28.1.1 Case 1

This is a 62-year-old woman with a history of dry eyes (Fig. 28-1). She had a cosmetic lower eyelid blepharoplasty 3 years prior to evaluation. She had a facelift, endoscopic brow lift, and upper lid blepharoplasty 2.5 years prior to evaluation. She did okay for 2 years and then noted lower eyelid festoons. She was treated with a diuretic without improvement. She saw another physician who recommended filler, which she did not have. She had a negative thyroid workup. She was referred because of her prominent lower eyelid and midface festoons.

28.2.1 Case 1

This patient demonstrates one of the most common problems encountered following cosmetic lower eyelid surgery (Fig. 28-2a–d). She has laxity of her lateral canthal tendons and prominent midfacial festoons, and has significant complaints of dry eye symptoms.

28.2.2 Analysis of the Problem

On examination, the patient has laxity of her lateral canthal tendon. She has mobility of the lateral canthal angle (Fig. 28-2a). When a finger is placed at her lateral canthal tendon, it places the lower eyelid back to its normal anatomic position (Fig. 28-2b). However, the malar festoons remain. Placing one finger over the lateral canthal angle and one finger over the malar eminence repositions the lower eyelid and midface back to its normal anatomic position (Fig. 28-2c). Prior to undertaking surgery, the patient needed an appropriate workup. She had a free T3, free T4, thyroid-stimulating immunoglobulin, and thyroid autoantibodies studies performed. All of those tests were negative. Based on that evaluation, a lateral canthal tendon tightening and malar fat pad elevation (mini-cheek lift), in conjunction with a cosmetic lower eyelid blepharoplasty, was scheduled. It is intended to place the lower eyelid and midface back to its normal anatomic position and provide an aesthetically pleasing lower eyelid and midface. A 0.5-inch piece of tape placed over the malar eminence and then pulled tightly up to the temple elevates the lower eyelid back to its normal anatomic position, helping the patient preview the shape of the lower eyelids following surgery. The patient needs to understand the redundant or excess lower eyelid skin and folds will not be there after surgery (Fig. 28-2d). The intent of the tape test is simply to illustrate or preview the lower eyelid position.

28.3.1 Dry Eyes, Exposure, Epiphora

Case 2

Here is another clinical presentation with functional complaints that can also be addressed using the same technique described below. This is a 67-year-old woman. She had a cosmetic upper and lower eyelid blepharoplasty elsewhere. She had a subsequent excision and reconstruction of right medial lower eyelid basal cell carcinoma. She was referred for significant dry eyes and excessive reflex tearing due to the dry eyes. She had seen multiple doctors because of her dry eyes. On examination, she had lower eyelid retraction (Fig. 28-3; Fig. 28-4).

She had laxity of her lateral canthal tendons. She had malar fat pad descent. She had lateral canthal angle mobility and a significantly abnormal snap back test. She underwent a bilateral canthal tendon tightening and malar fat pad elevation (mini-cheek) procedure using a permanent Polydek suture. She stated that her excessive tearing and dry eye symptoms were significantly improved following surgery.

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