31 Lower Lid Retraction
Summary
Lower lid is a complex multilayered structure, which needs to be understood with regard to its anatomy, its interplay with the globe and surrounding facial structures, and its integrity in individual patients. Failure to appreciate these factors may lead to lower lid retraction, a common complication of eyelid surgery such as lower lid blepharoplasty. This chapter addresses anatomy and clinical evaluation of the lower lid in addition to providing illustrative examples of lower lid retraction and their surgical solutions.
31.1 Introduction
The normal lower lid position with the eye in primary gaze is at or slightly above the inferior corneal limbus. Lower lid retraction is an abnormally low position of the lower lid without eversion of the lid margin; retraction and canthal angle blunting are common complications of lower lid blepharoplasty, which not only result in an unaesthetic “sad,” “tired” appearance but also may cause ocular irritation and epiphora due to an ineffective tear column–globe contact. Persistent long-term ectropion is a less common complication.
Understanding the complex interplay between the tissues and gravity, which “age” the lower lid, and addressing these appropriately decreases the possibility of lid malposition following blepharoplasty.
Careful preoperative evaluation and apt surgical planning and execution are paramount in avoidance of poor outcomes.
The lower lid must be evaluated anatomically, considering it in its three lamellae: anterior, middle, and posterior lamellae. Vertical shortening should be assessed in all three planes. Isolated posterior lamella deficiency tends to invert the lid. Middle lamellar shortening, which is sometimes difficult to judge, can be a cause of operative failure; the most common primary deficiency is that of the anterior lamellae, the restoration of which will be discussed in this chapter and elsewhere. The restoration of the lid to its normal position also requires the assessment of the horizontal plane, treating lid laxity where required, in conjunction with the anteroposterior plane, where the failure to consider the orbital vectors may result in unexpected poor results.
A three-dimensional and three-planar assessment is imperative before embarking on corrective surgery for lower lid retraction.
31.2 Evaluation
31.2.1 Horizontal Laxity and Lateral Canthal Tendon Laxity
The lateral canthal tendon is assessed by grasping the lid and pulling medially; the displacement of the lateral canthal angle is then observed. Up to 2 mm of movement is considered normal (Fig. 31-1). The snap test is performed by pulling the central portion lid away from the globe and then allowing it to snap back into position; upon release, a normal eyelid should snap back against the globe immediately without a blink. A severely lax eyelid may require one or more blinks to return to normal position. If the lower eyelid can be distracted more than 6 to 8 mm away from the globe, then horizontal laxity is present.
31.2.2 Orbital Vector Analysis
A patient’s orbital vector is defined as the relationship between the globe (the corneal apex) and the malar eminence in the sagittal plane (Fig. 31-2). The main purpose of assessing for the vector is to avoid complications that arise from lower lid surgery on negative vector patients, who have very little malar support.
31.2.3 Evaluation of the Anterior Lamella: Skin and Orbicularis
The lower lid retraction may be exaggerated in up-gaze. It may be exaggerated further still by asking the patient to open their mouth while in up-gaze.
31.2.4 Evaluation of the Middle Lamella: Septum and Lower Lid Retractors
The middle lamella is evaluated by manual vertical distraction of the lower lid. While the patient is looking in the primary position, the lid is manually moved upward (opposite to that shown in Fig. 31-1b).
A patient with middle lamellar contracture will have lower lid tethering (Fig. 31-3), and the lid cannot manually be moved upward over the surface of the globe. This is in contrast to the patient with lower lid retraction associated with an overresection of skin only.
31.2.5 Evaluation of the Posterior Lamella: Conjunctiva and Tarsal Plate
Direct visualization of the conjunctiva will reveal any scarring in the inferior fornix following transconjunctival techniques. Manually elevating the eyelid will result in the eyelid margin rolling inward toward the globe.
31.3 Case 1. Postoperative Lower Lid Retraction Secondary to Anterior and Middle Lamella Complications
31.3.1 Patient History Leading to the Specific Problem
A 49-year-old lady had undergone bilateral lower lid blepharoplasties 6 months prior to presentation (Fig. 31-4). This surgery resulted in bilateral lower lid retraction and left lower lid diastasis from the globe. She then underwent a left lower lid canthoplasty elsewhere, but this failed to address the malposition. At presentation, she has bilateral lower lid retraction but the left was of particular concern due to the resultant corneal epithelial irregularity in her only-sighted eye; the other eye was affected by dense amblyopia. She was a nonsmoker and had no significant medical history.
Clinical photographs demonstrate postblepharoplasty syndrome with the eye in primary position and in up-gaze (Fig. 31-4). The purple skin markings illustrate the vector of retraction.
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