Lower Eyelid Laxity Blepharoplasty

Blepharoplasty is one of the most commonly performed plastic surgery procedures in the head and neck. When performed in carefully selected patients, upper and lower lid blepharoplasty can be a relatively simple and easily performed procedure. The surgeon's goal should be to obtain a natural-appearing, aesthetically pleasing result that betrays no sign of the operation. This is accomplished with little trouble in upper lid blepharoplasty because the natural upper eyelid crease naturally camouflages the operative incision line, and the long-term effects of scarring are usually minimal.

In the operated lower lid, however, critical analysis of the long-term results often shows alterations in the position of the lid and resulting unnatural functional and cosmetic deformities. Careful patient evaluation, thorough understanding of lower eyelid anatomy (especially as it relates to the lateral canthus), and understanding of the various techniques available to address problems can prevent these undesirable surgical complications.

This article discusses evaluation and surgical techniques that help surgeons select patients at low risk for postoperative lower lid complications. The adjunctive lower lid procedures that help obtain natural, functional, and aesthetically appealing lower eyelids are also discussed.[1, 2, 3, 4]

As blepharoplasty has become more common, procedures have been developed to address complications of lower lid blepharoplasty and to prevent complications. The procedures discussed in the section on surgical therapy are listed in chronological order. The emphasis was initially on function. Newer procedures were developed not only to provide functioning lower eyelids but also to maximize aesthetic ideals for the lower lid.

In addition to standard blepharoplasty, patients with poor lid tone and/or laxity of the lateral canthus may need adjunctive procedures in order to prevent postoperative scleral show or ectropion. The lateral canthal position relative to the medial canthus is also strongly related to aesthetics.

Types of post-blepharoplasty lower lid malposition include retraction (scleral show) and ectropion.

Post-blepharoplasty eyelid malposition is usually a result of a failure to recognize lower eyelid laxity before surgery. Anatomical causes of lower lid malposition include the following:

• Laxity of the lid suspension system

• Horizontal eyelid laxity

• Anterior lamella vertical deficiency

• Middle lamella vertical deficiency

• Posterior lid vertical deficiency

Focus examination of the lower eyelid on the following:

• Amount and character of skin: Evaluate the amount of excess skin as the patient looks upward. This stretches the skin and gives the surgeon an idea of how much redundant skin is present. If the amount of excess skin is only evaluated in a neutral or downward gaze, ectropion may be present after skin resection.

• Presence of pseudoherniated fat: Evaluate all 3 fat pads for pseudoherniation, which is also best evaluated in upward gaze. To differentiate fat herniation from edema, apply gentle pressure to the upper lid in upward gaze. Herniated fat becomes more pronounced with pressure, but no change in fullness occurs when lower lid edema is present.

• Position of the lower lid relative to the lower limbus: To measure for lower lid retraction, evaluate the lateral, central, and medial relationship of the lower lid to the inferior limbus while the patient is in neutral gaze. Ideally, no scleral show should be beneath the inferior limbus. In certain individuals, scleral show may be normal but should not be increased surgically.

• Margin reflex distance-2 (MRD2): This is an objective measurement that may be taken by shining a light in the patient's eyes when they are at the same level as the examiner's eyes. The distance from the corneal light reflex to the lower lid is normally 5.5 mm but will be increased in patients with ectropion. The difference between the normal MRD2 and the measured MRD2 may give an indication of how much skin is needed to correct an ectropion caused by anterior lamella deficiency.

• Presence of hypertrophied orbicularis muscle: Hypertrophied muscle may manifest as a noticeable band in the lower lid.

• Tone of the lid: Assess lid tone with the snap test and by evaluating the lateral canthus.

• Snap test: Pull the lower eyelid downward and assess how long it takes to return to a normal position. A return of less than 1 second (without blinking) is normal.

• Distraction test: If the lower lid may be pulled more than 7 mm from the globe, then laxity may be present.

• Pinch test: Gently pull the lateral canthus medially. Minimal movement demonstrates a normal lid. When there is laxity, the canthus can be moved more than 2 mm or to the lateral limbus.

• Negative vector: The relationship of the cornea to the inferior orbital rim is examined from the lateral view. In most patients, a line drawn from the cornea touches the inferior orbital rim. In patients with a negative vector, the inferior orbital rim falls posterior to this line. These patients may be at risk for lower lid malposition (increase in scleral show), but they may also be at risk of a hollowed-out appearance after blepharoplasty if fat repositioning is not performed as part of their procedure.

