Dr. Debraj Shome, S09498, Dr. Shilpa Taneja Mittal, Dr. Rinky Kapoor
Lower eyelid retraction, combined with hollowness, ectropion and entropion, can occur following a routine lower eyelid blepharoplasty. Excess skin excision & scar formation causes eyelid retraction due to anterior lamellar shortening.
To raise the lower eyelids into the correct position, skin grafts have been used and placed on the visible skin surface of the lower eyelid to lengthen it. Lateral tarsal strip has been described too. All of these provide inferior, un-aesthetic results.
We describe the sub-periosteal mid face lift, using a trans-conjunctival and an intra-oral approach. The mid face lift releases the scar tissue tethering the lower eyelid & raises the lower eyelid skin, providing extra tissue to the skin lamella. The posterior lamella is then lengthened using a hard palate graft.
To the best of our knowledge, this prospective trial comparing traditional lower eyelid retraction treatments with the mid-face lift in 20 patients is the first of its kind the world over
Lower eyelid blepharoplasty is the removal of fat, and sometimes muscle and “excess skin” from the lower eyelids. In many cases, those who undergo the procedure obtain a very satisfactory result. However, the problems known as retraction, hollowness, ectropion and entropion will occur in a percentage of patients. Though these problems can occur randomly, those with large, prominent eyes seem to be at greater risk.
Blepharoplasty performed through the skin routecan specifically cause many problems. These are a set of almost impossible to treat problems – lower eyelid retraction (sometimes combined with hollowness, ectropion and entropion), all of which can occur following a routine lower eyelid blepharoplasty.
The mid-face lift has been used by us out of our desire to solve this set of problems.We are particularly skilled in this technique which incorporates both reconstructive and cosmetic components to achieve the best possible structural, functional and aesthetic results.
Understanding the problems that can occur following a lower blepharoplasty:
To understand how retraction, ectropion and entropion can occur, one must understand the basic anatomy of the lower eyelid. The lower eyelid is made up of three layers. These three layers, when they are adequate and free to move independently of one another, allow the lower eyelid to function normally, such as rise appropriately, close completely, and interface perfectly with the eye itself.
Following a lower eyelid blepharoplasty, the formation of scar tissue in any one or a combination of these three layers can cause them to adhere to one another and become “tethered,” or to contract. A patient can therefore undergo a perfectly successful lower blepharoplasty, then during the healing process develop retraction, ectropion, entropion or a combination thereof.
- Lower eyelid retraction – This means that the eyelid is pulled down and the white part of the eye below the iris is showing. This is also known as “round eye” or “scleral show.” Lower eyelid retraction can occur following a routine lower eyelid blepharoplasty due to an inadequacy of the middle layer of the three layers that make up the lower eyelid.
- Hollowness – This is the gaunt or “sunken in” look which can result from the removal of too much fat of the lower eyelid area during a routine lower eyelid blepharoplasty.
- Ectropion – The medical term for an eyelid that is “rolled out” or “hanging away” from the eye. Ectropion can occur following a routine lower eyelid blepharoplasty due to an inadequacy of the outermost layer of the lower eyelid which includes the skin.
- Entropion – The medical term for an eyelid that is “rolled in” toward the eye. Entropion can occur following a routine lower eyelid blepharoplasty due to an inadequacy of the innermost layer of the lower eyelid.
What if these problems go untreated or uncorrected?
If a patient has retraction with or without ectropion or entropion, the eye will be overexposed to air. Exposure of the eyes can gradually create a myriad of problems such as chronic irritation, tearing, mucous, discharge,redness, pain, a gritty sensation, and even the breakdown of the cornea itself. In addition, if a patient has entropion, the rolled in eyelid and lashes can rub against the eye which irritate and can damage the eye’s delicate surface. Hollowness can occur in any of these situations due to removal of too much fat.
What methods are available to correct retraction?
To raise the lower eyelids into the correct position, surgeons have used skin grafts placed on the visible skin surface of the lower eyelid to lengthen it and/or have tried to raise and tighten the lower lid by suturing it at the outer corner. Skin grafts are almost never well matched to the surrounding eyelid skin and therefore are very rarely aesthetically pleasing, particularly for patients concerned about their appearance. Likewise, the tightening of the eyelid at the outer corner is not usually successful and can cause the lower eyelid to fall even lower, much like tightening the belt of a man with a protruding belly will result in his trousers being secured lower on the bulge of his belly rather than higher.
How is the mid face lift procedure to treat lower eyelid retraction performed?
We use the sub-periosteal mid face lift, performed through an upper gingival incision, to correct the challenging problems of retraction, ectropion, entropion and hollowness and is a better, more predictable option than skin grafts or eyelid tightening in almost all cases.
In this procedure, to obtain the slack needed to raise the lower eyelid, the entire cheek and midface is raised, over a sub-periosteal plane. This raising is done through an incision at the upper gingival sulcus, from the inside of the oral cavity. Scarring from the previous surgery or surgeries is removed, and adhered layers are separated. A graft is then placed on the inside of the lower eyelid (rather than placing an aesthetically unpleasing skin graft on the outside of the eyelid). This inner eyelid graft is a hard palate graft and acts as a permanent and supple stent or support. Fat which is harvested from the abdomen (through a tiny incision below the umbilicus) may be necessary to fill in any hollowness of the lower eyelid area that is not filled in by the raising of the cheek and midface. The lower eyelid is then reconstructed and re-draped in the ideal structural, functional and aesthetic position. There are no visible incisions on the skin surface in this procedure.
In this prospective trial, we present our results of the use of the mid face lift to treat the problems of retraction posed by over enthusiastic and damaging blepharoplasty. This is the first prospective trial, using an intra-oral mid face lift, to treat the problems of eyelid retraction, caused by blepharoplasty.