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Lower eyelid retraction is when the vertical position of the lower eyelid is centrally shortened, creating excessive scleral show often associated with eye irritation as well. In its most severe form the lower lids and cheek tissue can look pulled down and the eye symptoms can be very significant. The most typical cause of lower eyelid retraction in the non-elderly population is surgical. Over resection of lower eyelid tissues and wide undermining done in efforts at midface lifts can result in scarring and subsequent tissue retraction.

Treatment of lower eyelid retraction can be challenging and is certainly not simple. Pulling any anatomic structure back up and resisting the force of gravity and scar contracture over time usually belies a single surgical procedure to be effective in the most severe cases. The complete approach to lower lid retraction consists  of adding structural support and tissue suspension. Structural support means infraorbital rim implants to the bone and spacer grafts to the middle layer of the lower eyelid. Soft tissue suspensions refer to outer eyelid corner and cheek mound upward relocations.

In the comprehensive approach to severe lower eyelid retraction my first step is lower eyelid release through a transcutaneous incision (1mm below the lash line) and a double hole lateral canthoplasty is performed. The double hole technique is important as it is the most secure method to lift up and reposition the outer eye corner. Passing the suture through lateral brow bone, engaging the lateral canthus and then passing the suture back through the bone to tie it down in this elevated position assures form fixation. Drilling the double holes and placing/tying the suture is done through a small lateral upper eyelid incision.

Once the lateral canthoplasty is completed the spacer graft is performed. While a palatal graft has been traditionally used and may offer the stoutest interpositional lid graft the intraoral donor site is quite painful and takes weeks to fully heal. Thus I prefer to use an allogeneic dermal tissue graft. (e.g., Alloderm) I use a long graft and then pass the outer aspect of the graft up along the infraorbital rim and secure it to the bone. This creates an additional sling effect and support to the outer aspect of the lower eyelid.

The third step is the placement of an infraorbital rim implant for which a standard style will work just fine. This requires a subperiosteal cheek release to develop the pocket which concurrently mobilizes the cheek tissues needed for the lift. The implant is secured to the cheekbone with a single titanium microscrew.

Once the implant is secured a midface lift is done by suspecting the cheek tissues far superiorly to the skull bone or anterior temporal fascia. From a small incision superiorly a tunnel is dissected on top of the deep temporal fascial and connected to the lower eyelid site. The suture ends are passed upward and tied down to the bone or fascia superiorly.The lower eyelid is finally closed under no tension at the orbicularis and skin levels.

In this comprehensive approach to lower eyelid retraction repair all elements of the problem are addressed. While not every lid retraction patient will need every surgical step, knowing all the potential options allows one to take a partial or complete approach based on the severity of the lid retraction.   

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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