Lower Eyelid Trouble After ZMC Fracture Repair, Will It Fix Itself? (photo)

You have ciccatricial (scar based) ectropion of the lower eyelid, which is likely due to scarring from your ZMC fracture repair. Since it has only been 1 month since your surgery, I recommend that you try massaging and eyelid taping over the next 6 months, as well as using lubricating drops. Your surgeon will show you exactly how this is done by demonstrating and applying tape. Even if this does not completely resolve the issue, you will be a better candidate for corrective eyelid plastic surgery in the future should you choose to have it.

It is unfortunate and frustrating when the surgery to correct one problem leaves you with a new issue. The incision used to correct your facial fracture was disguised in your lower eyelid skin crease. This approach traverses the lower eyelid blinking muscle and the septum.  This can cause weakness of the muscle either due to direct injury or due to injury to the nerves that supply the muscle on its underside. Scar formation may also cause tethering of the eyelid along the bony rim. I frequently see patients who have this same issue.  It can still occur when the incision is placed on the back side of the eyelid (trans-conjunctival), but it is less likely, although that is a moot point at this stage. 

Upward massage of the eyelid with your fingers should be performed frequently with the goal of free movement of the lower eyelid.  Often this will provide improvement. Make sure your eye continues to be lubricated well with artificial tear drops and/or ointments. I suggest you avoid battery-powered massagers as there have been case reports associating them with cataracts when used near the eyes. Over time, if an issue remains, you should seek consultation with an oculoplastic surgeon.   A spacer graft may be required as a last resort.  Best of luck!

As others have noted you have lower eyelid ectropion where the eyelid gets pulled downward by scarring. This is a known complication of facial fracture repair. The good news is that many will improve with massage, eyelid taping, and time. Keep your eye lubricated and talk with your plastic surgeon. Cheers, Dr Kerr

Your lower eyelid is not moving well due to scarring and muscle/nerve weakness.  Some of that may improve over the next 6 months, at which time, if still problematic, you can consider lower eyelid surgery to improve its position, by an oculoplastic surgeon. In the meantime, keep your eyes lubricted.

You have a classic ectropion ("ek tro pee yon").  Ectropion can have many causes (old age, trauma, scar , muscle weakness).  Your ectropion is most likely secondary to scar from the surgical access to fix the orbital rim and/or repair the orbital floor of your ZMC fracture.  Typically with massage and time this will resolve.  Sometimes steroids injected in the scar will soften it.  The typical time to allow resolution is a minimal of 3 months.  If it does not resolve with time and/or steroids then surgical correction will be necessary.  The surgical method would tighten the lower eyelid and restore the normal anatomy.

Dr. ES

There are many different approaches to fixing a ZMC fracture, which can be quick complex and challenging. We deal with results like yours not uncommonly. Besides massage and time, there are some interventions that might mitigate the scarring and accelerate softening of the scar. These include injections of Kenalog [steroid] and/or 5Fu [a type of anticancer medication that has antiscar activity]

Discuss these options with your surgeon, or obtain a second opinion.

Best of luck

Alex

It is ideal to approach ZMC fractures through a variety of incisions that help hide the work.  However, it is also common to see an infracillary incision like you have.  Surgeons continue to employ this type of direct incision to gain immediate access to the fracture site.  Repairing these fracture can be challenging.  In my opinion, this incision runs the risk of damaging the motor nerve that supply the lower eyelid.  Also it is possible for the eyelid to become tethered after surgery.  It appears that you may have both of these issues.  I also understand the opposing view which is the less conspicuous incisions add significant time to the surgery and can limit necessary assess for repair.  I would advise patience here. I do not believe there is an advantage to fixing this issue early provided the eye is comfortable.  Time does help in some cases.  But I do agree that if you are frustrated with your progress a second opinion is appropriate.  Generally revisional work can be considered once you have healed for 6 to 12 months.

ZMC fractures are done through multiple incisions. Commonly a subtarsal incision is performed to maintain the orbicularis muscle function.  Often when I do ZMC fractures i suspend the soft tissue along the lateral temporal region and then support the lower eyelid with steri-strips to the lateral temporal region as well. you have some tethering opost-op which  may be scar tissue or muscle weakness.  Massage may help now.  You should follow closely with your surgeon. Good luck.

Photos posted are very good, thanks. At 4 weeks way way to early to discuss this issue. What has your surgeon of record told you? Massage is a good idea but clear it with your surgeon. 

There are 2 possible things occuring in your lower lid.


The soft tissue of the cheek needs to be resuspended by the periosteum. It is pulling the eyelid down.

You have the beginning of cicatricial ectropion due to violation of the inferior orbital septum.


Both of these are known and extremely common problems after repairing a ZMC fracture. There are NOT many ways to repair a ZMC fracture. There are actually only a few. Your motor nerve is NOT damaged and injection with kenalog or 5-FU will NOT completely fix your problem. Massage may help a little but most likely you will need a revision. Make sure you use eyedrops. Don't blame your surgeon. Blame the person who hit you in the ZMC. Make sure you are seen by a plastic surgeon certified by the American Board of Plastic Surgery since they are trained in reconstructing the ENTIRE skull.

Good luck!