How Do I Manage Lower Eyelid Malposition Following Lower Eyelid Blepharoplasty?
What abnormalities of the lower eyelid do you see after blepharoplasty? What causes them and how are they avoided? How do I know if a tarsal trip procedure will be helpful? How long do you wait before considering surgical intervention?
In my experience, the most commonly encountered complication of lower eyelid blepharoplasty is eyelid retraction. Other forms of malposition include ectropion and contour abnormalities such as blunting of the lateral canthal angle. Successful intervention for eyelid malposition after blepharoplasty is dependent on identification of the type and mechanical nature of the distortion.
I would first like to touch on eyelid laxity. Failure to recognize and treat horizontal laxity at the time of surgery is a contributor to all varieties of malposition. Ideally, eyelid laxity is identified preoperatively and managed at the time of surgery. Preoperative evaluation should include assessment with horizontal distraction and snap-back tests. These tests assess the laxity of the canthal tendons and the intrinsic loss of elasticity that occurs with involutional changes in soft tissue. Canthal tendon tightening may be accomplished with lateral and medial canthoplasty techniques. The most commonly performed procedure for correction of horizontal laxity is the tarsal strip procedure—discussed in detail in Question 5. Having no cure for loss of elasticity, judicious use of horizontal shortening of the lower eyelid can improve the horizontal tension on the eyelid and elevate (or prevent retraction of) the lower eyelid margin.
Globe prominence should also be assessed preoperatively. Prominent globes predispose the eyelid to displacement/retraction. Blepharoplasty should be approached conservatively in terms of skin excision in such patients. Consideration should also be given to elevation of the suborbicularis oculi fat pad (SOOF) to counter any tendency toward retraction (Figure 49-1). One last consideration surrounds correction of horizontal laxity. In patients with prominent globes, horizontal laxity should be addressed; however, care should be taken not to overtighten the eyelid, which results in paradoxical lowering of the eyelid.
Figure 49-1. (A) A patient with prominent globes before lower eyelid blepharoplasty. (B) To avoid retraction, fixation of the SOOF and a lateral tarsal strip procedure were performed in addition to a standard transcutaneous blepharoplasty.
On occasion, after lower eyelid blepharoplasty, mild foreshortening of lower eyelid skin limited to the lateral canthal area may result in blunting of the lateral canthal angle (Figure 49-2). As in all things, prevention is preferable to postoperative repair. When removing small amounts of lower eyelid skin, I would recommend that you elevate and attach the free edge of the remaining lateral skin-muscle flap. This can be sutured to the periosteum at the lateral canthus with a 5-0 Vicryl suture (Ethicon, Somerville, NJ). This supports the lateral aspect of the lower eyelid and keeps it from retracting inferiorly. When lateral blunting is encountered postoperatively, I take a stepwise approach to management. The usual initial step is releasing lower eyelid skin sutures to allow some relaxation of the wound. I also recommend massage and steroid injections into any focal areas of cicatrix. If the lateral blunting persists, then surgical correction is usually required. A lateral tarsal strip-type tightening of the lateral canthus will usually reform the blunted canthal angle (see Figure 49-2). When there is significant skin foreshortening, then one may need to augment the lower eyelid with a posterior spacer graft or augment the lower eyelid anterior lamella with a small skin graft (see Question 7). These usually leave a reasonable cosmetic result if limited in their extent. If there is a palpable scar band resulting in localized retraction of the eyelid, then a “V-Y” advancement of lower eyelid skin allows some vertical relaxation in exchange for some additional horizontal tightening of the skin (Figure 49-3).
Figure 49-2. Lateral canthal blunting following blepharoplasty before (A) and after (B) reparative lateral canthoplasty.
Figure 49-3. Contour abnormality due to focal scarring of the left lower eyelid (A). The area of scarring is released with a “V-shaped” incision (B). The eyelid is then able to be elevated to a normal position and the incision sutured in a “Y” configuration (C). The eyelid is in a more natural position (D) following the “V-Y” advancement flap.
Ectropion can be transient and self-limited. Facial and eyelid edema in the early postoperative period may cause reversible malposition of the lower eyelid. Anterior to posterior thickening of the eyelid may cause a mild mechanical ectropion that will resolve with time. Postoperative decrease in orbicularis function may also contribute early ectropion. The weight of the edematous tissue may cause downward gravitational traction on the eyelid. Elevation of the head of the bed while sleeping and massage/compression of the eyelid may speed resolution. If exposure and conjunctival edema are contributing to the patient’s discomfort or the eyelid malposition, a temporary suture tarsorrhaphy may improve comfort and diminish conjunctival edema via mechanical compression by the eyelids. In this early and reversible type of ectropion, the eyelid is just thickened by edema and remains vertically mobile. One may distinguish this from anterior lamellar shortening. If the lower eyelid distinctly resists upward movement with gentle vertical displacement with the index finger, vertical shortening of the eyelid may be suspected.
Occasionally, ectropion can be permanent and one of the most challenging complications following blepharoplasty. This occurs as a result of removal of too much skin and orbicularis. This can be very challenging to repair and I strongly encourage avoidance by cautious excision of skin. Ectropion due to anterior lamellar shortening may be apparent in the early postoperative period, or may not develop until years later. When mild skin shortage is identified in the immediate postoperative time period, I will sometimes release the sutures to open the wound and place suture tarsorrhaphies. By allowing the wound to granulate, small overcorrections may be compensated for. Unfortunately, in severe cases, skin grafting may be required (Figure 49-4).
Figure 49-4. (A) Ectropion following lower eyelid blepharoplasty. (B) Improved eyelid position
1 month following full-thickness skin grafting.
Eyelid retraction following blepharoplasty is discussed in detail in Question 7. I will just touch on the basics here. Causes include shortening of the vertical height, horizontal laxity, or mechanical distortion from cicatricial changes (ie, scarring). Initial treatment includes aggressive topical lubrication to decrease symptoms and prevent keratitis or ulceration. Middle lamella shortening occurs when there is fibrosis in the healing eyelid, or when there is iatrogenic incorporation of the orbital septum into the anterior or posterior lamella of the eyelid. The orbital septum is rigidly fixed to the arcus marginalis of the inferior orbital rim. Inadvertent suturing of the septum to the skin creates a rigid scar band that resists upward displacement. In selected patients, surgical trauma alone incites an abnormal fibrotic reaction that creates this same noncompliant scar band. Early identification of abnormal scar retraction may be treated with steroid injection, massage, and upward traction of the eyelid. When the problem persists or is identified later, correction typically requires release of the scar tissue and placement of a spacer graft to discourage reoccurrence. A posterior approach through the conjunctiva and lower eyelid retractors allows release and recession of the scar and lower eyelid retractors. The eyelid is then supported with a spacer graft such as hard palate mucosa.
In summary, it is better to avoid, rather than treat, lower eyelid malposition following blepharoplasty. Recognizing and addressing lower eyelid laxity, tailoring surgical technique to globe prominence, and use of judicious skin excision are key. When encountered, the management of lower eyelid malposition is tailored to the specific abnormality.
Patel BC, Patipa, M, Anderson RL, McLeish W. Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip. Plast Reconstr Surg. 1997;99(5):1251-1260.
Patel MP, Shapiro MD, Spinelli HM. Combined hard palate spacer graft, midface suspension, and lateral canthoplasty for lower eyelid retraction: a tripartite approach. Plast Reconstr Surg. 2005;115(7):2105-2114.
Patipa M. The evaluation and management of lower eyelid retraction following cosmetic surgery. Plast Reconstr Surg. 2000;106(2):438-453.