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

At 4 weeks after surgery my lower eyelid position has not changed much. When comparing left and right, the right one feels firm and only slightly moves when I smile or squint, appearing like the area around the scar is stuck there. Feels like I need the skin to get soft and the area around the scar to get unstuck! Is it common for the eyelid to appear hard and stuck like that? Is it lack of muscle tone? Should I be massaging it? Will time soften the scar and provide more flex? Thank you! Alex.

Doctor Answers 13

Ectropion of the lower eyelid

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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.

Eyelid retraction after subciliary incision

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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!

Brett S. Kotlus, MD, MS
New York Oculoplastic Surgeon
5.0 out of 5 stars 63 reviews

Eyelid ectropion

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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

Lower eyelid malposition after orbital fracture surgery

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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.

Abnormal Eyelid Position of Repair of Broken cheek

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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

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

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The tightness and lack of normal motion of the right lower lid after a repair of the cheek bone area is common due to the extensive needed separation of the muscles from the bone. The tissues get quite stiff and take time to soften and release. I think massage is crucial in your case, you can even use one of those small battery powered point massagers to help soften the tissue.

ZMC and lower eyelid issue

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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.

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

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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. 

Sequelae after ZMC fracture repair

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There are 2 possible things occuring in your lower lid.

  1. The soft tissue of the cheek needs to be resuspended by the periosteum. It is pulling the eyelid down.
  2. 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!

Facial bone fracture sequelae

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Your posted photos are mostly consistent with scar tissue between the skin and deeper layers and possibly reattachment of soft tissues lower on the bones. In order to expose and fix the fracture the soft tissues on top of the bone have to be freed up. In some cases they reattach lower on the bone. Your best bet now is massage possibly with suture, finger or hook upward traction on the lower eyelid and if the issue does not resolve after a few months of this conservative treatment you will need additional 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.

Aaron Stone, MD
Los Angeles Plastic Surgeon

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.