Key points

Overview

Lower eyelid retraction (an inferiorly displaced lower lid margin) is a potential complication of lower blepharoplasty attributed to scarring in the middle or posterior eyelid lamellae. It is clinically defined as inferior displacement of the lower eyelid margin unrelated to skin shortage and eyelid eversion; however, eyelid retraction and ectropion (lower eyelid eversion) can occur simultaneously with different degrees of severity. Lower eyelid retraction has been described after both transcutaneous and transconjunctival blepharoplasty approaches, although the latter may confer less risk of retraction because of theoretic preservation of septal integrity.

Certain anatomic configurations predispose the development of lower eyelid retraction after blepharoplasty, yet eyelid malposition can occur without prediction. Scenarios that suggest a predilection to retraction include lower eyelid laxity and poor structural lower eyelid support. Partial or complete dehiscence of the lateral canthal tendon (and less frequently the medial canthal tendon) is often seen in cases of lower eyelid laxity. Maxillary and inferior orbital rim bony hypoplasia, malar fat atrophy, and presence of a so-called negative vector, in which the globe significantly projects more anteriorly than the maxilla, can also lend to postblepharoplasty retraction.

Intraoperative and postoperative circumstances can be associated with retraction secondary to cicatrix formation. Excessive bleeding or hematoma formation can lead to unwanted fibrosis. Overzealous fat removal from lower eyelid fat may volume deplete the inferior orbit/lower eyelid and contribute to loss of lower eyelid support, which can, in turn, lead to lid retraction.

Sequelae of lower eyelid retraction can be both cosmetic and functional. The eyelid aperture and lower eyelid margin contour and canthus are altered with inferior displacement that can vary in degree from the medial to lateral position across the eyelid. Lagophthalmos, punctal malposition, dry eyes, and exposure keratopathy may ensue, and patients frequently experience a foreign body sensation, epiphora, photophobia, irritation and pain. The dynamic closure of the eyelids is restricted, which may compromise ocular surface lubrication and lacrimal pump functioning.

Correction of lower eyelid retraction includes one or more of the following steps:

• •
  

  Scar release

  
  
• •
  

  Eyelid mobilization and repositioning

  
  
• •
  

  Stabilization

  
  
• •
  

  Addition of structural support

  
  
• •
  

  Measures to prevent recurrence

Mild cases can sometimes be improved with conservative measures including:

• •
  

  Massage

  
  
• •
  

  Injections of antimetabolites and immunomodulators (5-fluorouracil and kenalog)

  
  
• •
  

  Injectable hyaluronic acid fillers

  
  
• •
  

  Suture or tape tarsorrhaphy

Those cases that are unresponsive to conservative measures or those with a more severe presentation require surgical intervention ( Fig. 1 ).

Eyelid retraction.

Overview

Lower eyelid retraction (an inferiorly displaced lower lid margin) is a potential complication of lower blepharoplasty attributed to scarring in the middle or posterior eyelid lamellae. It is clinically defined as inferior displacement of the lower eyelid margin unrelated to skin shortage and eyelid eversion; however, eyelid retraction and ectropion (lower eyelid eversion) can occur simultaneously with different degrees of severity. Lower eyelid retraction has been described after both transcutaneous and transconjunctival blepharoplasty approaches, although the latter may confer less risk of retraction because of theoretic preservation of septal integrity.

Certain anatomic configurations predispose the development of lower eyelid retraction after blepharoplasty, yet eyelid malposition can occur without prediction. Scenarios that suggest a predilection to retraction include lower eyelid laxity and poor structural lower eyelid support. Partial or complete dehiscence of the lateral canthal tendon (and less frequently the medial canthal tendon) is often seen in cases of lower eyelid laxity. Maxillary and inferior orbital rim bony hypoplasia, malar fat atrophy, and presence of a so-called negative vector, in which the globe significantly projects more anteriorly than the maxilla, can also lend to postblepharoplasty retraction.

Intraoperative and postoperative circumstances can be associated with retraction secondary to cicatrix formation. Excessive bleeding or hematoma formation can lead to unwanted fibrosis. Overzealous fat removal from lower eyelid fat may volume deplete the inferior orbit/lower eyelid and contribute to loss of lower eyelid support, which can, in turn, lead to lid retraction.

Sequelae of lower eyelid retraction can be both cosmetic and functional. The eyelid aperture and lower eyelid margin contour and canthus are altered with inferior displacement that can vary in degree from the medial to lateral position across the eyelid. Lagophthalmos, punctal malposition, dry eyes, and exposure keratopathy may ensue, and patients frequently experience a foreign body sensation, epiphora, photophobia, irritation and pain. The dynamic closure of the eyelids is restricted, which may compromise ocular surface lubrication and lacrimal pump functioning.

Correction of lower eyelid retraction includes one or more of the following steps:

• •
  

  Scar release

  
  
• •
  

  Eyelid mobilization and repositioning

  
  
• •
  

  Stabilization

  
  
• •
  

  Addition of structural support

  
  
• •
  

  Measures to prevent recurrence

Mild cases can sometimes be improved with conservative measures including:

• •
  

  Massage

  
  
• •
  

  Injections of antimetabolites and immunomodulators (5-fluorouracil and kenalog)

  
  
• •
  

  Injectable hyaluronic acid fillers

  
  
• •
  

  Suture or tape tarsorrhaphy

Those cases that are unresponsive to conservative measures or those with a more severe presentation require surgical intervention ( Fig. 1 ).

Eyelid retraction.

Anatomy

The lower eyelid is anatomically divided into layers: anterior lamella (skin and orbicularis oculi muscle), middle lamella (orbital septum), and posterior lamella (tarsus and lower lid retractors). This categorization is a useful way to conceptualize the relationships between eyelid components but can oversimplify the truly intricate lower eyelid anatomy.

The tarsoligamentous sling concept has been used to describe the 3-dimensional configuration of the lower eyelid with anchoring points between the medial and lateral canthal tendons and their respective bony orbital attachments. The lateral attachment is typically 2 mm higher than the medial one, and the central lid bows anteriorly and inferiorly following the curvature of the globe. The tautness of the sling is influenced by the horizontal length of the eyelid and the resting tonicity of the circumferential orbicularis oculi muscle.

The tarsus, a connective tissue support plate, resides in the most cephalic portion of the lower eyelid and is intimate with both the capsulopalpebral fascia and capsulopalpebral muscle (middle lamella), which attach to its caudal border and the conjunctiva (posterior lamella), which firmly adheres to its posterior surface. Additional attachments at the inferior tarsal border include the suborbicularis fascia and the orbital septum, which extends inferoposteriorly to attach to the orbital rim (arcus marginalis). The inferoposterior extension of the capsulopalpebral fascia forms a condensation at Lockwood’s suspensory ligament, then envelops the inferior oblique muscle and travels posteriorly in the orbit to merge with the inferior rectus muscle fascia. The most anterior portion of the orbital fat lies between the orbital septum and the lower eyelid retractors.