What Procedure Will Best Fix Lower Lid Retraction from Skin Pinch Incision?

Question

I am now 4 months post op from lower blepharoplasty with a skin pinch incision that left me with ectropion / retracted lower lids. What procedure best fixes my problem -- canthopexy or canthoplasty with cheek lift? Would restylane help boost my lids up or will I need surgery? Also, seems most oculoplastic surgeons who specialize in such repairs are in CA. Any recs for Chicago doctors who routinely fix this issue? I can't risk another failed surgery so would travel to the best. Many thanks.

Kenneth D. Steinsapir, MD · Answer

First, your right eye appears much more prominent than the left eye.  This is most likely a preoperative status that was unnoticed by your plastic surgeon.  

	A canthoplexy, or its more involved cousin, canthoplasty are surgical procedures that shorten the lower eyelid.  Surgeons who perform these procedures on individuals in your circumstance are guilty of linear mechanical thinking: Shorten the eyelid and you will pull it up.  Unfortunately, what is going on here is taking place on a spherical surface.  When we fly from say Los Angeles to London, the pilot does not fly a straight line.  On a flat surface the shortest distance between to points is a straight line.  However, on a curved surface, the shorten distance between two points is a curved line, known as a geodesic.  Pulling the eyelid tight on the eye will not lift the eyelid.  Counterintuitively, it will lower the eyelid as the shortened eyelid will find the shortest path on the eye which will actually be under the curve of the globe.  Thus tightening the eyelid will actually make your situation worse.

	How then is this problem addressed?  The answer is a matter of lengthening the eyelid both horizontally and vertically.  This is the rational for the various grafting methods used to address these types of problems.  You can go to my website (lidlift dot com) and read about these surgeries.  One other issue with your surgery I would point out it the outward rotation of your lower eyelid margin.  Normally this eyelid edge is not visible.  A hard palate graft with a canthoplasty can be used to control the rotation of the lid margin and this would also be an important aspect of reconstructing your eyelids.

	It is interesting that practicing in Los Angeles, I do see a very large number of patients from Chicago.  There are excellent oculoplastic surgeons in Chicago.  However, I do not believe they offer these types of specialized reconstructions.  As you are only 4 months out from surgery, I recommend waiting a few more months before considering reconstructive surgery.  I think it is likely the right side will need work done.  The left side might settle down enough that with some fillers you will be satisfied with the result.  The key is dry eye.  If the eyes are uncomfortable as a result of the surgery, this may tip you toward needing work on the left side as well.  Please do not have the eyelid fixed incorrectly as this makes the ultimate reconstruction even more complex.

	I hope that information is helpful.

David J. Levens, MD · Answer

Your photo shows a slight ectropion on the right only.  At 4 months it may still be possible to massage and stretch the lid up a bit at the corner.  If that is not successful, it may be best to consider a revision surgery for which likely a canthopexy would be sufficient and the least invasive of the three surgical options you mentioned.

	Restylane injection would not likely be successful at improving the problem.

	You should consult with your treating surgeon first for recommendations. If he/she does not provide the reassurance/solution that you are seeking, then a second opinion is very sensible.

Aaron Stone, MD · Answer

Your lower eyelids turn out at the edges. They do not look retracted as the lids are not pulled away from the eyeballs and the white does not really show under the irises. I suspect your previous surgeon removed the part of the eyelid closing muscle that lies directly over the cartilage in the eyelid (pretarsal orbicularis muscle). This is the part of the muscle that lies directly below the eyelashes. When we perform a lower eyelid blepharoplasty we try to preserve the pretarsal portion of the muscle and remove some of the lower preseptal portion of the muscle along with the skin. Without this muscle the upper edge of the eyelid loses support and tips over. Although it looks similar to senile or involutional ectropion it is not the same as the senile form is accompanied by loss of muscle tone and eyelid elasticity with the outer corners of the eyes at a lower level than the inner corners, which is why horizontal lid shortening procedures like canthopexy/plasty are required. Given your younger age and surgical history I doubt a pinch of the lid or downward retraction would show the laxity that would justify a canthopexy. Also your outer corners of the eyes are higher than the inner corners. Your best option is likely to be a hard palate graft to recreate the support lost with removal of the pretarsal muscle. The hard palate tissue is stiff enough without being rigid to supply the necessary support. A horizontal tightening procedure in the absence of this support will be like a person with a protruding round belly who keeps tightening their pants belt. The more they tighten the lower the belt goes until it is below their round protruding belly.
	
	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.

Mehryar (Ray) Taban, MD, FACS · Answer

You have already had problems with eyelid surgery so you should go to someone who is experienced in improving your problem. Distance should be a secondary factor. 

	It does appear that you are lacking enough skin which is pulling your lid down. By simply tightening the lower lid (canthoplasty or canthopexy) won't work and it will make it worse.  You need skin. The two ways to get is either by skin graft/flap ("switch flap") or midface lift.  Repeat surgery should be delayed for 6 months after your last surgery.

	Dr Taban

Scott C. Sattler, MD, FACS · Answer

You've got unilateral lower lid retraction with mild scleral show - I think a canthopexy on the right side would restore lid position symmetry. Although midfacial fat grafting and dermal fillers can help support lower lid position, they are not the standard restorative procedure for this problem.

What Procedure Will Best Fix Lower Lid Retraction from Skin Pinch Incision?

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Answer: Canthopexy can fix lower lid retraction after bleph surgery

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What Procedure Will Best Fix Lower Lid Retraction from Skin Pinch Incision?

Answers (7)

Answer: Lower lid retraction after blepharoplasty

Answer: Lower lid retraction after blepharoplasty

Answer: Canthopexy can fix lower lid retraction after bleph surgery

Answer: Canthopexy can fix lower lid retraction after bleph surgery

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