Droopy Eye After Mid Face Lift

Linda

You will need to weigh your confidence in your current surgeon to know the right thing to do.

There is no substitute for an in depth personal consultation. Occasionally the lay description of what is going on and what is actual going on are not the same.

If you were 100% confident in your surgeon, you would not be casting about for opinions from strangers. I am going to advise you to listen to your feelings. Please do not blindly follow the recommendations of this surgeon or any surgeon if it does not make sense. Please do not "double down," on a second surgery unless you have a clear understanding of what is going on, and what surgery is planned, why is it necessary, what are the risks of the second surgery, what is the probability of success or failure?

Honestly, sometimes surgeons just panic in these situations. They have a fix-it mentality. He or she just wants to take care of the problem. However, this may not actually be the right time to fix the problem.

Lower eyelid surgery and midface surgery have significant risks associated with them. These risks may not be understood by your surgeon. The fact that your surgery has a complication does not mean that your surgeon did anything below the standard of care. However, what is done to address the problem can make a profound difference and should not be rushed.

Here is the big problem with lower eyelid surgery and midface surgery done through a skin incision under the lower eyelashes (infracillary incision): the anatomy described in some of the most important recent papers in the field are inaccurate. I know this may be hard to believe. I recently reviewed the entire literature on this subject and presented before the Fall 2010 American Society for Ophthalmic Plastic and Reconstructive Surgery Scientific Symposium.

It seems that some of the core papers describe anatomic hypotheses rather than proven anatomic fact. For example, it is clear that the soft tissue of the cheek is mobile (i.e. it slides when we smile). Analogously, the lower cheek is mobile over the lower half of the face. In this location, the nerves that supply the muscles of facial expression around the mouth travel in such a way that it is possible to safely dissect in this plane in the lateral half of the lower face, and this is a key aspect to the so-called deep plane facelift. Similarly, surgeons dissect under the skin and lower eyelid muscle to perform midface lifting. It is understandable that they would hope that this could be done without injuring the nerves that supply the eyelids. Not surprisingly, published papers appear to support this hypothesis which is the basis for a number of standard lower eyelid procedures.

Unfortunately, a hypothesis is a scientific guess. It does not make an established anatomic fact. There is also clear evidence in published papers suggesting that the nerves that supply the lower eyelid orbicularis oculi muscle travel in this so-called glide plane, which is actually just somewhat mobile fat and loose connective tissue between the cheek bone and the orbicularis oculi muscle. Complicating matters with regard to surgeon experience, it is clear that it is possible to do some degree of dissection in this plane without significantly altering the nerve supply to the orbicularis oculi muscle. We just not know how much is too much until after surgery. Additionally, when this dissection is carried out laterally into the crowsfeet area, it is also possible to do significant damage to the nerves that provide innervation to the orbicularis oculi muscle in the upper eyelid as well. This is significant because the elements of the orbicularis oculi muscle within about 5-8 mm of the lower eyelid margin are responsible for blinking the eye closed. WIthout this critical blink function, tears are not moved across the corneal surface properly resulting in dry eye and tearing issues. When the lower eyelid slumps, it does not properly cover the lower portion of the eye and there is increased corneal drying.

Returning to the situation you are describing, I am very concerned that in an attempt to remedy your situation, your surgeon will perform a very aggressive lateral canthal tightening procedure. This effectively shortens the eyelid. This is the most obvious remedy for this situation but uniformly this is a mistake and it substantially complicates future reconstructive efforts. First the globe is not a flat object but a round sphere. Pulled tight, the lower eyelid will seek to follow the shortest path around the fullness of the eye. So in some cases, much to the would-be eyelid reconstructive surgeon's surprise, the eyelid may actually take up a much lower ultimate position under the maximum curvature of the globe. With unusual efforts, such as drill hole canthoplasty (not recommended), it is possible to draw the eyelid straight like a tennis net. However, in this case, there is too much tension in the eyelid and it can actually result in increase cornea discomfort.

The answer in these situations to avoid further eyelid tightening. Rather, the best course is to allow the tissues to heal for now. Then in 6 months or more to comeback and address the situation. Generally what is done very much depends on the findings at the time. However, by preserving as much of the lower eyelid and not cutting out tissue as will occur with a canthoplasty performed at this time, there are many more options and increased likelihood of an improved outcome.

Measures now should be supportive including artificial tears, ointment at bedtime and possibly finger winking to stretch out the corner of the eyelid.

I strongly recommend that you put that proposed surgery on hold and seek several expert opinions. Do keep lines of communication open with your surgeon. Look for oculoplastic surgeons for consultation who have as a focus of their practice the repair of unsatisfactory cometic eyelid surgery. Be skeptical of solutions that must be done "urgently" or don't make sense. Please do not be in rush to fix this although the desire to do so is completely understandable. While very few of these mend themselves, with time it may improve so that less work may be needed than first thought. It is hard to be patient in these situations.

You may need to travel to find the appropriate experts. 

