15.1 Patient History Leading to the Specific Problem

The patient is a 67-year-old woman who underwent a bilateral upper eyelid blepharoplasty 10 years ago. She developed lagophthalmos with dry eye symptoms on the left side since the surgery (Fig. 15-1). She tried conservative measures with massage and scar creams, but she had persistent symptoms of foreign body sensation, pain, itching, and redness in her left eye that only temporarily improved with artificial tears and ointments. These symptoms progressively worsened and she presented desiring correction of her lagophthalmos.

15.2 Anatomic Description of the Patient’s Current Status

Lagophthalmos, or inability to fully close the eyelids, can develop from a number of causes. Paralytic lagophthalmos can result from any etiology affecting the facial nerve, such as trauma, iatrogenic injuries to the facial nerve, cerebrovascular accidents, tumor resection, infections, or Bell’s palsy. Proptosis or retraction of the eyelids can also often lead to lagophthalmos, most notably in patients with thyroid eye disease.

Cicatricial lagophthalmos often stems from trauma or surgery. In cases of postblepharoplasty lagophthalmos, aggressive skin excision is the most common cause for both upper and lower lid blepharoplasty. Although lagophthalmos appears to occur more commonly following a lower lid blepharoplasty, patients are usually more symptomatic after an upper lid blepharoplasty, likely due to more corneal exposure with upper lid involvement. Lower lid retraction and associated lagophthalmos can also result if a horizontal tightening procedure was not performed (canthopexy or canthoplasty) or if physiologic or pathologic exophthalmos was not addressed.

Cicatricial lagophthalmos from anterior lamellar insufficiency can typically be avoided by a thorough examination and careful planning. It is necessary to take into consideration the degree of forward displacement of the eyes when planning for a lower lid blepharoplasty. Exophthalmometer measurement greater than 15 mm generally necessitates an eyelid spacer graft to the lower lids in order to avoid retraction and associated lagophthalmos. Commonly used eyelid spacer grafts include porcine acellular dermal matrix (Enduragen), decellularized porcine derived membrane (TarSys), or an ear cartilage graft. When evaluating for an upper lid blepharoplasty, it is crucial to distinguish true blepharoptosis from dermatochalasis and also to take note of brow ptosis that is contributing to the dermatochalasis. Intraoperatively, excessive skin excision can be avoided by generally leaving at least 20 mm of skin on the upper lid from the brow–lid junction to the eyelid margin, when performing an upper lid blepharoplasty. This can be combined with the “pinch” technique, where the redundant skin can be gently grabbed with a forceps to estimate the amount of skin that needs to be excised (e.g., Green fixation forceps) until slight eversion of the eyelashes is noted.

Although the skin shortage often goes unnoticed when the eyelids are open, it becomes obvious with eyelid closure due to the presence of lagophthalmos. Lagophthalmos often leads to exposure keratopathy, where the surface of the eye becomes dry due to poor corneal coverage and rapid evaporation of the tears. If this progresses, it can cause infections, permanent scarring, or even perforation of the globe and blindness. The degree of lagophthalmos often correlates to the severity of the exposure keratopathy.