Thank you for your question.
You submitted a question without an image but in your question, you do detail some important
factors that are concerning regarding your situation after undergoing cosmetic eyelid
surgery.
You state that you developed an ectropion, you developed some eyelid recession.
Basically, there was some skin removed, some muscle tissue probably removed and you’ve
had some opinion where there was an advice about a skin graft.
And at this point, I think you’re concerned of course about the health of your eyes, you
describe as painful and red.
And basically, I think you’re trying to get a handle on what is the most appropriate
procedure even though you didn’t submit a photo.
Well, I can certainly give you my perspective as a specialist.
A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial
plastic and reconstructive surgeon.
I have been in practice in Manhattan and Long Island for over 20 years and I specialize
in revision surgery after cosmetic eyelid surgery whether it’s upper or lower eyelid
surgery.
In fact, patients come from around the world for exactly these types of problems and I’ve
developed my own approach which I think will be meaningful as I explain the basis for my
approach.
So to begin with, it is important to understand that the lower eyelid is actually deceptively
complex when it comes to eyelid surgery and that it is still fairly common for people
to have complications of lower eyelid surgery because from my perspective, there’s a wide
range of doctors who perform these procedures.
And periodically, what was always a reliable approach, for example, the external approach
for a lot of doctors, unfortunately results in some of these complications.
And so essentially, when we think about a complication of surgery whether it’s eyelid
surgery or any other type of surgery, we essentially have to, the goal is to restore anatomy and
to restore both the appearance and the function.
So before explaining how I typically address this type of situation, I’ll basically give
you some very simple understanding of the anatomic principles.
You see, the lower eyelid actually is, as I said, complex in its structure and any type
of imbalance in that structure can result in a malposition or an undesirable position
that can cause exposure of the eyes.
So for example, we’ll start with the front of the eyelid, the front of the eyelid often
referred to our field as the anterior lamella is basically skin and I think you can also
include the orbicularis muscle, the muscle that supports the eyelid.
So in a scenario such as an absence of skin can cause the eyelid to evert or cause an
ectropion, there can be situations when there’s tension and pulling on the lower eyelid that
can also cause the same type of scenario.
Now there’s also basically a middle lamella which we refer to as the septum and that particular
structure, in a way, acts like a pillar in a way to support the lower eyelid.
Even though you come across it in surgery, it’s very thin but I’ll explain further
after I describe the posterior lamella.
The posterior lamella is basically the conjunctiva and lower eyelid retractors.
Again, a compromise in the integrity of this tissue can essentially result in a collapse.
So when we think of the eyelid, we think of the layers as being individual layers that
can be relatively thin but together, they form like a sandwich which essentially acts
like a pillar and a pillar that vertically supports the eyelid.
Then another important anatomic element is the lateral canthal tendon and this is the
tendon that holds up the eyelid to the bone at the outer corner.
So the strategy of surgery is to restore anatomy.
And so it involves a proper examination where you determine, basically asking the most simple
questions.
Is there enough skin at the front of the eyelid?
If not, you need skin.
Is there enough support to the lower eyelid?
Usually, especially in eyelid retraction, in my experience, usually that’s a big issue.
And therefore, you need support from the inside and that typically requires some type of grafting
procedure and there are a lot of different options for the types of grafts.
Now, the last part is of course the lateral canthal tendon.
Is the eyelid stable enough to be able to anchor to the top layer of the bone called
the periosteum or is it necessary to create what’s called the drill holes and place
stitches to hold the eyelid.
This is pretty involved and this does require, in my opinion, a lot of experience of course
in this area.
But I think it’s also important to understand the person’s individual course of healing.
You know, in surgery, we put things in the right place but then we rely on the patient’s
ability to heal.
Now there are factors that can contribute to undesirable healing.
One of the most important is cigarette smoking or smoking in general.
Basically, when people smoke, they’re not only creating issues with their lungs but
they’re basically generating free radicals which can create a lot of inflammation which
is not favorable and can disrupt proper healing.
They create carbon monoxide essentially poisoning and diminish the amount of oxygen delivery
to the tissue.
And since smoking affects the smallest vessels, they can also affect proper healing.
In line with that not necessarily specific to smokers, I use a lot of technology that’s
from the regenerative medicine field such as the use of platelet-rich plasma (PRP) and
extracellular matrix to help expedite the healing for my patients so that we can maximize
their ability to heal properly and lead less to unpredictability.
So understanding the principles of eyelid retraction and ectropion can guide you as
to the basis of what the surgeon is proposing.
I find that a lot of times, people want to and naturally want to take, when I hear these
types of details, they pretty much feel like they’re overwhelmed and often say, “Can’t
you just put a stitch and just pull it up?”
Well, that’s usually, when a situation is more advanced, it’s not going to work.
And a lot of times people come to me after they’ve seen me and they went and had other
procedures such as different ways to pull the eyelid up and they end up with more scars
and worse off than where they started.
And essentially, you have to try to wrap your mind around these ideas and understand that
there are no shortcuts.
There can be limited procedures but it might give you a little bit of improvement but generally
speaking, understanding that restoring anatomy is critical.
A lot of times, people are afraid of skin grafts and the term skin grafts but there’s
an art to doing this and understanding that there’s going to be a healing process but
it is the necessary choice in order to achieve an outcome with a timeline that goes to one
year not to one week.
So I would recommend that you meet with qualified and experienced oculofacial plastic and reconstructive
surgeons.
Those of us who specialize in this type of area with a lot of experience with complications
of eyelid surgery and learn about your options so that you can at least have a good sense
of understanding of what is involved and be able to commit to the plan in a way that makes
sense to you and that you understand and work with the doctor so that you ultimately achieve
the best outcome for this unfortunate consequence.
So I hope that was helpful, I wish you the best of luck and thank you for your question.