Unhappy with Blepharoplasty. Drooping and Pulling Down of Lower Lids? (photo)

I am now 18 months post blepharoplasty and am not entirely happy with the results. The scars have healed with a definite drooping and pulling down of the lower lids, one side moreso than the other (and despite taping for 6 weeks post surgery and massage). Is another surgery the only way to rectify this?

Doctor Answers 9

Revision involves anchoring eyelids to a solid structure in the eye area's anatomy

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As a cosmetic oculofacial plastic surgeon, the lower eyelids being pulled down is one of the most common reasons why people come to me for revisions after cosmetic eyelid surgery. The people that tend to come to me have significant droop after one or two additional procedures were attempted but further  revision was still needed.

The lower eyelid is a complex structure. Even plastic surgeons and facial plastic surgeons don’t always appreciate the complexity nor have all the tools to repair a situation like yours. The lower eyelid is like a suspension bridge and the outer aspect of the lower eyelid has to be suspended from a solid location. That solid location is called the lateral orbital rim and the structure is called the lateral canthal tendon, where the lower eyelid attaches to the bone.

When people come to our practice that have this issue, they often had plastic surgeons pull the skin up and try to attach the skin to the upper eyelid, muscle, or other soft tissue structures that can all cause the eyelids to be pulled down further. The other aspects of the anatomy had to do with the amount of skin in the lower eyelid, so they try things such as mid-face lifting to recruit the skin to get the lower eyelid up. It is sometimes necessary to skin graft to restore the amount of skin because there’s skin shortage. Probably the least understood concept happens to be the pillars that are necessary to vertically hold up the lower eyelid. Like the pillars on a bridge, you have to have something from the rim of the eye, that space to the lower part of the backbone of the eyelid, in order to keep the eyelid in a vertical position. A lot of people get small pinches and tucks but the center or the rest of the eyelid tends to sag because it’s not supported in those areas.

To determine the type of surgery that you need, you need a proper examination. When I see patients for this type of issue, I do a couple of things: I examine the outer corner to see how much I am able to lift without too much stress or resistance, and I pull the lower eyelid upward in order to see how much skin and how tight things are, and then we come up with a game plan. Sometimes it’s minimal like a procedure called a lateral tarsal strip, a lateral canthal plasty, or something more extensive such as drill hole canthopexy and grafting.

It's important to first see your cosmetic surgeon who performed the surgery because he knows your personal anatomy and understands what was done on your eyes. If your doctor is not confident and you don’t feel the sense of certainty of the doctor’s ability, then seeking a specialist who has extensive experience with revision lower eyelid surgery, or sometimes referred to as lower eyelid retraction or scleral show, is ideal for you. I hope that was helpful, and thank you for your question.

Revisional lower eyelid surgery

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You appear to have lower eyelid retraction after lower blepharoplasty. That could be due to a number of reasons including tight skin of the lower eyelid, scar tissue inside the lower eyelid, weak orbicularis muscle (responsible for closing the eyes), or a combination of these factors. There are nonsurgical (filler injection to "stretch" and lift the lower eyelids) and surgical options (skin graft or midface lift) available, depending on the exact problem and goals. See an oculoplastic surgeon for evaluation.

Scleral show

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It looks like you have some bowing and scleral show laterally in both eyes.  This may be the result of poor tone in the lower lid. An exam in person will determine the best treatment. You may need a canthoplasty which is a method to tighten the lower lid and resuspend it.

Volume for lower lid malposition

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The first line of correction for this is volume restoration of the lower lid.  This can be done with restylane or preferably fat.  It is significantly less invasive than reoperating.

Mark Glasgold, MD
Highland Park Facial Plastic Surgeon
4.5 out of 5 stars 46 reviews

Lower lid blepharoplasty dissatisfaction

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You certainly could have a revisional procedure.  You appear quite young and I am wondering about your reason for undergoing surgery.  Faces, and results, aren't symmetrical as a rule.

Lid pulling after lower lid rejuvenation

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Downward pulling of the lower lid is called ectropion and after 18 months despite massage it is likely you will need a procedure to correct the situation. We see this when the lid tone is naturally lax, or the skin overtightened. A canthoplasty can support the lid and restore a natural eye shape.

Ectropion Correction after Eyelid Surgery

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Thank you for the question and posting your picture. The drooping you are concerned about is caused by a loose lower eyelid. In mild cases, the result is "scleral show" -- some of the white part of the eye shows under the colored part. In other cases, the lower eyelid rolls out and does not completely contact the upper eyelid with closure. This is ectropion, and requires repair. There are many ways to address ectropion, including repeating the eyelid surgery with addition of a canthoplasty (elevating the lateral most part of the eyelid, where it attaches in the socket), performing a canthoplasty alone (a tarsal strip procedure), or using a midface lift to elevate the entire lower eyelid and cheek complex. You should follow up with your surgeon to share your concerns, and seek a second opinion from a qualified practitioner.

Pulled eyelid (ectropion) after blepharoplasty

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Some causes for this appearance can be corrected with steroid injection, but this far after surgery it's not that likely to help. Either a procedure to secure the outer corner of the eyelid or skin graft might be needed, depending on the cause. I recommend you discuss your concerns with your surgeon and seek a second opinion to help you decide what to do. Best wishes. 

Lower eyelid rounding after blepharoplasty

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Dear jtwweller

  • Although temporary non-surgical injections can be performed, they would have to be repeated
  • Seek a consultation with your surgeon and/or a second opinion
  • Lower eyelid tightening can be a fairly simple and effective surgery to help you with this problem, but discuss the risks and benefits in detail. 

Best Wishes

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.