Eyelid surgery is arguably the most delicate and complicated surgery of the face. So much so that there is a surgical specialty dedicated exclusively to the eyelids and the area around them, that is, oculoplastic surgery. Of any eyelid surgery, lower eyelid plastic surgery can be considered the most challenging because it carries a much higher risk of complications than other surgeries. There is nearly no room for error in lower eyelid surgery.
The lower eyelids are very important to the blink mechanism by helping to keep the eye moist and protecting the cornea. Lower eyelid surgery carries the risk of affecting this mechanism and thus causing corneal exposure and secondary dry eye. The most feared complications of lower eyelid surgery, especially aesthetic surgery, are cicatricial ectropion and eyelid retraction. Both conditions refer to the eyelids turning away from the eye, leaving the surface of the eye exposed and unprotected.
Causes of lower eyelid retraction after blepharoplasty
Lower eyelid retraction is caused by mechanical forces that pull down on the eyelid when too much skin is removed or the eyelid is not tightened during a blepharoplasty operation. Therefore, when skin is removed from the lower eyelids, the surgeon must be extremely careful to remove only the correct amount. This comes with experience, but the key is to remove less skin than appears to be necessary. When it comes to lower eyelid skin removal, less is always more.
The second cause of lower eyelid retraction is laxity of the eyelids. Thus, during a lower eyelid blepharoplasty, it is important to also perform a canthoplasty, a procedure that addresses this issue. Not doing so will result in eyelids that sag and become everted or ectropic, leaving the cornea exposed to air.
The risk of lower eyelid retraction can be decreased by performing lower eyelid bag surgery through the inside of the eyelid instead of making an incision in the skin. This can be done when the lower eyelid bags are not associated with much skin laxity or excess skin. However, if the surgeon has to remove skin, the best way to prevent retraction is to remove less skin than appears necessary and tighten the lower eyelid with a canthoplasty.
Treatment of lower eyelid retraction
It is best to prevent lower eyelid retraction, but if it happens, it will be necessary to correct the problem since it will inevitably cause severe dryness of the cornea, potencial visual complications, and significant psychological stress for the patient. Lower eyelid retraction is aesthetically undesirable and potentially dangerous for the eye.
If the cause of the retraction is excess skin removal, a skin graft will most likely have to be grafted to the lower eyelids. This graft is usually taken from the skin behind the ear. The aesthetic result is not ideal, but it might be the only way to protect the eye. Another way to mobilize skin onto the lower eyelids is to perform a midface lift to recruit skin from the cheek. A midface lift will avoid a skin graft; however, it is a very complicated surgery with a lengthy recovery period and has potential complications of its own.
On the other hand, if the cause of the retraction is laxity of the eyelid, the problem can be corrected with a procedure that tightens the eyelid, called a canthoplasty. This is performed through a small incision in the outer corner of the eye without the need of a skin graft. A canthoplasty generally boasts good results and a short recovery period.
Give the eyelids time to heal
Whatever the type of surgery needed to correct lower lid retraction, it is usually wise to wait at least three months from the primary operation to allow tissues to heal and the swelling to disappear. This will allow for more predictable results and a better outcome.
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