Fig. 18.1 Clinical photograph showing severe lower eyelid retraction 5 years after skin and muscle flap lower eyelid blepharoplasty in a mid- dle-aged patient

vision [2, 3]. In addition, some patients present with tearing, typically related to reflex secretion from exposure keratopathy or to stenosis of the lacrimal puncta from keratinization of the lid margin and medial ectropion. Tearing can also functional naso-lacrimal duct obstruction, from altered eyelid mechanics and weakness of the orbicularis oculi muscle with malfunction of the lacrimal pump.

18.2Anatomy of the Eyelid and Cheek

The normal position of the lower eyelid margin is tangential to the inferior limbus while the lateral canthal angle should rest approximately 2 mm above the position of the medial canthus [3, 4]. After successful blepharoplasty, the lateral canthus should continue to sit 2 mm above the medial canthus. If the lateral canthal angle is inferiorly displaced, a round eye will result, which is cosmetically undesirable (Fig. 18.3). If the lower eyelid margin is inferiorly displaced, even if the position of the lateral canthus is adequate, the patient will present with eyelid retraction and scleral show, both of which cause cosmetic and functional deficit (Fig. 18.4) [3, 5, 6].

Anatomically, the lower lid is composed of three lamellae (Fig. 18.5) [3, 4, 7]. The anterior lamella consists of skin and the orbicularis oculi muscle and may be thought of as a continuum from the corner of the mouth to the lower eyelid

retraction and ectropion. This same surgeon will then believe that the only cause for this complication is the removal of too much skin and will try to correct it by performing a fullthickness skin graft which is very likely to make the unhappy patient unhappier, because of skin color and texture differences (Fig. 18.2).

The postblepharoplasty patient with eyelid retraction was motivated to have the original surgery for cosmetic considerations and will rarely be satisfied with an excellent anatomic reconstitution in the presence of an even faintly visible skin graft. Only a minority of these patients will accept to trade appearance for function, in order to alleviate the severe ocular complications of eyelid retraction. Most patients with eyelid laxity or retraction present with symptoms of exposure keratopathy such as ocular irritation, photophobia, and blurry

Fig. 18.3 Clinical photograph showing marked rounding of lateral canthi and shortening of the horizontal palpebral aperture in a patient who underwent skin and muscle flap lower eyelid blepharoplasty 6 years ago

Fig. 18.4 Clinical photograph showing eyelid retraction, after skin and muscle flap lower eyelid blepharoplasty, despite normal position of the lateral canthi

margin. The middle lamella consists of the orbital septum, which originates from the arcus marginalis at the inferior orbital rim and inserts on the inferior tarsal margin. In the unoperated state, the septum is distensible (stretchable) but becomes rigid if scarring occurs secondary to surgery or trauma. The posterior lamella is composed of conjunctiva and either tarsus (superiorly) or lower eyelid retractors (inferiorly). The eyelid fat lies between the orbital septum and the eyelid retractors, similar to the preaponeurotic fat in the upper eyelid.

The orbicularis oculi is a circular sphincter muscle with three parts: the pretarsal orbicularis oculi, which lies anterior to the tarsus; the preseptal orbicularis oculi, which overlies the orbital septum and the orbital orbicularis oculi, the part that overlies the bone surrounding the orbit (Fig. 18.6). The tissue layers just below the inferior orbital rim, from anterior to posterior are skin, orbital orbicularis oculi muscle, suborbicularis oculi fat (SOOF), periosteum, and bone. The SOOF is continuous inferiorly with the cheek fat pad (Fig. 18.7). After the fourth decade, the orbital orbicularis oculi muscle, the SOOF, and the cheek fat pad start to descend [8]. Thus, when reconstructing the lower eyelid, the mobilization and elevation of the SOOF, either in a preor a subperiosteal plane, will elevate the overlying orbital orbicularis oculi muscle and the skin. Midface advancement recruits skin for the eyelid and helps avoid skin grafting.