The fact that this question is being asked in this forum indicates that you do not enjoy very good communication with your surgeon.  If a doctor was suggesting to me that I have surgery in 12 days, I'd want to know why, what's the diagnosis, what is the procedure expected to accomplish, what are the risks and expectations.  You must find these things out.  The eye complaints may be facial nerve related.  

There are many reasons to wait and let the nerves regenerate and very few reasons to take surgical action.  The main priority is to keep your eye from drying.

I would take the doctor’s advice and do as they recommend.  They may have a suture around a nerve causing this problem or something else.  If they are not a Board Certified Plastic Surgeon, I would involve one at this point.  You want someone trained on complications, and one who has seen a few variations on the theme.

The midface lift attempts to lift the fat of the cheeks through an incision usually for lower eyelid surgery only.  In releasing a ligament (arcus marginalis), a strict anatomic barrier between the lower lid and the cheek converts the lid and cheek into one anatomic unit.  If there is any loss of support for the repositioned cheek, the lid falls with it.  It's somewhat hard to fix.

The dissection during a midface lift is in the area of nerves that supply the muscles around the eye. Normally, the surgery occurs in a different plane, so the nerves aren't cut, but stretching or cautery can rarely cause temporary injury. It's hard to comment about the upcoming surgery without knowing what is being planned exactly. Usually, it is more a matter of time for the nerves to heal (presuming they're not cut).

If you have injured motor branches to the orbicularis oculi muscle, time and healing may be a better option than re-operation. More scar tissue and more injury may result from an ill-advised attempt to "fix" things!

It should be clear just what your surgeon plans to do with this re-operation. You may be (incorrectly) assuming he will find and repair the nerve(s) that were bruised or severed, and that just like plugging in your holiday lights, all will be back to normal. This will NOT happen, and I can confidently assert that your surgeon does not have this in mind. I suspect that he is planning a canthoplasty or canthopexy procedure to tighten and raise your droopy lower eyelid so that your lid position is higher, your cornea is not as dry, and your tearing is reduced. Unless done properly, this may actually lower the lid position, since a tighter lid will follow the shortest (orthodromic or geodesic) distance over a sphere--your eyeball (just like an airliner following a "great circle" shortest route across the globe).

All surgeons confronted with a complication or less-than-ideal result want to "make it better" or "fix it," and the sooner, the quicker we can put that problem out of our mind! Unfortunately, this zeal often makes things no better, can make things worse, and each unsuccessful re-operation (even if they're somehow "free') reduces your trust in your surgeon's judgment and his ability to ultimately correct your problem.

Please read Dr. Steinsapir's well-written answer to this question. Please read the other comments of our colleagues here who all question the wisdom of re-operation. No one can promise that this will get better on its own, but any of us who have seen this before understand that prudent caution in re-operation is usually better than injudicious surgery. It may be good advice to seek out another opinion or two from experienced oculoplastic surgeons, ophthalmologists, or senior board-certified plastic surgeons or facial plastic surgeons who have extensive experience in eyelid and mid-face problems. In the meantime, keep your lids taped at night, well-lubricated with ophthalmic ointment, and do not dab at your swollen sclera with a tissue (that just makes things worse). Best wishes!

You likely have muscle and/or nerve injury from the surgery.  The function of the muscle and/or nerve can return over the next few months, and I recommend observation (with frequent ocular lubrication) in the meantime.  Further surgery at this time can further damage the muscle and/or nerve.  You should consult an oculplastic surgeon.

Dr Taban

It appears that somehow in your surgery a branch of your facial nerve was injured.  This occurrence is extremely rare.  It's possible it was just stretched and should come back.  I was wondering, have you ever had Bell's palsy?  I've heard a few anecdotal reports that a facelift can trigger an old Bell's palsy.  Regardless, it seems like you and your surgeon are having some problems communicating.  If there is anything that doesn't seem to make sense, I'd recommend spending the time to as him/her.  It's always good to have a good understanding of your procedure before proceeding with surgery.

Dr. Cat Begovic M.D.

 

Hello and thank you for the question.

It is possible that in the process of the midface lift, a facial nerve motor branch injury was incurred, thus explaining the droopy lid. This is under the assumption that you did not undergo concomitant blepharoplasty as well, which can produce droopy eyelids in some cases.

Without examining you, it is difficult to make a determination as to why your surgeon wants to perform a re-operation in the short course.  A lack of lower eyelid support  as a consequence of the facial nerve injury can lead to a potential dry eye syndrome also know as keratoconjunctivitis sicca. This can put your cornea at risk for drying out, and thus requires a preventative interventional procedure whether surgical or non-surgical.  With all that being said, facial nerve injuries vary in their severity and nature. Often times, the injuries are only partial and regeneration is seen with time. In the interim, though, it is imperative that your eye remain well hydrated and protected from exposure.

I recommend you consult with your surgeon to discuss these issues further if you are having persistent concerns. 

Best,

Glenn Vallecillos, M.D., F.A.C.S.