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Lower eyelid retraction, or pulling down on the lower eyelid with separation of the lid margin from the eyeball, is a risk of every single procedure that involves a lower eyelid incision. This is true whether the surgery was done for a cosmetic or reconstructive purpose. Besides the aesthetic distraction of the lower eyelid malposition, symptoms of dryness, eye irritation and even chronic tearing almost always occur to some degree. The intimacy of the lower eyelid up against the eyeball can not be underestimated.

While these scar deformities can be due to numerous anatomic factors, the most common would be loss of tissue of the outer tissue layers. (anterior lamella = skin and muscle) From a cosmetic standpoint, the lower blepharoplasty is the most frequent offender. High risk patients combined with over resection of tissues is a set up for creating lower eyelid retraction. But there are many other reasons for its occurrence such as aging, tumor resection and traumatic injuries.

A wide variety of techniques for correction of lower eyelid retraction have been described. The extent of the procedures depends on how the anatomic rearrangement is being approached from local tissue rearrangement to recruitment of distant tissue. The more severe the lower eyelid retraction the greater the need for bringing in tissues from beyond the eyelid margin.

In the July 2017 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Vertical Midface Lifting with Periorbital Anchoring in the Management of  Lower Eyelid Retraction: A 10-Year Clinical Retrospective Study’. In this paper the authors review almost 200 hundred patients with moderate to severe lower eyelid retraction and over 300 eyelid surgeries in which vertical repositioning of tissues (midface lift) was done to treat it. In their technique a direct midface lift (SOOF suspension to the orbital rim) was combined with two different techniques of strengthening the lateral canthus. (a spacer graft was also used in roughly one-third of the cases) In 98% of the patients (195 off 199) satisfactory correction of the lid retraction was obtained. Only 2 patients (2%)  needed another surgery due to inadequate correction.

Midface lifting for lower eyelid correction is not new. It has long been recognized that the  lower eyelid and the cheek tissues are contiguous and what happens to one can potentially affect the other. Bringing the cheek tissues up into the eyelid can be done through a subsidiary incision with only a minimal extension of the lateral canthal skin incision. The purely vertical pull is the key and it must be done by direct anchorage to the orbital rims using bone holes and sutures. This is a very powerful technique and its ability to bring tissue upward can often be seen in the redundancy that occurs in the lateral canthal area.

Dr. Barry Eppley

Indianapolis, Indiana

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