Eyelid Problems After Surgery or Aesthetic Procedures - Real Cases and Real Lessons

The eyelids are small in size but incredibly complex. They rely on the balance between the eyelid crease, levator function, brow support, canthal tendons, and midface tension. When any of these are altered, especially without proper preoperative diagnosis or postoperative follow-up, the entire periorbital region can be affected.

Here are several real cases that highlight how varied eyelid problems can be, and why accurate assessment matters.

Case 1: Three Procedures Done at Once, Without Clear Communication

A young woman travelled overseas expecting a straightforward eyelid procedure. Instead, she underwent three separate operations in the same sitting, none of which were properly explained.

1. A forehead lift

She was told this would “open up her eyes,” even though she did not have brow ptosis. This unnecessarily pulled her brows and therefore her eyelid crease higher than her natural position.

2. Eyelid crease lowering

In the same surgery, the surgeon then attempted to lower the eyelid crease back down again. However, the crease was set too low, largely because the aesthetic ideal in that country favours a low, subtle crease close to the lash line. This is quite different from what many of our Southeast Asian patients prefer.

This difference in aesthetic goals was not discussed pre-operatively, leaving her with a result she did not expect.

3. Lateral canthoplasty

A lateral canthoplasty was also performed during the same operation, again without clear explanation of why it was needed.

She returned home with multiple delicate procedures done but:

• with no postoperative guidance,

• no understanding of what had actually been done, and

• no plan for follow-up once she flew home.

How She Eventually Ended Up Seeing Me

She initially went to a GP for stitch removal. The GP struggled, because lateral canthoplasty sutures are not routine stitches and should not be removed casually.

Removing the wrong suture can destabilise the canthus, leading to:

• rounding of the eye,

• downward drift,

• persistent tightness, or

• visible scleral show.

Recognising the risk, the GP advised her to seek a plastic surgeon. When she came to me, she had:

• a too-low upper lid crease,

• asymmetric brow position,

• early lower-lid tightness, and

• non-absorbable canthal sutures that required precise removal under magnification.

I then guided her through what to expect in terms of recovery as she had not received this information before her surgery.

Lesson from Case 1

Eyelid surgery must begin with proper diagnosis and a clear discussion of aesthetic goals. A forehead lift she never needed led to an elevated crease, followed by an overcorrection, all compounded by the lack of postoperative care once she returned home. A single misdiagnosis triggered a cascade of arguably unnecessary procedures.

Case 2: “Droopy Eyelid” After Botulinum Toxin Abroad - Two Problems, Two Causes

A different patient came to me worried she had developed a droopy eyelid after receiving Botulinum toxin overseas. On examination, she actually had two separate issues, each requiring different management.

1. True eyelid ptosis caused by Botulinum toxin diffusion

The first problem was a genuine eyelid droop on one side due to Botulinum toxin diffusing into the levator muscle, a known complication. This was not a pre-existing anatomical issue and largely due to poor injection technique.

I performed targeted injections to the palpebral portion of the orbicularis oculi to help reduce the downward pull, and her eyelid position improved as expected.

2. Brow ptosis unmasked once the forehead muscles (frontalis) were paralysed

She also had long-standing compensated brow ptosis and excess upper eyelid skin. Before treatment, she subconsciously lifted her brows using her forehead muscles, masking the heaviness.

Once the Botulinum toxin paralysed these muscles, the brow descended to its true position, lower than she realised. This then created the ongoing sensation of heaviness even after the eyelid ptosis had improved.

Lesson from Case 2

Botulinum toxin can reveal underlying anatomy that patients never knew they had. The eyelid and brow can both contribute to heaviness, and treating one does not address the other. Proper diagnosis prevents unnecessary anxiety and complications.

Case 3: Early Ectropion One Month After Lower Eyelid Surgery

Another patient underwent lower eyelid surgery overseas using a subciliary approach, However, about one month postop, she noticed:

• outward turning of the lower eyelid,

• irritation of her cornea, and

• changes in eyelid position

She received next to no guidance at all during this period, and early warning signs were dismissed. While her overseas surgeon was willing to revise the ectropion, she still had to travel back across countries for the correction. Unfortunately, not long after the revision, the ectropion recurred again.

This illustrates that no one approach is risk-free, especially without structured follow-up.

