Droopy Eye After Mid Face Lift

Linda

You will need to weigh your confidence in your current surgeon to know the right thing to do.

There is no substitute for an in depth personal consultation. Occasionally the lay description of what is going on and what is actual going on are not the same.

If you were 100% confident in your surgeon, you would not be casting about for opinions from strangers. I am going to advise you to listen to your feelings. Please do not blindly follow the recommendations of this surgeon or any surgeon if it does not make sense. Please do not "double down," on a second surgery unless you have a clear understanding of what is going on, and what surgery is planned, why is it necessary, what are the risks of the second surgery, what is the probability of success or failure?

Honestly, sometimes surgeons just panic in these situations. They have a fix-it mentality. He or she just wants to take care of the problem. However, this may not actually be the right time to fix the problem.

Lower eyelid surgery and midface surgery have significant risks associated with them. These risks may not be understood by your surgeon. The fact that your surgery has a complication does not mean that your surgeon did anything below the standard of care. However, what is done to address the problem can make a profound difference and should not be rushed.

Here is the big problem with lower eyelid surgery and midface surgery done through a skin incision under the lower eyelashes (infracillary incision): the anatomy described in some of the most important recent papers in the field are inaccurate. I know this may be hard to believe. I recently reviewed the entire literature on this subject and presented before the Fall 2010 American Society for Ophthalmic Plastic and Reconstructive Surgery Scientific Symposium.

It seems that some of the core papers describe anatomic hypotheses rather than proven anatomic fact. For example, it is clear that the soft tissue of the cheek is mobile (i.e. it slides when we smile). Analogously, the lower cheek is mobile over the lower half of the face. In this location, the nerves that supply the muscles of facial expression around the mouth travel in such a way that it is possible to safely dissect in this plane in the lateral half of the lower face, and this is a key aspect to the so-called deep plane facelift. Similarly, surgeons dissect under the skin and lower eyelid muscle to perform midface lifting. It is understandable that they would hope that this could be done without injuring the nerves that supply the eyelids. Not surprisingly, published papers appear to support this hypothesis which is the basis for a number of standard lower eyelid procedures.

Unfortunately, a hypothesis is a scientific guess. It does not make an established anatomic fact. There is also clear evidence in published papers suggesting that the nerves that supply the lower eyelid orbicularis oculi muscle travel in this so-called glide plane, which is actually just somewhat mobile fat and loose connective tissue between the cheek bone and the orbicularis oculi muscle. Complicating matters with regard to surgeon experience, it is clear that it is possible to do some degree of dissection in this plane without significantly altering the nerve supply to the orbicularis oculi muscle. We just not know how much is too much until after surgery. Additionally, when this dissection is carried out laterally into the crowsfeet area, it is also possible to do significant damage to the nerves that provide innervation to the orbicularis oculi muscle in the upper eyelid as well. This is significant because the elements of the orbicularis oculi muscle within about 5-8 mm of the lower eyelid margin are responsible for blinking the eye closed. WIthout this critical blink function, tears are not moved across the corneal surface properly resulting in dry eye and tearing issues. When the lower eyelid slumps, it does not properly cover the lower portion of the eye and there is increased corneal drying.

Returning to the situation you are describing, I am very concerned that in an attempt to remedy your situation, your surgeon will perform a very aggressive lateral canthal tightening procedure. This effectively shortens the eyelid. This is the most obvious remedy for this situation but uniformly this is a mistake and it substantially complicates future reconstructive efforts. First the globe is not a flat object but a round sphere. Pulled tight, the lower eyelid will seek to follow the shortest path around the fullness of the eye. So in some cases, much to the would-be eyelid reconstructive surgeon's surprise, the eyelid may actually take up a much lower ultimate position under the maximum curvature of the globe. With unusual efforts, such as drill hole canthoplasty (not recommended), it is possible to draw the eyelid straight like a tennis net. However, in this case, there is too much tension in the eyelid and it can actually result in increase cornea discomfort.

The answer in these situations to avoid further eyelid tightening. Rather, the best course is to allow the tissues to heal for now. Then in 6 months or more to comeback and address the situation. Generally what is done very much depends on the findings at the time. However, by preserving as much of the lower eyelid and not cutting out tissue as will occur with a canthoplasty performed at this time, there are many more options and increased likelihood of an improved outcome.

Measures now should be supportive including artificial tears, ointment at bedtime and possibly finger winking to stretch out the corner of the eyelid.

I strongly recommend that you put that proposed surgery on hold and seek several expert opinions. Do keep lines of communication open with your surgeon. Look for oculoplastic surgeons for consultation who have as a focus of their practice the repair of unsatisfactory cometic eyelid surgery. Be skeptical of solutions that must be done "urgently" or don't make sense. Please do not be in rush to fix this although the desire to do so is completely understandable. While very few of these mend themselves, with time it may improve so that less work may be needed than first thought. It is hard to be patient in these situations.

You may need to travel to find the appropriate experts. 

There are many reasons to wait and let the nerves regenerate and very few reasons to take surgical action.  The main priority is to keep your eye from drying.

I would take the doctor’s advice and do as they recommend.  They may have a suture around a nerve causing this problem or something else.  If they are not a Board Certified Plastic Surgeon, I would involve one at this point.  You want someone trained on complications, and one who has seen a few variations on the theme.