness the transcutaneous blepharoplasty technique is often performed by general plastic surgeons this approach has the potential to compromise the strength of the eyelid structure by separating the layers which are stronger when intact in addition there is potential compromising of the function of the orbicularis oculi muscle which works like a belt supporting the lower eyelid this can lead to the lower eyelids sagging or pulling downward making the eyes look rounded instead of retaining their original shape and it’s referred to as lower eyelid retraction

The lower eyelids may also rotate inward causing irritation from the eyelashes known as entropion or avert outward causing irritation from exposure known as ectropion further worsening this compromise of the integrity of the lower eyelids is caused by the common practice of eyelid skin removal as a strategy to improve the appearance of fine lines and wrinkles

A common misconception held by many surgeons and the general public is that the fine lines and wrinkles are the result of excess lower eyelid skin so many surgeons excise skin when performing transcutaneous bluffing this removal of skin often leads to the lower eyelids retracting even further and can lead to a more rounded look and worse a skin shortage where the eye is not adequately protected this can cause the tears to not be evenly distributed over the eyes to maintain proper eye health in some situations there can even be a limitation in high closure when sleeping I approach lower eyelid retraction ectropion and aunt ro beam with one guiding principle restoration of anatomy eyelids that look good function well this means for eyelid retraction in order to restore anatomy I have to use tissue grafts such as dermis cellular matrix graft and even skin grafts to reconstruct and provide vertical support

I also have to repair the anatomic structural connection to the bone called the lateral canthal tendon each patient situation is unique and requires proper evaluation I use advanced wound healing technology such as PRP or platelet-rich plasma and a cellular matrix to improve my patient tissue healing and consequently their outcomes it’s often the case that lower eyelid fat prolapse is associated with the deficiency in the projection of the cheek bone and bone structure under the eyes the paradox is that there is excess fat pushing forward while deficient bone is not projecting forward enough I usually recommend placement of hyaluronic acid filler at the bone level to address bone volume deficiency some doctors advise fat repositioning with lower eyelid surgery where a small extension of fat still connected to the eye is stretched and bent over the bone to try to address this deficiency this pedicle of fat is usually too small to address hollowing and the blood supply is kinked over the bony orbital rim resulting in prolonged swelling irregularities or the fat just dying from the blood vessels being bent and compressed to provide adequate volume as well as a more predictable result

I use hyaluronic acid fillers such as Restylane and Juvederm to address hollowness in the lower eye area as well as the cheek bones I bring to my patients attention the relationship between the bone structure around the eyes and the eyes themselves so they can look their best it is of course much better to completely avoid lower eyelid retraction of other complications than it is to need extensive and expensive revision surgery so many people opt for cheaper lower eyelid surgery to save money without understanding why the surgery is being done so cheaply quality and cheap simply don’t go together so opting for cheaper lower eyelid surgery can be much more expensive to fix not to mention the cost of time off work and the expenses of travel

So how do I minimize the risk of lower eyelid retraction I start with the approach of preserving the lower eyelid support structures such as the lower eyelid skin and the orbicularis oculi muscle I preserve lower eyelid Anatomy by using a specialized technique called transconjunctival blepharoplasty transconjunctival blepharoplasty involves no external incision because the fat pockets responsible for under eye bags are sculpted from behind the eyelid the lower eyelid skin and the orbicularis oculi muscle are completely preserved and the results look natural since there is no scar from an external incision and there is no compromise in the support structure I also avoid skin removal because under eye wrinkles and fine lines are an issue of skin quality not excess skin quantity for under eye wrinkles I improve the quality of the skin by stimulating collagen production and resurfacing the skin collagen can be stimulated using a laser or radiofrequency device to induce collagen production collagen is the protein that gives skin its strength

In addition the application of heat also makes the skin contract and tighten to further stimulate collagen production and blood supply in the lower eyelid skin without heat I use platelet-rich plasma platelet-rich plasma also called PRP is a concentration of wound healing and growth factors present in the blood which are activated when you have a cut if there is redundant lower eyelid skin or a fold I’ll perform a skin pinch excision I still focus on maintaining the natural shape and the character of the lower eyelids I perform lower eyelid surgery under local anesthesia with Lite IV sedation so patients don’t have to deal with the stress of general anesthesia as well as the side effects of general anesthesia patients are comfortable throughout the surgery and what is generally referred to as a twilight state of consciousness they walk out of our office alert and happy soon after surgery

