Eyelid Revision Surgery - Managing Unintended Consequences

Blepharoplasty is one of the most commonly performed facial procedures, but not all results age well or heal as expected.

For patients experiencing issues such as hollowing, eyelid malposition, or asymmetry, revision blepharoplasty (also referred to as secondary eyelid surgery) may offer both functional and aesthetic improvement.

These cases are often more complex than primary surgeries and require a thoughtful, conservative, and tailored approach.

Here is a quick rundown of the main complications I see in my daily practice:

1. Complications from Excessive Skin Resection (Upper or Lower Eyelid)

• Lagophthalmia (incomplete eyelid closure)
Removing too much upper eyelid skin during blepharoplasty can result in difficulty fully closing the eye, a condition known as lagophthalmia. This leads to dryness, irritation, and exposure-related symptoms. Correction often requires revisional eyelid surgery, which may include lengthening skin and weakening the levator muscle.

• Ectropion or Lower Eyelid Retraction
Over-resection of lower eyelid skin or postoperative scarring can pull the lid downward, leading to lower eyelid malposition. Patients may experience redness, blurriness, tearing, and aesthetic distortion. Depending on severity, correction may involve:

• Canthopexy (lateral eyelid support)

• Horizontal eyelid tightening

• Midface lift with or without skin grafting in advanced cases

2. Fat Mismanagement: Too Much or Too Little

• Upper Eyelid Hollowing (A-Frame Deformity)
Over-removal of fat or skin in the upper eyelid can lead to a sunken, skeletonized look, commonly known as A-frame deformity. This is a frequent reason patients seek eyelid hollowing correction. Volume restoration using fat pad repositioning or microfat grafting is often effective.

• Lower Eyelid Hollowing
Similar issues in the lower eyelid can result in a hollow, aged appearance. Treatment depends on severity:

• Mild: Fat grafting to the tear trough or lid-cheek junction

• Severe: Orbicularis muscle and cheek fat resuspension for structural support

• Recurrent Fat Pad Herniation
Fat herniation after blepharoplasty may reappear over time or if incompletely treated during the initial procedure. Revision aims to restore smooth contour without overcorrection, maintaining a natural appearance.

3. Missed Diagnosis: Brow Ptosis or Palpebral Ptosis

• Residual Eyelid Ptosis
In some cases, the original surgeon may have overlooked levator muscle dysfunction. Patients are left with a low upper lid (ptosis) or asymmetry. Revision may require levator advancement or Müller’s muscle tightening, standard techniques in ptosis repair surgery.

• Brow Ptosis After Upper Blepharoplasty
If the brows were compensating for upper eyelid heaviness preoperatively, removing skin can unmask underlying brow descent. When this dynamic is not recognized, or if the patient declines a brow lift during the initial consultation—brow ptosis may appear or worsen post-op. Many patients later return seeking correction once the imbalance becomes noticeable.

In such cases, the solution isn’t more eyelid surgery, but a brow lift to restore upper facial harmony.

Conclusion

Revision eyelid surgery is not about doing more, it's about doing exactly what's needed, and nothing more. The goal is to restore function, symmetry, and natural expression, not to over-correct or erase signs of character.

If you're dealing with complications after eyelid surgery, such as sunken eyes, eyelid asymmetry, or persistent puffiness, a personalized plan can help restore balance and confidence.