6 days post surgery my Wife has significant Lower Eyelid sagging aka "Scalero Show" in the outer portion of each eyelid. (photo)

It is not a desired result.  It is not an intentional result.  But it is a known effect of this type of surgery.  The literature on this subject is very confusing even to surgeons who seem to do a lot of lower eyelid surgery.  Here is the dilemma.  The plastic surgery literature contains important papers by leading surgeons supporting the use of this approach when performing lower eyelid surgery.  This may be done in conjunction with a lateral canthal procedure to support the lower eyelid.  Here is the problem, many surgeons were trained to perform surgery in this fashion.  They feel it is effective at addressing both the lower eyelid fullness from herniated orbital fat and to remove excess skin in the lower eyelid that causes wrinkles.  Unfortunately, this surgery interferes with the delicate balance of the lower eyelid.  Along the lower eyelid is a portion of the orbicularis oculi muscle that supports the edge of the lower eyelid.  Think of it as functioning as a hammock.  Well regarded papers in the peer reviewed plastic surgery literature advise surgeons that the nerves to this muscle come into the eyelid from the side and that it is safe to make a cut in the skin and muscle just below the lower eyelid eyelashes.  This skin muscle incision leads to significant damage to the motor nerves that supply this bit of orbicularis oculi muscle.  That is because the nerves to not enter the eyelid from the side.  There is a more substantial body of anatomic work that shows that these motor nerves reach the edge of the eyelid perpendicular to the eyelid margin.  I agree with this work and believe that the skin muscle incision results in a motor nerve injury that weakens the hammock function of the lower eyelid.  Now it is a bit more complicated.  The canthal surgery done to support the lower eyelid can actually shorten the lower eyelid margin.  This leads to the lower eyelid being pulled down further on the eye surface due to the topology of the eye being spherical.  Also since the upper eyelid is tethered to the lower eyelid at the lateral canthal angle, one other issue is seen in your wife's pictures-the tethered lateral corner of the eye effective pulled the upper eyelid down.Now, will these issues get better with time.  Well, the truth is that most everything does improve with time.  However, in studying these pictures, I suspect that revisional work may be necessary to make these lower eyelid satisfactory.  I would strongly advise you against letting a surgeon further shorten the lower eyelid (sometimes described as a tuck).  Fixing these situations and staying out of these troubles requires a great deal of operative judgement.  I think minor interventions such as taping the lower eyelid and, when the eyelid has healed sufficiently, message of the eyelid can provide some help.  Ultimately, if the eyelids do not heal in a satisfactory manner, it is critical not to use up the remaining eyelid resources with well intentioned surgery that will not accomplish what is needs but rather have a definitive correction 6 to 12 months after the initial surgery. 

Hi. The lower eyelids are pulled down, from tight skin and possibly weaker muscle closure. It is best to wait at least 3 months before considering any corrective surgery. In the meantime, lubricate your eyes and do squinting eye exercises.  See an oculoplastic specialist.

is certainly not a desired result and you should be in contact with your surgeon as to what you should do to manage this and how best to protect your exposed globes.  Your surgeon is best equipped to know if you should ride this out with massage and external support or if early intervention may be needed (some of us save the skin for such problems).  It is imperative the globe be protected from excessive exposures at this time.

This amount of show can be seen in the weeks following external approach to lower blepharoplasty. It is not an uncommon occurrence. Without being able to do a physical examination myself, and relying solely on the photos, I feel that in her case the circumferential muscle that encircles the eye isn't wanting to work well after the surgery. The appearance should improve as the muscle "wakes up" and starts to provide support again.This much show can absolutely resolve on its own without a revision surgery. In fact, I would expect it to. Close follow-up with your surgeon and adherence to his/her postop instructions are the best thing that you & your wife can do to advocate for yourselves at this time. You want a great outcome. So does your surgeon.Good luck! Please update us with her progress.  Harry V. Wright MD

Thank you for posting your pictures. This is one of the most common complication seen after a transcutaneous lower blepharoplasty. Seems from the picture that you have a negative canthal tilt (your lateral eye corner is lower than your medial) and this will predispose you to this type of complication since your eyelid has less support. Canthopexy or canthoplasty during the blepharoplasty is done routinely by many surgeons in patients at high risk for this complication (e.g. prominent eyes, negative eye vector, negative canthal tilt, etc). Since your problem is pretty obvious and I hardly believe it will resolve with conservative measures such as lateral eyelid push-ups, you may consider asking your surgeon for revision by either canthopexy/plasty (based on tissue mobility at the lateral canthus) immediately or you may need to wait instead 3 months after inflammation is improved. Best time to revise this problem is immediately after surgery or 3 months after. Worst time would be  between 3-6 weeks. Good luck with everything. Hope this was helpful.

There are lots of factors that determine the severity of scleral show that can occur postoperatively.  Everyone's body reacts differently to surgery, and it is difficult to predict who may need surgery in 3-6 months and who will not.  While you are correct in identifying the typical treatment modalities, treating scleral show is not something that I'd recommend doing without the close guidance of your surgeon.

The lower eyelids are being pulled down too far.  Be sure to tape them and protect your corneas with lubricant.  A lateral canthopexy/plasty will likely be needed to correct this.  A temporary canthoplasty may be effective.  You will need to see an oculoplastic specialist.