Following eyelid surgery (blepharoplasty), asymmetries between the eyes may emerge as a source of intense stress. This article was written to inform the candidates who are considering eyelid surgery as well as the patients who experience anxiety and confusion in the early postoperative period. I hope you will benefit it.

First of all, if you still do not know, the truth that you must learn and that has been repeated many times in the content of this blog is that the human face is not symmetrical.

Periocular area is no exception to this rule.

Scientific studies have shown that when carefully observed, there is a noticeable level of asymmetry between the upper eyelids and eyebrows in 92% of people and between the lower eyelids in 90%. As a rule, asymmetries less than 1 millimeter are called “natural” asymmetries and we do not strive to achieve a theoretical symmetry beyond this level. If your expectation is beyond human nature, you will inevitably be disappointed.

Asymmetries around the eyes are influenced by many factors.

The amount of eyelid skin,

Asymmetric functioning of mimic muscles,

Defects in the levator mechanism and mechanical drooping of the eyelid (Ptosis),

Asymmetric formation or loosening of the ligaments forming the upper eyelid fold,

Asymmetrical positioning of fat pads or lacrimal glands around the eyes,

Bone asymmetries around the eyes,

Vertical, horizontal or forward-backward malposition of the orbits relative to each other (orbital dystopia),

Anterior bulging or posterior displacement of the eye against the surrounding bones or each other (exophthalmos/enophthalmos),

Eyebrow asymmetries and asymmetric drooping of the eyebrows,

Volume differences under the eyebrows,

Strabismus,

Past traumas,

Neurological diseases, hormonal diseases, infections, allergies, Botox, etc…

This list goes on and on…

Moreover, the factors on this list are potential causes of asymmetries between the eyes of people who have not yet undergone surgery.

We always document the anatomy of the orbital area with high resolution, standardized studio photographs before the surgery. When you look at these photos for analysis, you can see some structural asymmetries that you haven’t noticed in the mirror for years.

Most of the asymmetries that patients notice for the first time after surgery are also present preoperatively. You can see this in the before and after photos. Only a few of the asymmetry factors I have listed above are factors that can be handled during eyelid surgery. The remaining tens of them cannot be corrected with eyelid surgery. After eyelid surgery, they may even become more noticeable when the camouflaging effect of excess skin and fat bags disappears.

Therefore, if there is an asymmetry that bothers you after eyelid surgery, you should first make sure whether it is an asymmetry which existed before the eyelid surgery, one you have not been aware of and one that cannot be corrected with eyelid surgery.

For instance, if there is a horizontal, vertical or anterior-posterior level difference (orbital dystopia) between the eyes, no surgery can render the eyelid structure symmetrical.

In summary, some asymmetries can unfortunately not be corrected.

It is best to know these before the operation.

We talked about asymmetries between the eyes and eyelids of normal people who have not undergone surgery as well as their causes. Now it’s time to cover surgery-related asymmetries.

In the first 2-3 weeks after eyelid surgery, differences in healing may be observed between the right and left sides in almost every patient. In blepharoplasty, 5-10 small vessels are cut on average, and the bleeding of these vessels is stopped using surgical techniques. If even one of these veins leaks a little blood after the surgery, a more intense swelling, bruise and scar tissue will occur on that side. On the swollen side, the eyelid may appear lower, the eyebrow may appear higher, and the eyelid crease may temporarily lose depth. After surgery, the superficial mimic muscle and/or the levator muscle responsible for opening the eye may temporarily lose strength. The healing tissue formed between the tissue layers after the surgery and the scar tissue that replaces this tissue may temporarily prevent the eyelid layers from sliding on each other. Depending on the scar tissue, there may be temporary difficulties in opening or closing the eyelid.

It takes about 3 months for the tissue to heal, the scar tissue to dissolve, the muscle functions to return and the lymphatic edema to dissipate. In some patients (2-3%), this process may take longer. Particularly in combined periocular surgery, asymmetries in the early recovery period are more pronounced, and prolonged recovery is more common.

People want to achieve the look they long for after plastic surgery. It may be difficult to wait, but it is not possible to evaluate the final aesthetic result in the first 3 months. I do not mean that everything will be symmetrical once recovery is complete. This is because after the recovery is complete, asymmetries that need to be corrected or are impossible to correct may remain. In the first 3 months, you cannot know for sure whether the asymmetry is structural or is related to the recovery process. It would be a big mistake to make a surgical revision before the early recovery process is complete. For instance, if you perform ptosis surgery to remove the asymmetry on the side looking lower due to scar tissue, that side will remain higher permanently when recovery is complete.

Well, on the other hand, you came for a follow-up visit in postop month 3, and there is still a significant (>1mm) asymmetry between your eyelids. How do we proceed in this case?