Fig. 18.6 Anatomy of the orbicularis oculi (upper and lower lid) and adjacent muscles. (A) Frontalis muscle; (B) corrugator muscle; (C) procerus muscle; (D) orbital portion of the orbicularis oculi muscle; (E) preseptal portion of the orbicularis oculi muscle; (F) pretarsal portion of the orbicularis oculi muscle

horizontal eyelid laxity, vertical inadequacy of the anterior

Lower Eyelid Retraction

After blepharoplasty, the structure and the position of the eyelid should be preserved. The lateral canthus should continue to be 2 mm superior to the medial canthus and the lower eyelid margin should still lie tangential to the inferior limbus. Consequently, each of the three lamellae should have adequate vertical height. There are five possible causes of postblepharoplasty lower eyelid retraction: untreated

inadequacy of the posterior lamella, and weakening or paralysis of the orbicularis oculi muscle. Eyelid malposition after surgery can result in ectropion, if the anterior lamella is vertically shortened; entropion, if the posterior lamella is vertically shortened; or retraction, if the middle lamella is vertically shortened [1–14].

The incidence of postblepharoplasty lower lid retraction is also influenced by the prominence of the globe relative to the anterior projection of the inferior orbital rim (see chap. 26),

by intra and postoperative bleeding, and by the degree of disruption of the orbital septum which results in inflammation and subsequent scarring [12–14]. The wound healing process also plays a role in the development of lower eyelid retraction. Hematoma within the surgical planes induces contraction during the healing process. An eyelid with horizontal laxity or even a normal eyelid may be pulled down by gravity under the weight of postoperative edema and heal in an inferior position [10, 12, 13].

The most common surgical error that causes eyelid retraction is the excessive removal of skin and muscle from the lower eyelids. Removing anterior lamellar tissue in the face of uncorrected lower lid laxity further increases then incidence ectropion and/or lower eyelid retraction.

18.4Presentation

The unhappy post-lower eyelid blepharoplasty patients usually complain of the loss of the almond shaped of their eyes, pulled down lower lids, and a tired or fatigued appearance. Frequently, they also have functional concerns such as blurry vision, red eyes, ocular discomfort, irritation, and tearing [1, 3, 5, 6]. Even though these patients have inadequate vertical lower eyelid skin, they often complain of excess lower eyelid tissue, especially when they smile. The apparent excess skin

in the lower eyelids after blepharoplasty is due in part to the loss of skin elasticity and cannot be corrected by further removal of skin.

18.5Preoperative Evaluation

The evaluation of patients with lower eyelid retraction starts with measuring the lateral canthal position relative to the medial canthus and the margin-reflex distance 2 (MRD2) which is the distance from the pupillary light reflex to the lower eyelid margin. The “distraction” and “snap” tests are then performed to assess for horizontal lower eyelid laxity and elasticity, respectively. Vertical adequacy or inadequacy of the lower eyelid is determined next and is an essential part of the evaluation. Asking the patient to squint and smile helps determine if the eyelid can rise without restriction. The patient is then asked to close the eyelids gently and raise the eyebrows and any degree of lagophthalmos should be measured. It is also important to note if the lower eyelid moves upward and the punctum moves medially, with lid closure. Failure of the eyelid to move in and upward with closure is suggestive of paralysis of the orbicularis oculi muscle. The lower eyelid is then pushed superiorly with one or two fingers to determine whether there is any tethering to the inferior orbital rim. The patient is asked to open the mouth to see if stretching the anterior lamella pulls the eyelid inferiorly. The relative degree

of proptosis is measured with the Hertel exophthalmometer. The degree of globe prominence relative to the cheeks and inferior orbital rim is probably even more important, as this dictates whether the lower eyelid needs to be horizontally shortened or vertically elevated. The shortest distance between two points is a straight line. However, as the eyelids travel on the meridian of the globe, for prominent globes the distance from the medial canthus around the globe to the lateral canthus is greater. The “procedure surgeon” who plans to horizontally tighten the lower eyelid in the face of a prominent globe in hopes of vertically elevating the lid will find that horizontal eyelid tightening over a prominent globe results in lowering of eyelid position.