Always address laxity of the lower eyelid to prevent complications in blepharoplasty.

The lower eyelid is commonly described as a series of layers.

• The anterior lamella is composed of the outer skin and orbicularis oculi muscle.

• The middle lamella consists of the orbital septum.

• The posterior lamella consists of the tarsus, the lower lid retractors, and the conjunctiva.

The lateral canthus is the tendinous insertion of the orbicularis oculi muscle into the lateral orbital rim. The canthus is composed of an inferior retinaculum that is in continuity with the lower lid and an upper retinaculum that is in continuity with the upper lid. The upper and lower lid fuse to form a common band that inserts into the Whitnall tubercle inside the lateral orbital rim.

Note the image below.

Aesthetics related to anatomy

See the list below:

• Aesthetically appealing eyes have an almond shape.

• Because the shape of the upper lid is relatively constant, the shape of the lower lid is the primary determinant of the overall shape of the eye.

• Ideally, the lower lid margin should abut the inferior limbus of the iris.

• The lateral canthus is approximately 2 mm higher than the medial canthus, so the lower lid elevates slightly over the entire distance of the palpebral fissure. This elevation, however, is not a strictly linear phenomenon.

• The medial portion of the lid is relatively horizontal with only a slight upward curvature. The lid curves downward, slightly lateral to the limbus, to invoke an open look before curving upward from this point to the lateral canthus.

Medical problems such as glaucoma, myasthenia gravis, active thyroid disease, or unilateral blindness may be contraindications.

Dry eyes may be worsened by blepharoplasty. A Schirmer test can identify these patients preoperatively. An abnormal Schirmer test result alone may not be significant, but when combined with a tear film breakup time, it signals the potential for postoperative dry eye syndrome.

Patients with lower lid laxity have a relative contraindication to blepharoplasty performed without some adjunctive procedure to prevent postoperative ectropion or eyelid malposition.

Big eyes equal big trouble. Exophthalmos may be the result of a medical condition, such as thyroid disease, but also occurs as a normal variant. Patients with bulging eyes often have a pronounced negative vector, and lower lid surgery may cause them to have a hollowed-out postoperative appearance or functional problems (eg, scleral show, ectropion) related to eyelid malposition. Consider fat repositioning or mobilization in these patients.

Lower lid tightening or repositioning may result in an increase in eyelid malposition in the patient with exophthalmos. To understand this, it is helpful to think of a belt being pulled tightly over a large pannus. As the belt is tightened, the pannus must go up or down to accommodate the tightening. If the eyelid is shortened and tightened in a patient with exophthalmos, the result is usually more exposure of the eye, leading to scleral show or ectropion. Frank exophthalmos must be diagnosed, and the etiology must be determined, because the appearance of these patients is often worsened by any type of blepharoplasty or lid tightening procedure.

See the list below:

• A Schirmer tear test measures tearing function. This may be performed preoperatively to exclude dry eyes, which may be a contraindication to lower lid blepharoplasty.

• Visual acuity test results should be documented before performing surgery in or around the eye.

Many procedures are used to correct lower eyelid laxity, but the following "workhorse" techniques are most commonly used[5] :

• Pentagonal wedge resection: In this procedure, a pentagonal wedge is resected from the lower lid, and the wound is then closed. The wedge can be located anywhere lateral to the limbus, and several techniques for this procedure have been described. Pentagonal wedge resection shortens the lid in the horizontal plane. The technique is not widely used in cosmetic blepharoplasty because it addresses only one aspect of the pathology, horizontal lid laxity. It frequently changes the normal almond shape of the eye and may cause notching of the lid margin or lateral canthal rounding.

• Lateral tarsal strip: After performing a lateral canthotomy and an inferior cantholysis, a tarsal strip is fashioned by denuding the epithelium and conjunctival surfaces from the most lateral aspect of the tarsus. Appropriate tightening of the lid is achieved by gauging the amount of tarsus to be resected (if any) and suturing the tarsal stump to the periosteum inside the medial aspect of the lateral orbital rim. This is a very powerful technique for cases of severe laxity or ectropion, but it is seldom the technique of choice in primary cosmetic blepharoplasty because of the resultant lid shortening and the possibility of lateral canthus distortion.

