26.3.5 Lower Lid Retraction

Lower lid retraction is a more common and in many ways difficult condition to treat than upper eyelid retraction. The techniques used in the treatment of TED are generally applicable to the patient with primary or postoperative lower lid retraction.

Lateral canthoplasty of the tarsal strip variety by itself is generally long-term ineffective in the treatment of lower lid retraction. A posteriorly placed tarsal strip canthoplasty appropriate to the usual patient may even increase lower lid retraction (bowstringing effect) in the patient with a very prominent eye (Fig. 26.2). A canthotomy is performed when undertaking a transorbital lateral decompression surgery, and a simultaneous release of the conjunctiva and lower lid retractor layer allows the opportunity to improve the lower lid retraction, with recession of the eyelid retractors and an appropriate lateral canthotomy procedure. Long-term improvement is often obtained in this situation, aided by the placement for 3–5 days of reverse Frost traction sutures in the lower eyelids, which maintain an upward pull.

Attempts to treat lower lid retraction without the placement of a spacer graft are often difficult and unsatisfying. For this reason, spacer grafts to the lower eyelid are generally employed when attempting to permanently correct lower eyelid retraction. Various allografts of human and porcine collagen [18–20] have been utilized and are usually effective in treating small to moderate amounts of lower eyelid retraction.

Hard palate mucosa has proven for over 20 years to be the premier posterior lamella spacer in the treatment of lower eyelid retraction [21–23]. Appropriately placed, hard palate mucosa accurately corrects lower eyelid retraction in a predictable and permanent fashion (Fig. 26.7).

Occasionally, patients present with eyelids lacking anterior lamella (skin) to a degree that full-thickness skin grafting is essential to reliably reposition the eyelid. Midface elevation is always a consideration in the treatment of lower eyelid retraction with various cosmetic and functional benefits. These lifts may be performed trans-eyelid, or via a transtemporal approach as an extension of the temporal dissection performed for endoscopic browlift surgery. Because of the cosmetically undesirable aspects of full-thickness skin grafting of the eyelid, it is appealing and oftentimes appropriate to perform midface lifts as part of a repair for eyelid retraction.

26.4Cosmetic Treatment of the Tear Trough in the Prominent Eye

Fat repositioning techniques of blepharoplasty can be effective in safely treating the tear trough deformity in the patient with a prominent eye [24–26]. By necessity, these techniques generally incorporate a release of the arcus marginalis with undermining of the soft tissues of the orbital rim and cheek in an intra-suborbicularis oculi fat (SOOF) or subperiosteal plane. The fat repositioning tends to elevate and anteriorly

Fig. 26.8 Patient with TED and mild exophthalmos (a) before and (b) after lower blepharoplasty with intra-SOOF technique of fat repositioning. Lessening of fat pseudoherniation, preservation of eyelid

Fig. 26.9 Patient with prominent eyes, relative midface hypoplasia, and a prominent tear trough deformity (a) before and (b) 6 months after four-lid blepharoplasty with lower lid intra-SOOF fat repositioning, erbium-YAG laser skin resurfacing, and fat transfer to the midface

margin position, smoothing of the tear trough, and an elevation in the apparent orbital rim position are all apparent in a cosmetically desirable way

project the inferior orbital rim and eyelid–cheek junction, both desirable in the patient with eye prominence (Fig. 26.8). This is in contrast to purely subtractive techniques which do nothing to specifically address either of these facial defects.

Midface lifting is often beneficial from a cosmetic perspective in patients with prominent eyes that have no explanatory medical or surgical history. Elevation of the ptotic malar tissues to provide more coverage for the tear trough area may be performed in conjunction with implants or fat repositioning blepharoplasty techniques. Trans-lid techniques of SOOF or midface lifting are excellent adjuncts to blepharoplasty. The temporal approach to midface lifting as an extension of the temporal endoscopic browlift dissection is also an excellent method of elevating a ptotic midface in a patient with a prominent eye, while safely providing cosmetic correction.

