Surgeons called upon to revise other clinicians' cosmetic work

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Oculoplastic surgeon reports performing lower eyelid revisions following transcutaneous lower-lid blepharoplasty
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Within your area of expertise, what revision procedure do you most often perform?

Richard A. Weiss, M.D.
Newport Beach, Calif.

Dr. Weiss

"As an oculoplastic surgeon, I am frequently called upon to revise lower eyelids that have become droopy, retracted or ectropic after transcutaneous lower-lid blepharoplasty. This is the most common complication after transcutaneous lower-lid blepharoplasty and can occur because of exuberant scarring of the middle lamella (orbital septum), inadvertent removal of excess skin or from downward healing vectors in patients with pre-existing horizontal lower-lid laxity. It can also occur following laser skin resurfacing of the lower eyelids. "Why does this happen? The lower eyelid is not very well supported, particularly in the age group commonly seeking this surgery. With age, the medial and lateral canthal tendons stretch. Of course, in most people this does not become a problem. However, in a lax lower eyelid, even the smallest amount of skin removal during blepharoplasty can result in lid retraction, a rounded canthus or frank ectropion. While this sometimes responds to frequent upward massage and eyelid exercises (10 to 20 forced eyelid closures hourly), the treatment is often surgical, and the timing depends on the severity of the symptoms and the extent of the problem.

"In my opinion, the gold standard for correction of significant postoperative lower-lid retraction or cicatricial ectropion is some form of the lateral tarsal strip procedure. This produces a secure and dependable horizontal tightening and elevation of the lower lid with minimal surgical intervention. This procedure was first described by Anderson in 1979¹ and has stood the test of time. Since first learning this method during my ophthalmology residency and oculoplastic fellowship, I have been using it successfully for 31 years with, some variations as needed, depending on the individual situation.

"A horizontal incision is made for approximately 1 cm in the lateral canthus and the inferior crus of the lateral canthal tendon is then identified. A lateral tarsal strip is fashioned and attached to the superior inner aspect of the lateral orbital tubercle. I prefer a double-armed 4-0 Mersilene suture, although others use absorbable sutures. The canthus is reformed with a vertical mattress suture through the grey line. I sit the patient up on the operating table to assess symmetry if the procedure is done bilaterally and aim for a slight overcorrection, because gravity and healing vectors will usually bring down the canthus slightly postoperatively.

"This procedure can be combined with a free skin graft from the upper eyelid or behind the ear in cases where a paucity of skin is the culprit. If there is tethering of the lower eyelid because of scarring of the orbital septum, this can usually be released through a transconjunctival approach. In these cases, at the end of the procedure a suture is placed through the lower eyelid margin and taped to the brow to stretch the eyelid upward and prevent recurrence of scarring.

"However, the real takeaway message here should be that the most effective 'treatment' is prevention. Always evaluate the laxity of the lower eyelid with a snap test and distraction test. If excess laxity is identified, perform some type of lid-tightening procedure at the time of the initial surgery to prevent this complication. Also, be conservative with skin excision and aware that lid retraction can also occur with laser skin rejuvenation."

References:

1. Anderson RL, Gordy DD. Arch Ophthalmol. 1979;97(11):2192-2196.

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Surgeons called upon to revise other clinicians' cosmetic work

Article-Surgeons called upon to revise other clinicians' cosmetic work

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