Of course, the surgeon should always warn the patient that there is a chance of being worse following enhancement. Enhancement often makes the difference between a very happy patient and a patient who is dissatisfied. Ultimately, this can make the difference between a refractive practice that steadily grows and one that just sort of putters along. Some surgeons feel differently about this, typically citing a high rate of epithelial ingrowth after enhancement in which the flap is lifted. On the other hand, I have consulted on many patients who had a flap complication during enhancement in which an attempt was made to cut a new flap.
Appropriate technique is the key to successful flap elevation.
There are several techniques that can be used, but I will outline my own. First, mark the cornea so that the flap can be returned to its original position. Next, identify the edge of the flap by dragging a Sinsky hook radially through the epithelium from the limbus toward the center of the cornea until the hook catches on the flap edge. Then, open up the flap edge for no more than one clock hour by running the hook laterally along the flap edge. Finally, gently grasp this exposed edge of the flap with forceps and peel it back toward the hinge in one fluid motion.