• Dermal obiculare pennant: This procedure avoids the problems with the lateral tarsal strip procedure by making a pennant-type incision in the lateral canthal skin. The inferior retinaculum and tarsus are deepithelialized and placed through the lateral orbit to reposition the canthus. The technique is used in severe cases of laxity but is not preferred for cosmetic cases because of significant postoperative edema.

The foregoing procedures emphasize function, but for the reasons noted, the cosmetic result is not always ideal. The following procedures allow the surgeon to obtain an acceptable functional and cosmetic result and are therefore the authors' preferred procedures in cosmetic blepharoplasty.

• Inferior retinacular lateral canthoplasty: Make a small incision in the lateral upper lid crease over the lateral orbital rim. If an upper lid blepharoplasty is being performed, use the lateral aspect of that incision. Identify the inferior retinaculum of the lateral canthus and dissect it away from the superior retinaculum and its attachment to the Whitnall tubercle. Then, reposition it several millimeters higher to the medial aspect of the lateral orbital rim periosteum using a mattress suture.

• Lateral retinacular resuspension canthoplasty: Perform the procedure as described above, except position the entire lateral canthus superiorly as needed to tighten the lid and to elevate the lateral canthus in situations in which the lateral canthal position is dystopic. This can be accomplished by incising the lateral canthal tendon after the inferior and superior limbs have joined to form a common tendon and repositioning the canthus 2-5 mm superiorly along the inside aspect of the lateral orbital rim as a single unit.

• Lateral canthopexy: This is a very simple procedure used in lids that need reinforcement but may not need repositioning. The lid is tightened and repositioned by passing a double-armed suture through the lateral canthus and suturing to the medial aspect of the lateral orbital rim periosteum superiorly. The canthus is not divided in this procedure. The distance superiorly is adjusted by adjusting the tension in the knot to achieve the desired tightening and aesthetic position.[6]

With all of the above procedures, careful attention to detail is essential to ensure bilateral symmetry.

A study by Miller indicated that lower lid blepharoplasty using fat repositioning improves pseudoherniation and increases cheek and lower periorbital volume, providing long-term aesthetic improvement of the tear trough and upper cheek. The study included 10 patients and had a mean 12-month follow-up.[7]

A study by Van Slyke et al indicated that KS-pexy (the Kuhnt-Szymanowski procedure) can successfully be used to treat horizontal lower eyelid laxity. The surgery involves horizontal shortening of the lower lid beneath a skin-muscle flap blepharoplasty. The investigators found a 96.8% overall success rate among the 62 patients in the study, the average follow-up time being 41.1 months. The following complications were found[8, 9] :

• Chemosis (27.4%)
• New-onset dry eyes lasting more than 8 weeks (6.5%)
• Temporary lower eyelid malposition (4.8%)
• Lower eyelid malposition requiring surgical intervention (3.2%)
• Poor scar quality (1.6%)
• Lower lid abscess (1.6%)
• Transient conjunctivitis (1.6%)
• Lateral fat compartment swelling (1.6%)
• Canthopexy dehiscence (1.6%)
• Hordeolum (1.6%)
• Temporary V2 paresthesia (1.6%)

A study by Miranda and Codner reported that micro free orbital fat grafts can be safely and effectively employed to correct tear trough deformity in patients undergoing lower eyelid blepharoplasty, with a transcutaneous skin-muscle approach used to add volume from the fat graft directly to the depression. Complication rates were not found to increase in relation to the grafts.[10]

Obtain a general medical history.

Note any history of bleeding tendencies or the use of medications that may cause bleeding abnormalities.

For lower lid surgery, note any history of dry eyes or excessive tearing.

Patients with ectropion may have symptoms of corneal irritation or epiphora that warrant treatment.

As with any procedure, informed consent should be obtained. In addition to the standard risks of lower lid blepharoplasty, informed consent for the treatment of lower lid malposition should focus on the risk of asymmetry between the eyes, scarring, scleral show, tearing abnormalities, corneal irritation, and ectropion.

See Surgical therapy.

In the early postoperative period, treat any potential exposure of the cornea with lubricating drops.

