A challenging condition
As oculoplastic surgeons, we are accustomed to treating various complications from cosmetic eyelid surgery. However, one condition poses the most significant challenge: lower eyelid retraction after blepharoplasty.
Lower eyelid anatomy is remarkably intricate. More importantly, lower eyelid position is determined by a highly complex interplay of anatomical and mechanical factors such as tissue elasticity, muscle tone, adequate strength of eyelid tendons, and a perfect balance of pulling forces between the skin (anterior lamella) and mucosa (posterior lamella) layers of the eyelid. Furthermore, the lower eyelid and the upper cheek form one anatomical unit and should be treated as such.
What causes retraction after lower blepharoplasty?
Lower eyelid retraction is not infrequent after cosmetic surgery to treat bags and wrinkles under the eyes. Eyelid plastic surgeons greatly respect this operation because the lower eyelid is “unforgiving,” meaning the surgeon must have impeccable care when handling the delicate tissues in this area.
Most retractions occur when skin is removed to treat wrinkles under the eyes, although it may also happen after the surgeon removes fatty tissue, e.g., bags. Also, it is more probable that eyelid retraction will ensue if eyelid tendon laxity is not adequately addressed during the operation.
Whatever the cause, addressing the problem of retraction is a priority.
Why is treating lower eyelid retraction so challenging?
Treating post-blepharoplasty retraction is challenging because the goal is to recover normal eyelid position while achieving the best cosmetic result. A straightforward way to repair the retraction is to place a skin graft in the lower eyelid. The problem with this approach is that a skin graft can become thick and quite visible, making the cosmetic outcome suboptimal.
Another way to approach the problem is to employ the “4-point fixation” for lid retraction. It is the most effective, though quite elaborate, way to fix lower eyelid retraction.
The 4-point fixation for repair of lower eyelid retraction
The 4-point fixation involves releasing all scar tissue and giving vertical and horizontal support to the lower eyelid to prevent recurrence of the retraction.
Vertical support is provided by supplying mid-cheek volume through autologous fat grafting. The fat is grafted from the abdomen or thighs, processed, and subsequently injected deep over the maxillary bone to support and elevate the lid.
Next, scar tissue is meticulously released, and a spacer graft is placed in the posterior side of the eyelid to increase its vertical length. Hard-palate mucosa is best for this purpose.
A midface lift provides the third fixation point. It is crucial to fully release all the cheek ligaments that prevent cheek elevation; otherwise, the tethering effect of these ligaments will produce a recurrence of the retraction.
Finally, the lid is tightened horizontally with a canthoplasty. This step is critical for correcting any laxity and stabilizing the lid during healing.
Patience is vital
For patients who have experienced this complication, the most difficult aspect is giving tissues time to heal before embarking on a series of treatments that may worsen the problem. Surgeons should avoid any intervention before allowing a 3—to 6-month waiting period after the original surgery to repair the retraction.
When the swelling has disappeared, and it is evident that the retraction will persist, then it is time to proceed with the 4-point fixation repair. The surgery is performed in an outpatient clinic under general anesthesia. Results are not seen immediately; the healing process may take up to 6 months. While this time frame may seem very long, it is worth the wait.
A well-experienced oculoplastic surgeon has ample training to limit the risk of complications and can also treat them. Surgical complications are never desired; however, it is good to know that there are treatment options to address them when they occur.
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