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Secrets of a Beverly Hills Cosmetic Surgeon

with Robert Kotler, MD, FACS

Dr. Kotler's blog has now been retired. We appreciate all the wisdom and support he has brought to the WebMD community throughout the years.

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Tuesday, April 12, 2011

When Is Enough Surgery Enough?

Last week the entire nation was keyed into a trial in New Jersey in which a lady sued a cosmetic surgeon because of unhappiness with her eyelids following an upper eyelid cosmetic surgery.

The patient did suffer complications as a result of the surgery. Apparently her eyelid closure is incomplete. This has caused long-term dryness and the need to use drops and jellies, etc., to keep the delicate eye tissues from being damaged.

Apparently the patient had two prior upper eyelid surgeries and requested a third one from the surgeon. Whether or not the surgeon sought consultation with another specialist prior to taking on the case (generally a good idea before committing to a third visit to the same delicate and unforgiving tissues), is not known. However, the surgeon claims that he did advise the patient that incomplete eye closure was a risk of this surgery, which in fact it is.

It is important to understand that revision surgery, or repeat surgery, particularly of the upper eyelids, carries much more risk than the primary procedure. Often, because some skin has been removed at the first operation and perhaps the second, there is less skin available for removal at the third; therefore, such removal –- if performed at all — must be very judicious.

A big lesson from this matter is that the lady had two prior surgeries, and that only increases the odds, unfortunately, that success may be elusive and that the risk/reward ratio might become unacceptably high.

I have seen many patients like this in consultation. It is very important for the surgeon to very carefully examine the eyelids and brows, with particular attention to whether or not a droopy brow is part of the problem rather than the eyelid skin itself. This is an important distinction, because if it appears that there is heaviness of the upper eyelids, but it is really because the brow is drooping down, then correction of the brow is the solution and not further eyelid surgery.  In such cases, should further eyelid skin be removed, then the very complication that is the subject of this lawsuit likely ensues.

I am not critical of the surgeon per se, but he undertook a challenging case. I think it is wise in such cases to obtain consultation. I am a big fan of having the consultation done by a surgeon who might have even more experience and depth of specialty. Today, a sub-specialty of ophthalmology known as ophthalmic plastic surgery is the home to eye surgeons who further specialize in cosmetic and reconstructive surgery of the eyelids. They are the grand masters of eyelid surgery, and it is no surprise that they are doing an increasing percentage of the eyelid surgery today. That is healthy.

A second opinion or consultation is always in the interest of the patient and can be very important in helping the surgeon make the decision whether it is “go” or “no go.”

Finally, for your benefit, I will repeat one of my favorite mantras: “When in doubt,do without.”

- Robert Kotler, MD, FACS

Posted by: Robert Kotler, MD, FACS at 10:17 am

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