Several Concerns After Transcutaneous Lower Blepharoplasty (One Month Ago)

I strongly agree with Dr Steinsaper.  We routinely see this type of complication, but what is really scary is that often the primary surgeon does not acknowledge or recognize it and considers this normal healing.  It is wrong to call out a particular group of surgeons as we have seen a blatant disregard for the functional anatomy of the lower eyelid from every subspecialty including oculoplastic surgeons.

A properly performed transconjunctival blepharoplasty (approaching the fat through the inferior retractors rather than through the orbicularis occuli) eliminates the potential for this complication.

It is important for a surgeon who has experience treating this complication, known as middle lamella syndrome to work with you.  If there is a palpable scar contraction that is contributing to the lower lid malposition, it needs to be released.  The lower lid can be supported in a more normal position while the orbicularis oculi recovers using restylane injections.

Finally you can help others by spreading the word that patients need to have serious conversations with their surgeons about potential risks and benefits of all cosmetic surgeries, but particularly lower eyelid surgery.

Lower eyelid bags are the result of loss of support at the junction between cheek skin and lower eyelid skin.

When you remove fat, muscle or skin it can aggravate the problem or make the space under the eye look hollow.

The best answer if your eyelid does not correct after 3-4 months is to add back the support at the cheek with fat injections. This will both push up the lower eyelid margin and give you a more youthful look. A lateral canthoplasty may distort your eyelid shape and I don't like doing it for that reason.

It amazes me that surgeons have so much trouble learning from the past.  Yes, the paradigm that the majority of transcutaneous lower eyelid surgery is based on is wrong.  It if not per se the fault of your surgeon.  Most likely he or she is a general plastic surgoen who carefully follows the plastic surgery literature which supports this surgical approach.  Denial is not just a river in Africa.  Very important and influential papers encourage surgeon to perform transcutaneous lower blepharoplasty but the anatomic descriptions in these papers are not correct.  A large percentage of patients continue to have complications with this surgical approach.  Your fundemental problem is denervation of the orbicularis oculi muscle at the lower eyelid margin.  Yes you have scaring but the loss of motor function I believe is just as important a factor in the bowing and lateral scleral show exhibited by your eyes.  Over the course of the next 11 months, some of this appearance will often improve and the infracilliary scar will improve.  If the result is not satisfactory, simply performing a "tuck" or putting a stitch in the corner of the eyelid (euphemistic ways surgeons term lateral canthal reconstructions) will not help.  Steroid injections now will only damage the eyelid tissue so don't accept these treatments if offered.  Finger winking can be helpful to put these tissues on slight stretch each day.  More definitive reconstruction methods are generally needed.  I am also impressed with your upper eyelid ptosis.  If you have dry eye symptoms from the lower eyelid compromise, consider working with your ophthalmologist on this issue.

You have a valid concern and problem after surgery and should work with your surgeon to resolve the issue. You do not state whether your surgeon acknowledges that their is a problem. If he/she does not, ask for a referral to a colleague for a second opinion. Once they acknowledge the problem or you get them to do so you need to know the contributing factors (skin deficiency, muscle weakness, swelling and/or scar formation) and a treatment plan (massage, passage of time, temporary traction suture) to resolve the issue - stop it from getting worse. It is too early in the healing process for any revision surgery.

I hope you realize that this format of posting questions and receiving answers lacks the face to face direct communication required for you to make an informed decision regarding your surgery.

My response to your question/post does not represent formal medical advice or constitute a doctor patient relationship. You need to consult with i.e. personally see a board certified plastic surgeon in order to receive a formal evaluation and develop a doctor patient relationship in order to know if this assessment is valid.

You have lateral scleral show which means there is scar formation in the underlying tissue which is contracting and pulling the outer aspect of the lid downward. This may be temporary as sometimes this will improve as the muscle function recovers.  This retraction of the lid is also less common with transconjunctival but can occur with them as well. Although I now use a new lateral access technique, I still will do the open technique on patients with advanced problems and if this occurs I will inject kenalog diffusely in tiny amounts directly into the area which is contracting and will put the patient on a series of stretching exercises which has worked well. If you get to to three months out and there is no improvement you will require a secondary procedure for correction. Hang in there.

Your scar lengths appear average for transcutaneous lower blepharoplasty. The scars themselves, however, are more red/active looking than many. This occurs mostly in younger patients. The scars will improve markedly with time, but will take many months to fully fade. 

 

As for Lid position, squinting/stretching exercises are helpful, as is ongoing follow up with your surgeon. Ask about these exercises, and if he/she recommends any particular regimen of creams for the scar.