Injectable fillers provide a straightforward and precise tool for augmentation along the orbital rim and tear trough,

whether performed primarily in a patient “not ready for surgery” or as a postoperative adjunct [27, 28]. Hyaluronic acid fillers provide an excellent option for volume augmentation. Surgeons are cautioned to develop their skills gradually and use appropriate technique, introducing the filler from below and fanning into a deep plane along the orbital rim. It is tempting to simply parallel the tear trough with the needle pass; however, this technique markedly increases the risk for causing an undesirable thickening along the orbital rim that could necessitate reversal with an injection of the enzyme hyaluronidase, which rapidly eliminates contour issues related to excessive hyaluronate filler placement.

Autogenous fat grafting is also a helpful adjunct in treating prominent eye patient with cosmetic concerns. Fat may be used similarly to injectable fillers to increase the orbital rim projection and volumize the midface. It may be employed as a primary treatment or as an adjunct to other treatments

such as fat repositioning blepharoplasty and/or midface lift procedures [3] (Fig. 26.9). Fat transfer carries the disadvantage of unpredictable resorption and may require multiple treatment sessions to obtain adequate results. Nonetheless, it is a useful tool in the surgeon’s armentarium.

26.5“Rescue”Techniques with the Prominent Eye

All too often inappropriate or misdirected surgery results in an undesirable functional or cosmetic outcome after eyelid surgery. This risk is especially high in the patient with a prominent eye. Ocular exposure symptoms and cosmetically unacceptable eyelid retraction are the most common postblepharoplasty complications in this patient population.

Recognition of the patient’s anatomic features and the avoidance of “standard” subtractive techniques in at-risk patients will avoid most of these situations. When patients with these complications of surgery present, the treatment approaches are as described previously. The first surgery generally creates problems and impediments to correction.

Surgical correction often focuses on replacing what has been removed. For example, excessive fat resection may leave no fat to drape the orbital rim and camouflage the tear trough. In such cases, the harvest of a dermis-fat graft from the abdomen as performed in anophthalmic socket surgery and placement of an appropriately-sized graft after surgical exposure may provide adequate volume to correct this element of the patient’s condition.

Midface lifting via transeyelid or temporal approaches may be attempted to elevate ptotic midfacial tissues and recruit skin into the lower eyelid, correcting ectropion or lower lid retraction [29–31] (Fig. 26.10). Given the strong tendency for any vertical elevation to regress over the first year after surgery, the surgeon is advised to depend on this approach only as an adjunct or for the correction of mild degrees of anterior lamella deficiency.

Despite attempts to recruit anterior lamella tissue with midface lifting, the long-term treatment plan for patients with overdone “classic” blepharoplasty and a prominent eye often entails full-thickness skin grafting. In this regard, an ounce of prevention is worth a pound of cure, as the restorative surgery is much more difficult and complex than the initial misdirected procedure.

with Prominent Globes

Upper blepharoplasty should be conservative with an effort made to avoid excess skin removal, which is more likely to result in lagophthalmos and exposure keratitis. With prominent eyes, the vertical length of skin needed to drape the eye with the lid shut is increased. In this setting, there needs to be sufficient excess preseptal skin to allow for this closure. It is a good rule of thumb to mark the normal ellipse of skin to be excised, as with upper lid blepharoplasty in a normal globe projection, and then reduce the amount of skin excision by 20%. The common technique of pinching redundant skin until the lashes evert with mild lagophthalmos will result in an overly aggressive resection of skin in these patients. Backing off from these “normal” amounts of skin excision will allow a valuable window of safety during surgery. Similarly, do not aggressively excise (debulk) the orbicularis muscle in surgery. Orbicularis muscle weakness is a normal involutional change which can be iatrogenically enhanced or hastened with upper blepharoplasty. In the normal setting, corneal protective mechanisms such as the Bell’s phenomenon (globe supraduction with lid closure), tear production, corneal sensation, and lid closure are adequate to overcome a slightly overzealous blepharoplasty. In patients such as those with TED, these compensatory mechanisms are reduced or absent. For example many of these patients sleep with their eyes open (nocturnal lagophthalmos), have exposure findings (dryness), and have reduced eye elevation on closure (Bell’s phenomenon) from inferior rectus pathology inherent to the disease. These patients are often asymptomatic at presentation for aesthetic lid surgery. Any manipulation of these patients’ eyelids can lead to exposure symptoms, even in the best of hands. Careful evaluation and conservative surgery should be the rule in these patients.

