Lower eyelid retraction is defined as the inferior displacement of the eyelid margin that exposes the lower part of the eye and enables visibility of the sclera (scleral show). Patients may complain of irritated eyes, light sensitivity, and tearing. The retraction may cause exposure and excessive dryness of the cornea, a potentially serious condition. In many cases, it also causes an esthetic concern for the patient.
Lower eyelid retraction is the most common and feared complication after cosmetic surgery of the lower eyelids and cheeks. Retraction is usually bilateral, although it can affect only one eye or be asymmetric.
Surgical repair is complex and requires multiple techniques to correct eyelid position and prevent recurrence of the retraction. One surgery may be sufficient to address the problem, but some patients require additional interventions.
Surgical technique to repair eyelid retraction: 4 steps to achieving success.
Step 1: Fat transfer
Facial fat transfer is a critical component of the operation. Fat is harvested from the abdomen or thigh and carefully processed before being transferred onto the cheek with infiltration cannulas specially designed for this area.
This step provides support to the lower eyelid and midface, increasing the success rate of the operation.
Step 2: Spacer graft
The next step consists of harvesting a mucosal graft from the hard palate. The palate graft works as a spacer to increase the vertical length of the lower eyelid. Harvesting a graft of sufficient height and length is essential to provide adequate support for the eyelid.
After harvesting the graft, an incision is made on the posterior side of the eyelid, between the tarsus and the lower eyelid retractors. The graft is sutured to the eyelid’s soft tissue with absorbable stitches.
Step 3: Midface lift
A midface lift is then performed. This step is crucial to correct the retraction as it allows the surgeon to recruit skin from the cheek without needing a skin graft. When possible, avoiding a skin graft is beneficial to achieve the best cosmetic result.
The cheek is elevated with non-absorbable sutures. A slight overcorrection is necessary, as the tissues tend to settle with time.
Step 4: Canthoplasty
Lastly, a canthoplasty is necessary. The procedure consists of tightening the lateral canthal tendon at the outer corner of the eye. A canthoplasty provides support to the lower eyelid and upper cheek. Without a canthoplasty, the risk of retraction recurrence is extremely high. Therefore, this is a crucial step to increase the operation’s long-term success.
Recovery after repair of lower eyelid retraction
Surgical repair of lower eyelid retraction is an outpatient procedure. Patients are discharged on the same day as their operation and will wear an eye patch for one week. If the retraction is bilateral – that is, it affects both eyes – it may be necessary to operate one eye at a time.
Bruising and swelling should be expected, lasting up to 2 weeks after the operation. Fortunately, pain is minimal and can be managed with NSAID medications.
Results can best be appreciated one month after surgery.
Lower eyelid retraction repair is challenging but can be achieved with the right surgical approach.
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