Is a bilateral lower Canthoplasty, spacer cartilage grafts and skin grafts to lower lids required? (photos)

Question

I had upper & lower blepharoplasty performed about 10 days ago & now have Ectropion. The original surgeon advised massage & give it time to correct itself. I sought another opinion & was advised no amount of massaging would assist & that if I left it, it would get worse. I was advised to undergo a Canthoplasty & skin grafts to both eyes. I am very concerned about rushing into another surgical procedure so quickly given that there are two completely opposing views of my situation.

Thomas A. Mustoe, MD, FACS · Answer

At ten days, you are early in the healing period, and almost certainly your eyelids will improve somewhat over the next few months.  Taping, massage and other conservative manueuvers can help.  At some point, a canthoplasty and possibly some other procedures including a spacer graft, and even a skin graft might necessary, but at least the skin graft is very unlikely to be necessary.  The timing should be many months off.

Raymond Goh, MBBS (Hons), FRACS (Plast) · Answer

Hi. Thanks for posting your questions and photos.
Looking at your pre-op photos, it is clear that you had pre-existing lower eyelid and lateral canthal laxity, putting you at risk of developing ectropion with any surgery to the lower eyelids. At 10 days post surgery however, I would approach things conservatively (at least for a few more months), with the emphasis placed on eye protection and scar softening. If you feel that your eyes are dry and watery, lubrication and taping should be used. Massaging will help to soften the scars. 
Please keep in close contact with your surgeon, and to discuss surgical correction if conservative measures fail to improve things.
All the very best.
Dr Ray Goh

Mehryar (Ray) Taban, MD, FACS · Answer

Although you may end up needing revision lower eyelid retraction surgery, this is NOT the best time as you need to let the tissue heal before another surgery. I recommend waiting 3 months. See following website link and video for more details.

Jose Rodríguez-Feliz, MD · Answer

Thank you for posting your photos. The short answer is no surgery until 3 months post-op at least. As I analyze your pre-op photos, you were at an increased risk for this complication considering the negative (or downward) tilt of your lateral eyes. You also had already some roundness of the lower lids that was more prominent on the left lower eyelid. When I treat patients with these anatomic variants, lower lid support during the initial operation is needed. The most commonly used techniques to support the lid are either a canthopexy or a canthoplasty depending how lax is the lower lid and if it needs to be shortened. Some patients with severe scleral show (showing the white part of the eyeball between the lid and the iris), will need graft support also but this is much less common specially in a primary case. All these being said, the worse time to do surgery is now because all the tissues are inflamed and the sutures won't hold. In the mean time, what I would suggest is that you tape the lateral aspect to the eyelid up to provide support. I do think you should at least to the upwards "push ups" or massages to at least keep the scar tissue at its minimum. Use Refresh eyedrops 4x a day, and Refresh ointment at night so that your eye does not get dry from exposure during sleep. It is very likely that further surgery is needed in the future, but I would wait at least 3 months. In terms of the procedure that you would need, likely a canthoplasty vs. canthopexy. A cartilage graft is needed when the central aspect of the lid is still not touching the inferior limbus (black part) when you push with 1 finger on the lateral canthus. A physical examination will be needed to determine the best procedure in your case. But what ever you do, please don't have surgery now! Patience will pay off in this particular case. You don't want to go through surgery and end up with the same problem. Also, look for a plastic surgeon with training in oculoplastic surgery. Hope this was helpful. Good luck!

Earl Gage, MD, FACS · Answer

You may end up needing revision surgery at some point, but I agree with your original surgeon that time and lid massage are the most reasonable approach for now. Operating this early, when there is still a fair amount of inflammation and swelling, is not ideal and may yield unpredictable results.

Chien C. Kat, MD · Answer

Thank you for your question and the photos.10 days is still very early in your recovery period to be assessing the results of your surgery. There are occasions when an ectropion can settle and correct itself in time.I would not recommend rushing into further surgery just yet. Give it a good 6 weeks and then go back and see your surgeon for advice and see whether there have been any improvements, if you are still not happy by then you may wish to seek an alternative opinion. Good luck

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