A frost stitch may be used at the termination of surgery to splint the lower lid during healing. This is accomplished by placing a horizontal mattress stitch through the lower lid and securing it to the upper brow with tension directed in a superior vector to counteract any cicatricial pull-down of the lower lid.

Postoperative edema of the conjunctiva may be prolonged. Judicious application of steroid eye drops, limited to a few days, may be helpful.

Most postoperative problems are avoided by careful attention to details of lid position and symmetry at the time of the initial surgery.

Patients are routinely examined on postoperative days 1, 7, 14, and 28. Patients should be reexamined at 6 months; thereafter, yearly examinations should suffice. Encourage patients to call for an examination if any unusual problems occur in the healing period.

Postoperative photographs often reveal minor lid position problems that are not obvious in a dynamic examination.

Closely monitor the lower lid for any signs of developing ectropion, for scleral show, and for any significant changes in lid contour or position.

By carefully monitoring patients throughout the entire healing period, problems may be identified and corrected early. Surgeons must be critical of their work and must remain vigilant to catch problems early and to continue to improve their technique.

Complications of blepharoplasty in general are discussed in other articles. Complications of eyelid repositioning include the following:

• Lower lid malposition: This is the most common complication of cosmetic blepharoplasty. A study by Griffin et al indicated that although eyelid laxity, middle lamellar scarring, and anterior lamellar shortage have been associated with post-blepharoplasty lower eyelid retraction (PBLER), certain other factors play a more significant role in PBLER than has been thought. The study involved 46 patients, all of whom experienced eyelid retraction following primary transcutaneous surgery. The investigators determined that although eyelid laxity and anterior lamellar shortage were common in these patients, so were orbicularis weakness, negative-vector eyelid, and inferior eyelid/orbital volume deficit. Only 17% of eyelids in the study had a significant middle lamellar scar.[11]

• Scleral show: This most commonly occurs from failure to initially address a lax lid. If no lower lid tightening was performed, one of the previously discussed procedures may be needed to address lid retraction. The correct procedure depends upon the amount of laxity present and the degree of correction desired.

• Change in shape of the lateral canthal region: Such a shape change commonly occurs because of poor placement of the canthus during the tightening procedure or overcorrection. It may be addressed by redoing the procedure.

• Lateral canthal dystopia: This may be caused by poor positioning of the canthus or by using the wrong technique. Revision may be necessary after allowing an adequate healing period.

• Postoperative epiphora: This condition may be caused by edema. Use conservative treatment with observation and/or mild topical steroids. If epiphora persists after allowing time for edema to resolve, it may be due to excess lid laxity or tightness causing malposition of the ductal system. If the postoperative epiphora is due to laxity, a tightening procedure may be indicated; if it is due to excessive tightness, a revision of any tightening procedure performed is indicated.

• Ectropion due to deficiency of the anterior or middle lamellae: If ectropion does occur, the surgeon must determine the location of the pathology to adequately address it. If the anterior lamella is deficient, skin may be replaced with grafting. This is most often the result of aggressive removal of skin in a subciliary incision. The best treatment is avoidance. Skin should be removed conservatively with the patient's mouth open. Any skin removed may be placed in saline, refrigerated, and used during the first week of the postoperative course as a skin graft if needed to replace deficiencies.

• Ectropion is due to early formation of cicatrix in the middle lamella: Injection with low-dose steroids (0.1-0.2 mL of 5-mcg/mL triamcinolone acetonide [Kenalog] solution) may be used. Deficiencies of the middle lamellae may be addressed in the late postoperative period. Palatal mucosa, acellular cadaveric dermis (AlloDerm), and/or conchal cartilage grafts are commonly used.

A study by Kaur et al indicated that patients with lower lid laxity who undergo surgery with the lateral tarsal strip technique can experience significantly increased intraocular pressure in the operative eye. While the mean preoperative pressures in the study patients’ operative and contralateral eyes were 13.59 mmHg and 13.89 mmHg, respectively, the mean immediate postoperative pressures were 15.41 mmHg and 14.53 mmHg, respectively. Moreover, some patients maintained increased pressure at 3 months post surgery. The investigators suggested that in patients with glaucoma or suspected glaucoma, careful consideration be given as to whether lower lid tightening surgery should be performed.[12]

With careful patient selection and judicious use of ancillary procedures to address lower lid laxity, patients should expect a good cosmetic and functional result from lower lid blepharoplasty.