Lesson from Case 3

Complications after lower eyelid surgery are not always unpredictable. Ectropion following a subciliary approach is most likely the result of excessive skin removal rather than an unavoidable risk, leading to much tension on closure. When lower eyelid laxity is present, a lateral canthopexy, which supports the canthal tendon, should be part of the surgical plan from the outset. Revision of ectropion caused by a skin deficit is inherently limited, because what has been removed cannot be restored. This case illustrates that the recurrence was not simply bad luck; it was likely the consequence of an incorrect primary approach.

Case 4: Upper Blepharoplasty for Dermatochalasis - The Brow That Was Never Examined

An elderly patient returned after upper blepharoplasty performed overseas for dermatochalasis (excess upper lid skin). The indication was reasonable, but she remained unhappy with persistent upper lid hooding despite the surgery.

On examination, the explanation was straightforward: she had compensated brow ptosis that had not been assessed before the procedure. Over time, she had been subconsciously recruiting her forehead (frontalis) muscle to elevate the brow and open her eyes. Once the upper lid skin was removed, that stimulus was reduced and with it, the habitual frontalis contraction. The brow thus descended to its true resting position, and the residual skin became apparent.

When asked, she confirmed the foreign surgeon had not examined her eyebrows as part of the pre-operative assessment.

This is a known pitfall in upper eyelid surgery. Skin excision addresses the lid, but if the brow is the underlying driver of the hooding, the result will always be incomplete. Brow position must be assessed before any upper blepharoplasty, particularly in older patients where compensated brow ptosis is not uncommon.

Lesson from Case 4

Upper blepharoplasty and brow assessment are inseparable. Operating on the lid without examining the brow risks a poor result that would require revision surgery. This patient would have benefitted from a surgical brow lift to begin with, which would then reveal the full extent of dermatochalasis and hence, the amount of skin to be removed during subsequent upper blepharoplasty.

Case 5: Upper Blepharoplasty Done for Ptosis - The Wrong Operation for the Wrong Diagnosis

Another patient presented after being told she needed "upper blepharoplasty for ptosis" overseas. On examination, her eyelids appeared strange-looking and it was immediately apparent why: her MRD1 remained decreased and her eyelids still appeared droopy. The blepharoplasty had not corrected the ptosis at all.

True ptosis is a problem of levator function, which is the muscle or its aponeurosis responsible for lifting the eyelid. Removing skin addresses dermatochalasis, not the eyelid position. The two conditions can coexist, but they require different operations. A proper pre-operative assessment includes measurement of MRD1, assessment of levator excursion, and examination of the upper lid crease position.

The result was a patient with a tidier lid crease but the same functional droop, no better informed about what she actually had or what correcting it would involve.

Lesson from Case 5

Ptosis and dermatochalasis are not the same condition and are not treated the same way. Blepharoplasty alone will not correct true ptosis. Accurate diagnosis, including levator function assessment, is the foundation of any upper lid examination.

Why Eyelid Problems Are So Easily Misunderstood

The eyelids, brows, canthal tendons, and midface function in cohesion. A small change in one area can affect the rest. That’s why:

• A too-low crease may result from overcorrection, not swelling

• A “simple stitch removal” may risk undoing a canthoplasty

• A “droopy eyelid” may be brow ptosis unmasked by Botulinum toxin

• Ectropion can appear subtle at first but worsen without review. However, ectropion after lower eyelid surgery is not always an unavoidable complication. It may reflect excessive skin removal at the primary procedure, when a lateral canthopexy would have been the correct approach instead

• Persistent hooding after upper blepharoplasty may reflect brow ptosis, not inadequate skin removal. The brow should be corrected first to reveal the true extent of skin excess before the eyelid is touched.

• A droopy lid that persists after "ptosis surgery" may mean the wrong operation was performed - upper blepharoplasty does not correct true ptosis, which requires assessment and treatment of the levator

Accurate assessment ensures the right issue is addressed at the right time.

Takeaway

Eyelid surgery is one of the most intricate areas in cosmetic surgery. When done without proper diagnosis, when multiple procedures are performed together, or when aftercare is lacking, problems can arise quickly, or quietly, weeks later.

If you’ve had eyelid surgery or periocular treatments overseas and are unsure about your healing, seek an early review. Careful assessment can make a significant difference in keeping results safe, stable, and natural.

If you have concerns following eyelid surgery or aesthetic procedures, or are considering eyelid surgery in Singapore, you can read more about eyelid surgery at ZNG.

Written by Dr Ng Zhi Yang, Singapore Plastic Surgeon, and Founder & Medical Director of Doctor Stitch, a specialist-led cosmetic surgery aftercare service.