According to James Carraway, M.D., there are three scenarios that can result in the retraction of the upper eyelid, and for which blepharoplasty — done correctly — can serve as an effective corrective procedure.
"Upper lid retraction can be caused by previous surgical attempts to correct ptosis of the upper eyelid. Overcompensated, it gives the eye a wide-eyed, bulging look," says Dr. Carraway, professor and chairman of the division of plastic surgery at Eastern Virginia Medical School."Upper lid retraction can also be a result of a hyperthyroid condition, in which the extraocular and levator muscles are hypertrophic. Also, specifically Muller's muscle, another muscle that raises the eyelid, is overactive."
Even patients with normal thyroid function can have retracted upper eyelids. Dr. Carraway says that in these patients, the condition often is caused by a hyperactive Muller's muscle. In post-surgery patients of previous procedures, the condition is most often due to shortening of the levator muscle.
Orbital decompression, expansion
One corrective procedure for retracted eyelids caused by hypothyroidism is orbital decompression or expansion.
"In this procedure, the orbit is made larger and the globe sinks back into the newly created volume," Dr. Carraway says. "In euthyroid patients, the corrective procedure normally involves lengthening of the levator muscle and recession of the Muller's muscle."
According to Dr. Carraway, when the blepharoplasty procedure is being done to correct a problem caused by a previous surgical procedure, it can be significantly more involved.
"This usually involves going in and surgically 'releasing' the retracted eyelid by making an incision to release the scar tissue and then inserting a spacer, which can be either temporal fascia or bank sclera," he says.
Dr. Carraway notes that while blepharoplasty procedures to correct upper eyelid retraction are basically reconstructive in nature, they "obviously have a cosmetic component as well." Most commonly, he sees patients with this condition who have had previous eyelid surgery, which made this problem come to be more obvious.
Unfortunately, lid retraction is sometimes overlooked when evaluating patients for blepharoplasty, if the excess skin droops over the eyelid margin.
"A surgeon may fail to detect that the retracted margin of the eyelid is hidden by these skin flaps. We must remember that when evaluating a patient for blepharoplasty, the flap of skin should be lifted to see where the top of the lid actually is, and perform the procedure based on where we determine the lid margin to be." With careful evaluation, eyelid retraction and also ptosis can be diagnosed during the preoperative exam.