Most of our patients have little to no bruising and return to work in about a week like any surgery there are always risks risks can be minimized through the experience expertise and techniques used by the surgeon coming from an ophthalmology background and having an understanding of how to maintain the shape and retain the healthy function of the eyelids has been invaluable for my ability to help my patients undergoing lower eyelid surgery

I hope you found this information helpful thank you for your question

Solutions to Lower Eyelid Retraction and Ectropion

Replacing lost eyelid skin, and pulling up and anchoring delicate eyelid skin are difficult procedures. Dr. Prasad often performs grafts to build support and extra skin for the lower eyelids. These grafts may come from materials such as Enduragen, hard palate, and skin grafts.

  1. Canthopexy – tightening and suspending the lower eyelid. Small drill holes may be needed to anchor support called a drill hole canthopexy.
  2. Lateral Tarsal Strip – a procedure wherein the lower eyelid is separated from the upper eyelid with the objective of restoring the position of the lower eyelid and reinforcing the tone of the lower eyelid.
  3. Release of Lower Eyelid Retractors – the lower eyelid retractors are released through an incision to enable a more normal eyelid position. An eyelid spacer may be used to support the vertical postion of the lower eyelid.
  4. Posterior Lamellar Graft – The eyelid is composed of 3 layers. The posterior layer or lamella is the conjunctiva and lower eyelid retractors. A graft can be placed in this layer to restore eyelid position and function.
  5. Skin Graft – adding your own skin to the inside and outside of the eyelids to make up for skin lost from previous surgery.
  6. Cheek Lift – elevating the cheeks to bring up the position of the lower eyelids.
  7. Enduragen Graft – porcine acellular dermis matrix that is sterilized for human compatibility.
Dr Prasad doing surgical procedure in the operating room

Specialized Eyelid Repair Surgeries

Upper Eyelid Surgery Revision

Upper eyelid retraction also occurs when too much eyelid skin is excised or removed. Upper eyelid retraction can result in a constantly surprised look, and worse, leaves the eyes unable to close fully for sleep.

Upper eyelid retraction may require skin grafting, or grafts made up of temporalis fascia (taken from the scalp).

Misdiagnosed Ptosis Cases

Ptosis of the eyelids is often caused by a defect or stretching of the muscle that lifts the eyelids called the levator muscle. Ptosis is not only a cosmetic problem, but can impair vision, and even hinder the visual development of children who are born with the condition (congenital ptosis).

Ptosis correction surgery is a specialized procedure performed by oculoplastic surgeon / oculofacial plastic surgeon like Dr. Prasad.

Unfortunately, many ptosis cases are misdiagnosed by general plastic and cosmetic surgeons as hooded eyelids caused by extra skin. This misdiagnosis leads to surgeons performing upper eyelid surgery (upper eyelid blepharoplasty) when they think the problem is due to excess eyelid skin and fat, so skin and fat are necessarily removed.

Patients may soon find out that their eyelids are still drooping after surgery, and in some cases, find that too much skin was removed and they are no longer able to close their eyelids.

blepharoplasty patient who needed ptosis surgery

Correction of Ptosis Misdiagnosis

Restoration of lost upper eyelid skin can be done with skin grafting, if necessary, when eyelid closure is compromised. Ptosis correction surgery involves shortening or resectioning of the levator muscle (the muscle that lifts the upper eyelid). Ptosis correction surgery is an area of specialty for Oculofacial/Oculoplastic surgeons.

blepharoplasty patient who needed ptosis surgery before and after results

Double Eyelid Surgery Revision

Asian eyelid surgery or double eyelid surgery, is a procedure where fat above the upper eyelids (sub brow area) is removed and/or reduced to allow an upper eyelid contour, and create space in upper eyelid skin for sutures to be made, as well as create a connection between the eyelid and the levator muscle (the muscle that lifts the eyelid).

This enables an upper eyelid crease/fold to form. However, some surgeons may remove too much fat above the eyelids that can cause a hollowed look. Loss of fat above the upper eyelids can also occur naturally from volume loss due to aging.

before and after fat transfer to sub-brow to address hollowing
before and after fat transfer to sub-brow to address hollowing

The area of the sub brow where fat is removed has thicker skin than eyelid. Thicker skin is more appropriate for transferring/grafting of your own body fat to fill and provide volume for this hollow space.

Patient Reviews on Eyelid Surgery

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