After eyelid surgery (blepharoplasty), asymmetries between the eyes can be a source of intense stress. This article has been written to support and inform prospective patients considering eyelid surgery as well as patients who experience anxiety and confusion in the early postoperative period. I hope you will benefit.

First of all, if you do not already know, the fact that you should definitely learn and that has been repeated many times in the content of this blog is that the human face is not symmetrical.

The eye area is no exception to this rule.

Scientific studies have shown that there is a noticeable asymmetry between the upper eyelids and eyebrows in 92% of people and between the lower eyelids in 90% of people. As a rule, asymmetries below 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 are bound to be disappointed.

Asymmetries around the eyes are influenced by many factors.

o The amount of skin on the eyelid,

o Asymmetric function of the mimic muscles,

o Disorders in the levator mechanism and mechanical eyelid drooping (ptosis),

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

o Asymmetrical arrangement of the periocular fat pads or lacrimal gland,

o Bone asymmetries around the eyes,

o Vertical, horizontal, forward-backward position disorder of the eye cages relative to each other (orbital dystopia)

o The eyes are forward or backward in relation to the surrounding bones and each other (exoflatmus/enophthalmus)

o Eyebrow asymmetries and asymmetric eyebrow ptosis,

o Volume differences under the eyebrows,

o Lazy eye and strabismus,

o Previous traumas,

o Neurological (nervous) diseases, hormonal diseases, infections, allergies, botox etc...

This list goes 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 record the anatomy of the eye contour with high-resolution standardized studio photographs before surgery. When you look at these photos with an analytical eye, you can see some structural asymmetries that you have not noticed in the mirror for years.

Most of the asymmetries that patients notice for the first time after surgery are usually present before surgery. You can see this in before-and-after photos. Only a few of the asymmetry factors listed above are factors that can be intervened during eyelid surgery. The remaining tens of them cannot be corrected by eyelid or upper lid surgery. In fact, after eyelid surgery, it may become even 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 that this is an asymmetry that existed before eyelid surgery, that you were not aware of and that cannot be corrected with eyelid surgery.

For example, if there is a horizontal, vertical or forward-backward level difference between the eyes (orbital dystopia), no surgery can create a symmetrical eyelid structure.

In summary, some asymmetries unfortunately cannot be corrected.

It is best to know these before surgery.

We have talked about the asymmetries between the eyes and eyelids of normal people who have not undergone surgery and their causes. Now it is time to talk about the asymmetries associated with surgery.

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

It takes approximately 3 months for the tissue to heal, scar tissue to dissolve, muscle function to return and lymphatic edema to dissipate. In some patients (2-3%) this process may take longer.Especially in combined eye contour surgeries, asymmetries in the early healing period are more prominent and prolonged healing is more common.

People want to have the appearance they long for immediately after plastic surgery, it may be difficult to wait, but it is not possible to evaluate the final aesthetic result within the first 3 months.I do not mean that everything will be symmetrical when the healing is complete, because asymmetries that need to be corrected or cannot be corrected may remain after the healing is complete.It is just that in the first 3 months, you cannot know exactly whether the asymmetry is structural or due to the healing process.It would be a big mistake to perform a surgical revision before the early healing process is complete.For example, if you perform ptosis surgery to remove the asymmetry on the side that appears low due to scar tissue, that side will remain permanently high when healing is complete.

Well, you have come to the third month postoperative control and there is still a significant (>1mm) asymmetry between your eyelids. What should we do in this case?

1. First of all, we will analyze whether there is a problem with the design or execution of your eyelid surgery. We will check whether your surgical incision is equidistant from the eyelash border and your eyebrow, and whether the amount of skin we leave behind is equal.If there is an inequality, it can be corrected in clinical conditions, under local anesthesia, in a 10-minute procedure. However, in some cases, surgical maneuvers may need to be voluntarily performed asymmetrically.For example, if one eye is more anterior than the other, it may be necessary to leave more skin on the upper eyelid on that side or to place the upper eyelid fold higher.Similarly, on the side where the eye is more anterior, the lower eyelid canthopexy should be higher and in a more anterior position than on the other side.

2. We will analyze whether there is an asymmetry between the eyelids that cannot be corrected with aesthetic eyelid surgery and can be reduced with an additional surgical procedure. The most important and common problem in this category is droopy eyelid.A droopy eyelid (ptosis) is a condition independent of excess skin on the eyelid. It cannot be corrected with a standard eyelid surgery. Sometimes hidden ptosis before surgery may become more prominent with the removal of excess skin on the eyelid.In this case, it may be necessary to intervene in the müller muscle from the inside of the eyelid or in the levator muscle using the old eyelid incision to correct the asymmetry. There is a separate article on the blog about ptosis.I recommend you take a look.

3. We will analyze the eyebrow position and its effect on the eyelid. Eyebrow ptosis is an aesthetically closely related but anatomically and surgically independent condition to excess eyelid skin.The eyebrow may be lower on one side than the other and there is an illusion of more skin on the eyelid 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 a wrong strategy to take more skin from the side where the skin is more abundant due to asymmetric eyebrow ptosis. Because on this side, the eyebrow will go down even more.Moreover, if a brow lift / forehead lift procedure is performed in the future, the eyelid on that side will remain open due to the lack of skin.Typically, when the eyebrows are lifted with the help of hands in front of the mirror in this category of patients, the asymmetry in the eyelids is minimized. The ideal solution to this problem is to include brow lift surgery in the treatment plan. Alternatively, temporarily, the eyebrows can be slightly raised and balanced with asymmetric Botox application. Another alternative is to inject a very light filler/fat injection under the higher or less voluminous brow.

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

You should carefully evaluate the treatment plan recommended by your doctor during the preoperative examination. Sometimes patients may prefer a simpler application by avoiding combined treatments. However; ignoring the relationship of the upper eyelid with the forehead and the lower eyelid with the midface or leaving it out of the treatment plan has some consequences. While simplifying the process, you need to simplify your expectations about the results to that extent. If I suggested a combination of upper eyelid and forehead lift in the preoperative consultation and you left the forehead lift procedure out of the treatment plan for any reason (fear of surgery, work, healing process, cost, etc.), you should settle for asymmetries between your eyelids due to eyebrows. I have a separate article on this subject on my blog titled "upper eyelid forehead relationship and its importance in aesthetic treatment". Similarly, if I have recommended a combination of lower eyelid and mid-face lift and you have left the mid-face lift procedure out of the treatment plan, you should settle for asymmetries caused by mid-face sagging in the lower eyelid-cheek transition.I have a separate article on this subject on my blog titled "lower eyelid-midface relationship and its importance in aesthetic treatment".

Similarly, if I have recommended a combination of lower eyelid and mid-face lift and you have left the mid-face lift procedure out of the treatment plan, you should settle for asymmetries caused by mid-face sagging in the lower eyelid-cheek transition. I have a separate article on this subject on my blog titled "lower eyelid-midface relationship and its importance in aesthetic treatment".

The unpleasant part of the job is that treatments that complement the eyelids, such as forehead lift and midface lift, also have the potential to create their own asymmetries.

In summary, we encounter asymmetries very often in eye contour aesthetics. The realistic goal is to achieve the most symmetrical result that can be achieved for each patient. We can often achieve this goal with a single surgery, sometimes with complementary surgeries and procedures added to the first surgery, and rarely by revising the first surgery.

Eyelid surgeries can be a source of intense anxiety for symmetry-obsessed or impatient individuals.

Do your homework on obtaining information before surgery. Do not lose confidence in your doctor as soon as you see the asymmetry on the second postoperative day.

Stay with Love,

Stay Beautiful

O.B.