26.1 Patient History Leading to the Specific Eyelid Problem

This 55-year-old woman had a prior facelift with four-eyelid blepharoplasty (Fig. 26-1). Postoperatively, she developed progressive lower eyelid malposition. She was referred to our care, expressing concern over both the appearance of her lower eyelids and ocular surface discomfort. When attempting to manually elevate the eyelid with a finger, the eyelid had minimal upward mobility.

26.2 Anatomic Description of the Patient’s Current Status

The patient demonstrates the most common complication of lower eyelid blepharoplasty: lower eyelid retraction. It is best understood as the result of an imbalance in lower eyelid forces in which negative, downward vectors prevail over the lower eyelid’s upward support. Commonly encountered abnormal negative vectors that are found following aesthetic lower eyelid surgery include excessive skin resection, cicatrization of the anterior and middle lamellae, and lateral canthal dystopia/laxity. In addition to a suboptimal aesthetic, lower eyelid malposition and eyelid retraction can cause decompensation of the ocular surface through poor eyelid closure and excess exposure.

When clinically assessing lower eyelid retraction after blepharoplasty and deciding on a restorative approach, it is important to determine which of the three common negative vectors mentioned above (excessive skin resection, cicatrization of the anterior and middle lamellae, and lateral canthal laxity) are contributing to the retraction. This can be assessed by attempting to elevate the lower eyelid with a finger pushing upward, first at the lateral canthus and then at the central eyelid position (Fig. 26-2).

If, with upward pressure at the lateral canthus, the eyelid elevates to a sufficiently high position without bowstringing under the globe or inducing an unnatural bowing of the central or medial eyelid, then lateral canthal laxity is likely the predominant pathology and a simple tarsal resuspension should be sufficient to correct the malposition. However, if one meets significant resistance or if the eyelid creates a bowing deformity, additional negative vectors are likely at play and a simple tarsal resuspension is likely to fail.

One should next attempt to elevate the lower eyelid with a finger at the central lid position. If the lid elevates easily without resistance to a sufficient height, then middle lamellar scarring is the predominant vector that must be overcome, and a posterior lamellar spacer graft with canthoplasty will be the recommended surgical intervention. We prefer to use hard palate, though ear cartilage and acellular dermis are also commonly used with success as posterior lamellar spacer grafts to help correct lower eyelid retraction following blepharoplasty.

As was the case in the patient presented here, when upward pressure in any location across the lower eyelid fails to elevate the lower eyelid to a suitable position, it may be interpreted that a true anterior lamellar deficiency exists. Excessive skin resection resulted in a foreshortened anterior lamella that is now pulling the lower eyelid downward and outward, creating an ectropion. In these cases, one may also observe lower eyelid movement/retraction upon opening of the mouth. Chronic exposure of the ocular surface to the environment leads to dry eye, exposure keratopathy, and epiphora, and, if left untreated these can lead to more serious corneal decompensation. Unfortunately, with true anterior lamellar deficiency, neither a simple tarsal resuspension nor posterior lamellar lengthening surgery will sufficiently address the pathology.

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