Special attention should be given to marking of the upper eyelid crease in the presence of prominent eyes. In these patients, there is tendency towards a higher eyelid crease than nonprominent globes. A conventional surgical approach with the eyelid crease marked at a high anatomic position may exaggerate the appearance of an elevated eyelid crease after surgery. As such, marking the crease at 8–12 mm above the lash line and often a few millimeters below the anatomic crease for the patient is recommended. In TED patients who undergo simultaneous upper lid recession, the crease can be higher and asymmetric after surgery as the recessed levator aponeurosis drags the preaponeurotic fat back and elevates the eyelid crease postoperatively. Generally, no preaponeurotic fat is removed centrally in these patients, and a very limited (if any) skin excision is performed to avoid the appearance of an overly elevated upper eyelid crease.

globe protrudes, the surrounding fullness can mask or camouflage a degree of this prominence. When this soft tissue is reduced, the prominence may be unmasked to a further extent, leading to a sunken, surprised, and more proptotic appearance. TED patients often have abundant fat at surgery. It is important not to be misled by this exuberance of fat with aggressive excision. This can lead to very unhappy patients. Generally speaking, the medial fat pad is prominent and is judiciously debulked. The central fat should be preserved or minimally reduced. Laterally, the lacrimal gland may be prolapsed (sometimes excessively in TED patients) with associated temporal fullness. In these instances, it should be resuspended [32–34]. Simultaneous upper eyelid recession results in lengthening of the upper eyelid as previously noted, creating a hollower superior sulcus. Fat reduction should be less aggressive in this setting.

In the lower eyelid, great care in surgical technique is essential to avoid any cicatricial or other force that increases lower eyelid retraction. Fat preservation techniques with intra-SOOF or subperiosteal fat repositioning are excellent, especially when performed transconjunctivally [24–26]. The transconjunctival approach releases the lower eyelid retractors, providing much of the benefit of a postoperative traction suture, while avoiding trauma that can stimulate scarring to the anterior or middle lamella. Appropriate placement of malar implants can improve the relationship between the eyelid and globe and prevent eyelid malposition (vector correction) (Fig. 26.11).

Skin excision, if undertaken, must be very conservative in these patients, as is chemical or laser resurfacing of the skin. Canthal suspension can be quite challenging in patients with prominent eyes. “Bowstringing” of the globe can occur as a longer lower lid is needed to circumvent the added curvature imposed by the prominent globe. When sufficient vertical and horizontal length of the eyelid is not present, the lower lid will take the path of least resistance and ride down the globe (retract) with increased scleral show (Fig. 26.2). There are a few modifications of traditional canthoplasty which help prevent this eyelid malposition. First, the suture securing the lid to the lateral orbital rim can be left to hang back. This effectively horizontally lengthens the lid. The knot is tied after titrating its tightness and monitoring the lid position. Also the lid can be secured to a higher position on the lateral orbital rim (above Whitnalls tubercle) (Fig. 26.12). Finally, a graded translid midface suspension in addition to preseptal orbicularis muscle plication may be of added benefit in selected cases. As a general rule, staying out of harm’s way is the best course of action. Canthoplasty in these cases (when primarily aesthetic in nature) can open a Pandora’s box of problems, as patients will not concern themselves with case complexity and focus on immediate outcome only.