18.6Surgical Procedures

There are two groups of surgical interventions that are necessary for the correction of postblepharoplasty lower eyelid retraction in the cosmetic patient. The first group of procedures, called “lateral canthal resuspension,” is aimed at horizontally tightening the lower eyelid and can be either a canthopexy or a canthoplasty [1–10]. A canthopexy involves tightening the lateral canthal tendon without opening the canthal angle. In contrast, a canthoplasty implies performing a canthotomy/cantholysis before resuspending the lower eyelid to the lateral orbital rim periosteum. The lateral tarsal strip (LTS), first introduced in 1979, remains one of the most common canthoplasty procedures performed today [6, 15– 17]. LTS is a powerful technique, very useful in cases of profound eyelid laxity or ectropion where horizontal eyelid shortening is necessary to achieve adequate eyelid tightening. Unfortunately, this can also lead to shortening of the horizontal palpebral aperture, which is cosmetically undesirable, and patients will complain about it [18]. It seems that nobody wants a smaller appearing eye. Another unwanted effect of the tarsal strip procedure is the imbrication of the upper and lower eyelids laterally from supraplacement and shortening of the lower eyelid with preservation of the upper eyelid length [18, 19]. A modified LTS procedure that addresses this issue in patients with severe eyelid laxity, as seen in the floppy eyelid syndrome, has recently been described [20].

For less severe eyelid laxity, a canthopexy can be performed through either an upper or a lower eyelid incision, where the suture is passed under the skin without externalization through the lateral canthal angle [6, 21, 22]. A modified canthopexy technique where the suture is passed ab externo through a small incision in the lateral canthal angle has also been described [23–25]. With this technique, a double armed suture is buried in the lateral canthus and looped around the lateral canthal tendon. An upper eyelid incision is used to retrieve the suture and to attach it to the lateral orbital rim.

Although horizontal palpebral aperture shortening is usually not an issue with canthopexy techniques, eyelid imbriction can be seen if the inferior crus of the lateral canthal tendon is preferentially tightened or supraplaced.

We use a modified lateral canthal resuspension technique that tightens the upper and lower eyelids simultaneously without imbricating the eyelids and without shortening the palpebral aperture. This technique also obviates the need for performing a canthotomy and is done through an upper eyelid incision for which reason we called it “the lateral canthal resuspension-sine canthotomy” (LCR-SC, in press). One must realize that canthoplasties and canthopexies can only correct for horizontal eyelid laxity. If the lower eyelid is vertically inadequate, performing only a canthoplasty or a canthopexy procedure will not correct the problem.

The second group of procedures is of those that correct for the vertical inadequacy of the lower eyelid [4, 5, 8, 10, 11, 26–47]. The more prominent the globe, the less likely horizontal tightening will improve the final eyelid position. The standard horizontal eyelid tightening procedures can be anticipated to fail in patients with vertical inadequacy and to worsen the final lower eyelid position in patients with vertical inadequacy as well as relative prominence of the globe. After lysing the entire eyelid cicatrix that inhibits upward movement by tethering the eyelid to the inferior orbital rim, each individual layer is vertically augmented, as necessary. The anterior lamella is lengthened by performing a midface lift in which the entire cheek, which is continuous with the eyelid, is advanced and supported superiorly by suturing the orbital orbicularis oculi muscle and the SOOF, or the undermined cheek periosteum in subperiosteal midface elevation, to the orbital rim periosteum or temporalis fascia [5, 9, 10, 21, 23, 24]. To correct for middle lamella inadequacy, the vertically tethering middle lamella is horizontally divided from the inferior tarsal margin and all the scar tissue is lysed. A graft, the dimensions of which are calculated during the preoperative evaluation of the lower eyelid position, is then placed in the posterior lower eyelid to act as a spacer and prevent middle and posterior lamellar contraction during healing [4, 5, 8, 10, 11, 26–35, 40–47]. The posterior lamella is reconstructed by the same spacer graft placement between the inferior tarsal margin and the recessed conjunctiva and lower eyelid retractors. The graft becomes an inferior vertical extension of the existing tarsal plate and acts not only as a spacer but also as a buttress to support the lower eyelid. This buttress support for the lower eyelid is particularly useful and important in helping maintain a superior position of the reconstructed eyelid in the presence of a prominent globe.

In this manner, a total lower eyelid reconstruction, using a layer-by-layer independent reconstruction technique is performed. The anterior lamella is reconstructed with the mid-face lift, by recruiting both skin and muscle. The middle lamella is reconstructed by separation and scar lysis.