1. First of all, we will analyze whether there is a problem arising from the design or application of your eyelid surgery. We will see if your surgical incision is at an equal distance from the eyelash border and your eyebrow and whether the amount of skin we leave behind is equal. If it is not, it can be corrected under clinical conditions through a 10-minute procedure using local anesthesia. However, in some cases, it may be necessary to voluntarily perform asymmetrical surgical maneuvers. For example, if one eye bulges ahead of the other, it may be necessary to leave more skin on the upper eyelid on that side or to position the upper eyelid crease higher. Similarly, the lower eyelid canthopexy on the anteriorly-bulging side of the eye should be higher and more anterior than the other side.

2. We will analyze whether there is an asymmetry between the eyelids that cannot be corrected with aesthetic blepharoplasty but can be reduced by another surgical procedure. The most important and frequently encountered problem in this category is droopy eyelids. Droopy eyelids (ptosis) is a condition independent of excess skin on the eyelid. It cannot be corrected with a standard blepharoplasty. Sometimes, the preoperative hidden ptosis may become more obvious once the excess skin on the eyelid is removed. In that case, it may be required to intervene in the Müller’s muscle from the inner surface of the eyelid or the Levator muscle using the former eyelid incision to correct the asymmetry. I have a separate blog post on ptosis. I recommend you take a look at it.

3. We will now analyze the eyebrow position and its effect on the eyelid. Droopy eyelids is a condition that is closely related to excess eyelid skin from an aesthetic point of view but is anatomically and surgically independent from it. The eyebrow may be lower on one side than the other, and there will be an illusion of more eyelid skin on the side where the eyebrow is lower or more voluminous. You cannot reduce the asymmetry between the eyelids in a healthy way without correcting the position of the eyebrows. It is an incorrect strategy to take more skin from the side where the skin is more abundant due to asymmetrically droopy eyebrows. That is because the eyebrow will later go down even further on that side. Moreover, if an eyebrow lift/forehead lift is performed in the future, the eyelid on that side will remain open due to the lack of skin. In patients of this category, the asymmetry in the eyelids is reduced to a minimum when the eyebrows are manually raised, typically in front of the mirror. The ideal solution to this problem is to include a brow lift in the treatment plan. Alternatively, eyebrows can be slightly raised and balanced temporarily with asymmetric Botox. Another alternative is to make a small filler/fat injection under the raised or less voluminous eyebrow.

4. Unfortunately, eyelid surgeries are sometimes designed and performed in such a way that they cannot be surgically corrected. Some design elements such as the upper eyelid incision being designed too close to the eyebrow or eyelashes, too much skin being removed from the eyelid (in a way to leave less than 18 mm distance between the eyebrow and eyelash), too much skin being removed from the lower eyelid (more than 4-5mm), removing the fat pads on the eyelids completely, the incision on the lower eyelid being designed well below the eyelash level (>2-3 mm) and the incision scars extending beyond the bone frame surrounding the eye cannot be changed later.

During preoperative examination, you should carefully evaluate the treatment plan that your doctor recommends. Patients may sometimes prefer a simpler procedure to avoid combined treatments.

However, there are some consequences of ignoring the relationship of the upper eyelid with the forehead and of the lower eyelid with the midface or excluding such relationship from the treatment plan.  As you simplify the process, you need to simplify your expectations of the results to the same extent.

If I have suggested the combination of upper eyelid and forehead lift to you in the preoperative interview but you left the forehead lift out of the treatment plan for any reason (fear of surgery, work, healing process, cost, etc.), you should consent to the asymmetries between your eyelids caused by the eyebrows. There is another article on my blog on this subject titled “The relationship between the upper eyelid and the forehead and its importance in aesthetic treatment”.

Similarly, if I have suggested a combination of lower eyelid and midface lift but you left the midface lift out of the treatment plan, you should settle for asymmetries caused by midface sagging in the lower eyelid-cheek transition. I have another article on my blog on this subject titled “The relationship between the lower eyelid and the midface and its importance in aesthetic treatment”.

The downside is that complementary treatments of the eyelid such as forehead lifts and midface lifts also have the potential to create unique asymmetries.

In summary, we frequently encounter asymmetries in eye contour aesthetics. The realistic goal is to achieve the most symmetrical result possible for each patient. We can achieve this goal most of the time with a single operation but sometimes complementary operations and procedures with the primary surgery are needed, while a revision of the primary surgery is another option, albeit rarely.

Eyelid surgeries can be a source of intense concern for symmetry-obsessed or impatient individuals. Do your homework on getting preoperative information well. Do not lose your trust in your doctor as soon as you see the asymmetry on the second postoperative day.

Take good care…

… of yourself and your beauty.

OB

Not recommending or accepting the necessary procedures when there is a need for combined surgery.