2 months post lower lid surgery now too much white is showing, do I need a revision? (Photo)

Question

I had a lower lid surgery along with my facelift 2 months ago. My eyes look asymmetric, feel pulled down and too much white is showing, Do I need another surgery to repair it? Thanks

A.J. Amadi, MD · Answer

Lower eyelid retraction can occur after lower eyelid blepharoplasty, especially if a skin approach is used. Although the temptation is want to fix the problem right away, it is best to wait this one out because often the problem will self correct as the scar softens and relaxes with time. Depending on the severity of the problem, it would be best to wait about 6-12 months before considering surgery. This can be a difficult challenge for patients to accept, but I cannot stress the importance of waiting enough. Talk with your surgeon about your concerns, but don't jump the gun. At 6 months, you may want to consider consultation with an Oculofacial plastic surgeon (Oculoplastics) as we have the most experience in dealing with this complication/side effect of surgery. Good luck

Kenneth D. Steinsapir, MD · Answer

Unfortunately, the inferior scleral show caused by your lower eyelid blepharoplasty will not fix itself.  Generally we do recommend waiting more time before correcting this situation unless you are experiencing corneal drying that is not well managed with eyedrops and ointment. Part of the basis of your lower eyelid malpositions is related to the relative lack of projection of the lower eyelids. This type of eyelid does not respond well in my opinion to corrections that "tuck the lower eyelid." This tends to further pull the lower eyelid under the curvature of the eyes.  For that reason, I developed a comprehensive approach to these eyelids using a hand carved rim implant and hard palate graft.  Skepticism is warranted to approaches that only manipulate the eyelid.  This is an orbital rim projection problem. I recommend getting multiple opinions before making a decision on how to proceed.

Stan M. Valnicek, MD · Answer

Lower lid retraction or "scleral show" can happen after lower eyelid surgery.  It is a result of scar tightening pulling the lids down or localized weakness (due to interruption of nerve supply) of the resting tone of the muscle that holds the lid up when the eyes are open.  It can often be improved with time and upwards massage of the lid in the case of scar tissue.  With denervation, it also often improves over time (1-6 months) as the nerve regenerates.  At two months, it is still early and could likely improve.  It is very helpful to see your surgeon to discuss this issue and see if there is anything that might help speed up the recovery of the lid position at this point.  If it is not better by 6 months out, then you might need an opinion regarding lower lid release and/or repositioning.  It is really hard to give concrete advice specific to your situation from photos alone and a proper exam by your surgeon is the first step to addressing your concerns.

Mehryar (Ray) Taban, MD, FACS · Answer

Consultation is necessary. Also need photos of your eyes prior to the surgery. Communicate your concerns with your surgeon too. You may benefit from lower eyelid retraction surgery.

Evan Ransom, MD, FACS · Answer

Thank you for the photo and your question. At two months post-surgery, it is still fairly early in the healing process. When the white of the eye (sclera) is visible below the colored part of the eye (iris) in a relaxed position, this is called scleral show. It can be related to tightness in the lower eyelid skin or muscle following the surgery, swelling, scar tissue, or eyelid malposition (depending on how the surgery was performed). At this point, conservative measures are indicated. This includes massage (upward traction on the lower eyelid), eyelid exercises, and sometimes tiny injections of a medicine to break up scar tissue (kenalog or 5-FU). Please stay in touch with your surgeon throughout this process.

Curtis Wong, MD · Answer

as you show in your photo.  Having a pre-op photo would have helped determine if this is new or something that you already had.  Assuming its new and doesn't improve with time, you will need a procedure to help tighten the lower lid and elevate it slightly so the whites show like what they did before your procedure.   Best to be discussing your concerns with your surgeon and to see if there are any maneuvers to help your lid ascend to you can avoid a revision.

Chase Lay, MD · Answer

Thank you for the photo.  The very first thing to do is talk to your surgeon and get additional opinions if you feel they're needed (seems you do since you've contacted the Realself.com community).  We can't tell you what to do via the internet but you should know:1.  It's still early in your healing process and things will change.2.  If anything you should probably, not too vigorously, massage the lids in an upwards direction a few minutes at a time 3-5 times per day.3.  Talk to yours, or other surgeons, about what can be done in the mean time such as Kenalog and 5-FU injections.4.  If a revision is needed it could be simple or complicated.  Now don't let that vague statement scare you but do be aware that it may take some time and multiple surgical techniques to address lower eyelid retraction or ectropion if it is present.  This could include tarsal strips, fat grafting to the lower eyelids and mid face, or even in some severe cases skin grafting.Best of luck.  Chase Lay MD

Ronald V. DeMars, MD (Retired) · Answer

Obviously eyes come in many shapes. Without comparable preoperative photos we cannot give you a fair evaluation of your current status. If you are concerned it would be best to visit with your surgeon.

Brooke R. Seckel, MD, FACS (retired) · Answer

Thank you for your question.  When after a blepharoplasty too much weight is showing below the iris of the eye is called scleral show.  At the most important issue is whether or not you have eye irritation.  If you have excessive tearing or irritation of the eye during the day requiring a lot of drops and a procedure called a canthoplasty or canthopexy to lift and tighten the lower eyelid may be necessary.  I recommend that you consult and experienced board certified ophthalmologist with training in oculoplastic surgery.

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