34 The Spectrum of Postblepharoplasty Lower Eyelid Retraction (PBLER) Repair
Summary
Postblepharoplasty lower eyelid retraction is a complicated and challenging problem to surgically address. Its etiology is multifactorial and can include eyelid scarring, eyelid laxity, volume deficit, orbicularis weakness, negative vector topography, and anterior lamellar deficit. Appropriate correction requires a detailed preoperative examination with identification of contributing factors to determine the best surgical plan. On occasion, nonsurgical intervention such as eyelid filler injection may suffice.
34.1 Background
Postblepharoplasty lower eyelid retraction (PBLER) is a challenging and complicated eyelid malposition to address. Traditional teaching has been that it is caused by three principal factors: (1) unaddressed lower eyelid laxity, (2) anterior lamellar shortage, and (3) a “middle lamellar” or orbital septal scar. As such, the standard repair of these physical findings (“traditional surgery”) has been a combination of (1) canthal suspension, (2) midface lifting to recruit skin, and (3) a posterior lamellar spacer graft. The authors have studied PBLER in depth and have found that this combination of procedures, applied universally, leads to patient satisfaction with surgery in only 40% of cases (surgeon satisfaction much higher at 80%); recurrence is not uncommon, and orbicularis deficit (innervational or biomechanical), a negative vector globe/midface morphology, and a volume-deficient lower eyelid/inferior orbit are also significant etiologic factors present (yet often unaddressed). Appropriate treatment for this complicated and multifactorial problem requires identifying (1) its primary component causes, (2) the degree of intervention patients are willing to undergo, and (3) patient expectations. Final treatment is then tailored accordingly. Examples of various presentations and treatment options are reviewed below.
34.2 Physical Examination
It is important to quantify the amount of PBLER to assess efficacy of surgery in an evidence-based manner. This can be standardized by measuring scleral show (the amount of sclera visible between inferior limbus and the lower lid margin) and the Margin Reflex Distance 2 (MRD2; distance of corneal light reflex to lower lid margin) (Fig. 34-1). The authors prefer the MRD2 as an indicator of the degree of lower lid retraction. To best develop a plan to address PBLER, the authors have identified six critical factors that must be evaluated for each case. Assessing the presence and degree of each potential deficit directs treatment.
These parameters and how they are evaluated are listed below.
Orbicularis strength—lid squeezing (Fig. 34-1).
Internal eyelid scar—forced traction test (FTT): limitation of free upward excursion of the eyelid (Fig. 34-1).
Anterior lamellar shortage—patient looks up and opens mouth (Fig. 34-2).
Eyelid/inferior orbit volume deficit—subjective grading by visual inspection (Fig. 34-2).
Eyelid vector—subjective grading of globe/midface topography or slope (Fig. 34-2).
Eyelid laxity—snap back and distraction test (Fig. 34-3).
Fig. 34.2(a,b) Anterior lamellar shortage is present with simultaneous supraduction (patient looks up) and mouth opening the lower lid retracts further. (c,d) Frontal and oblique view of inferior orbit/lower eyelid volume loss. (e,f) Two examples of negative vector globe/midface morphology (globe protrudes further than midface, thus lower lid must maintain position against a gradient). 
Fig. 34.3(a,b) Eyelid distraction test. If the lower lid can be distracted more than 8 mm from the globe, eyelid laxity is present. (c,d) Eyelid snapback test. If the lower lid can be inferiorly displaced and not return to normal position without a blink, there is a positive test, which also signifies eyelid laxity.
34.3 Patient Examples
34.3.1 Case 1: Volume Deficit
A 36-year-old woman had transcutaneous (open approach) lower blepharoplasty 1.5 years ago. On examination, she primarily has volume-depleted lower lids, borderline anterior lamellar shortage, and no internal eyelid scar of significance. Her eyelid is not lax, there is good orbicularis function, and her eyelid vector is neutral. Her retraction was addressed well with lower lid filler treatment (Fig. 34-4).
Analysis
The predominant finding on this woman’s examination is volume-deficient inferior orbits/lower eyelids, and she is not keen on invasive surgery. She was treated by stenting her lower lids with hyaluronic acid gel filler. This is best accomplished with a stiff (high G) and viscous product, which allows excellent three-dimensional tissue expansion. In her case, 1 cc of Restylane was given to both lower lids with a 25-G, 1.5 cannula. The authors have found the cannula technique leads to less bruising, and this length of cannula allows treatment of the entire eyelid with one skin penetration. The authors have also found that a malar entry (mideyelid location) versus an eyelid entry point, independent of the cannula device, leads to less bruising than direct eyelid injections. The gel is placed over the bone (using noninjecting finger to feel the location of the tip of the cannula) of the inferior orbital rim in 0.1- to 0.2-mL deposits (after aspiration on plunger and retrograde injection), and is massaged on bone in a superior direction. The bone acts as a backstop for massage. Tissue expansion leads to lower lid elevation (Fig. 34-5). Original descriptions of this technique used a needle, and injections were given from the orbital rim to the lash line (Fig. 34-6). The authors prefer not to use needles in potentially scarred planes, as the scar may fix vessels in place and increase the likelihood of vascular complications. The authors also prefer to avoid injecting into the eyelid proper as they have found this leads to contour issues, significant bruising, and less predictable results. This procedure is less powerful when upward eyelid excursion is limited by severe scar or skin shortage. If there is significant negative vector present, the midface must be augmented simultaneously.
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