I Had Lower Eyelid Surgery 4 Months Ago and Right Eye Still has Droopiness, Options? (photo)

Question

My right eyelid still has some droopiness. My doctor is says he could put another stitch to hold it up. Is this the best option?

Jeffrey M. Darrow, MD · Answer

Your photos are helpful and do show more scleral show on your right side. An exam would help clarify if the healing in your lid is still active and is holding the lower lids down from the internal scarring. You appear to be young and your tissues good. Some gentle upward eyelid stretching, to lengthen the scar, and some active eye squinting exercises to strengthen the lower lid muscles may raise the lower lid over the next few months so as to avoid any new procedures. Your plastic surgeon knows exactly what was done at surgery and would be in the best position to examine and advise you

Steve Laverson, MD, FACS · Answer

My personal routine in this situation is for office revision of both lower lids, right more than left, to mobilize the lower lids upward and re-do the canthopexies. you are looking slightly upward in the submitted photo, so if the left lower lid is in good position in forward gaze, best leave it as is.

Kenneth D. Steinsapir, MD · Answer

Four months after surgery is a good time frame to judge the effects of surgery. Transcutaneous lower eyelid surgery damages the muscle that helps hold the lower eyelid margin in place against the eye. Removal of skin and scaring from surgery has created a vertical height issue in the right lower eyelid. Surgeons lacking post-blepharolasty reconstructive surgery experience commonly err thinking that this type of situation can be improved or cured by "putting a stitch in the corner of the eyelid." They believe this because they have sat through numerous lectures suggesting that a canthopexy will strengthen and support the lower eyelid. Unfortunately this is largely wishful thinking. The laws of topology dictate that the shortest path on a curved surface is not a straight line but a curved path called a geodesic. In ordinary life we most commonly encounter this type of mathematical relationship when we take a polar flight from a North American City to a City in Europe. When the plastic surgeon attempts to horizontally shorten the lower eyelid with the stitch which effectively tightens the lower eyelid, the surgeon is surprised when after the procedure the lower eyelid is actually worse than before. This is because the cathopexy effectively shorten the lower eyelid which must now follow an even shorter path around the eye. This shorter geodesic is even lower on the eye. Like Dr. Taban, I recommend that you find an expert in the correction of this type of lower eyelid issue and pass on a repair you have been offered. Your surgeon means well but the proposed procedure can make you worse rather than better. You need an oculoplastic surgoen who offers specialized methods for fixing the lower eyelid contour and position after aesthetic blepharoplasty.

Mehryar (Ray) Taban, MD, FACS · Answer

You have right lower lid retraction, postblepharoplasty. It is unlikely that just putting a stitchalone will hold it up, as there is tightness and traction on the lower lid. There may be other factors involved as well. You should consult an oculoplastic surgeon for options.

Sam Goldberger, MD · Answer

As others have stated, you have right lower eyelid retraction. A stitch does not fix this. You will need some type of reconstructive lower eyelid surgery to raise and support the eyelid. The best time to operate is at least 6 months after your last surgery. Please see an Oculoplastic surgeon who has experience in this type of surgery. Good luck.

Jeffrey Schiller, MD · Answer

Lower eyelid retraction used is still one of the more common complications of lower blepharoplasty. If there is scarring inside the eyelid pulling it down, injections of Kenalog (cortisone) or 5-FU or both can help the scarring soften and release the pulled-down eyelid. If this does not help, you may need corrective surgery. Generally surgery is done at least 6 months and sometimes longer after the first surgery so the active scarring and pulling has stopped.

	Your doctor may just be using shorthand when he says a "stitch" would help it. He might mean a lateral canthoplasty. Have a detailed discussion with your surgeon and you might also seek a second opinion from an oculoplastic surgeon because oculoplastic surgeons have more experience correcting eyelids which have gone the wrong way either from aging, trauma, or surgery.

Barry L. Eppley, MD, DMD · Answer

At four months after your blepharoplasty surgery, it is appropriate to adjust the corner of the drooping eye. This can be simply done under local anesthesia if you desire by doing a lateral canthopexy and lifting and repositioning the skin at the puter corner of the eye. i suspect this was what your surgeon was planning on and simply summarized the approach by calling it 'putting in a stitch to tighten it'. No surgeon would think that simply putting in a few sutures will solve this problem.

Roger Bassin, MD · Answer

By looking at your photo it appears you have cicatricial lower eyelid retraction. This means scarring in the lower eyelid which pulls the eyelid down. Most often I see this as a result of too much skin being removed during a cosmetic lower eyelid procedure, which it appears is consistent with your history. In my experience, since I see so much of this, putting 'a stitch' in the corner to tighten the lid doesn't help. The best results in my hands occur with a cheek lift to raise some extra skin from your cheek area to replace what has been lost. If you are having chronically dry and scratchy eyes causing tearing, it puts you at risk for corneal infections, so the urgency of the matter really depends on your 'symptoms'. Hope this helps and good luck

Michael M. Kim, MD · Answer

Hello Suzi,

	From your picture, you appear to have "rounding" of the right lower lid. This is usually due to the healing forces from surgery that exert a downward pull on the lid. It is still relatively early in the healing process and you should be in close contact with your surgeon regarding your concerns. In the meantime, techniques such as upward massage can possibly help, but if there is no progress after a period of time, you may need to have a small surgical procedure to correct that area. What you surgeon is talking about sounds like a "canthopexy" which is a suturing of the lateral aspect of the lid to tighten it up. Think of your lower lid margin as a hammock. The canthopexy is performed so that you are tightening one side of the hammock so it doesn't "droop" as much. Should that not be sufficient, slightly more involved procedures are available to get you where your lid in the right position.

	Good luck.

	Michael Kim, MD

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