Eyelid Malposition after Blepharoplasty: An Ounce of Prevention

Abstract

Upper and lower eyelid blepharoplasty are common procedures performed to provide a more youthful and rejuvenated appearance. However, this seemingly straightforward procedure may result in lid malpositions, frustrating the patient and surgeon alike, which ultimately require further treatment. We review preoperative assessment pearls to avoid these lid malpositions, as well as options for treating any postoperative complications related to lid position. Many of the techniques discussed in this article, in addition to many other oculoplastic procedures, are available to view in Dr. Richard C. Allen's operative video library at: http://webeye.ophth.uiowa.edu/eyeforum/video/plastics/ .

Upper and lower lid blepharoplasty are commonly performed procedures, which provide an opportunity for patients to achieve a more youthful, rejuvenated appearance. In this review, we address key preoperative considerations for surgeons, as well as management of the most common and challenging functional complications following upper and lower lid blepharoplasty.

Upper Lid Blepharoplasty

Preoperative Evaluation for Upper Lid Blepharoplasty

Patients should be evaluated at the preoperative appointment for pre-existing conditions that may lead to unfavorable outcomes with surgery. In addition to unsatisfactory prior wound healing or skin integrity, patients should be specifically evaluated for brow ptosis, ptosis of the upper lids, floppy eyelid syndrome, and lacrimal gland prolapse.

Dermatochalasis and brow ptosis are comorbid conditions; the vast majority of patients presenting for evaluation of upper lid dermatochalasis have some component of brow ptosis. The activation of the frontalis muscle by the patient to mechanically lift excess upper eyelid skin may obscure this, and care should be taken to evaluate the true brow position at the preoperative appointment by having the patient relax his or her brows. If brow ptosis is noted during the preoperative visit, the surgeon should consider a brow lift in addition to blepharoplasty ¹ ; this may be best performed in a staged fashion to avoid lagophthalmos and exposure keratopathy, but most surgeons would perform the two procedures concurrently. Studies have shown that brow descent is common after upper blepharoplasty, ² and patients should be counselled of this possibility at the preoperative appointment, even if obvious brow ptosis is not present.

Concurrent ptosis of the upper lid should also be assessed when considering blepharoplasty. Acquired involutional ptosis of the upper lid is a common condition, and dermatochalasis may conceal the true degree of ptosis. ³ At the preoperative evaluation, the upper eyelid skin should be manually elevated to determine if blepharoptosis is present. Blepharoplasty alone, without ptosis repair, may unmask a ptotic lid, resulting in an unsatisfactory outcome. ³ Additionally, lid ptosis may be an acquired and unexpected outcome following blepharoplasty, due to lid edema, hematoma, or levator complex injury, and this should be discussed as a potential risk at the preoperative appointment. ⁴

Floppy eyelid syndrome is a frequently underdiagnosed condition. Any patient undergoing upper eyelid surgery should be evaluated for this condition. Patients demonstrate easy or spontaneous eversion of the upper lids with associated conjunctivitis with or without keratitis. ^{5 6} Patients with floppy eyelid syndrome frequently have elevated body mass index and sleep apnea; this should be considered in any patient with a red eye and tearing. ⁵ Early recognition is key, as these patients should be referred for a sleep study and consideration of horizontal eyelid tightening procedures (full-thickness wedge resection or lateral tarsal strip) once positive pressure therapy is initiated. ⁶ A traditional blepharoplasty in these patients may lead to unpredictable results or worsen nighttime exposure.

Lacrimal gland prolapse (acquired ectopia) is found in approximately 15% of patients presenting for evaluation of upper lid blepharoplasty and may be a normal involutional periorbital change. ⁷ Most cases are not associated with specific preoperative findings, although patients may have lateral hooding. Several perioperative techniques have been suggested to manage lacrimal gland prolapse, most commonly repositioning of the gland. It is critical to identify and address lacrimal gland prolapse with attention to functional outcomes. ⁸ Inadvertent removal of the lacrimal gland may lead to significant dry eye. ⁹

Complications of Upper Lid Blepharoplasty

Complications after upper eyelid blepharoplasty may be due to inappropriate management of any of the anatomic structures involved, including skin, orbicularis muscle, orbital septum, and fat pads. While undercorrection may result in an unsatisfactory cosmetic result, overcorrection may result in lagophthalmos and potentially compromise the ocular surface.

Anterior lamellae overcorrection can result in both aesthetic and functional abnormalities. Risk factors for excess removal of fat and skin include previous eyelid trauma, “tight skin” owing to dermatologic abnormalities, and thyroid eye disease. ¹⁰ To avoid anterior lamellar deficiency, conservative skin markings should leave a minimum of 20 mm of upper eyelid skin from the lower margin of the brow to lid margin. ¹¹ In cases where upper blepharoplasty has been performed with forehead elevation or laser skin resurfacing, excess skin removal may be more likely to occur. ¹² Overcorrection of the anterior lamellae should initially be treated with early massage to attempt to release any early cicatricial contracture. Conservative therapy may also include corticosteroid or 5-fluorouracil injections to decrease contracture. Surgical intervention should be delayed, if possible, for at least 4 months. In severe cases with significant ocular surface disease (dry eye), reconstruction of the anterior lamellae with full-thickness skin graft, with or without release of septal adhesions, may be needed. ¹³ If possible, donor tissue for a full-thickness skin graft should be harvested from a region of similar consistency, such as the contralateral upper lid (if donor tissue is available), and should be measured for inset with a slight overcorrection to allow for intraoperative and postoperative contraction. ¹⁴ Eyelid skin typically does not develop a hypertrophic response, making keloid formation rare. Lid scars are more noticeable when depressed, such as in cases of excessive removal of the orbicularis muscle. ¹⁵

Undercorrection of the anterior lamellae may be treated with additional skin excision ¹⁶ ; however, it is critical to assess if there is true undercorrection. In some cases, there may be previously unrecognized brow ptosis, which can suggest undercorrection with additional upper eyelid skin folds. Manually placing the eyebrows in the appropriate anatomical position helps determine if there is true undercorrection or if the surgery unmasked or exacerbated previously unrecognized brow ptosis. Careful assessment of the position of the brows preoperatively can help reduce the likelihood of this problem occurring. ¹⁷ In a study of secondary blepharoplasties, 70% were due to excess dermatochalasis, and the median time from primary surgery was 8.7 years. ¹⁸

Careful assessment of lid ptosis and brow ptosis prior to surgery is crucial for reducing outcomes suggestive of postoperative asymmetry. ¹³ Mindful preoperative conversations can be helpful in assessing patient expectations. Aesthetic surgery rarely achieves complete symmetry; however, careful preoperative assessment of the tarsal platform (visible portion of the eyelid skin inferior to the eyelid crease) and consideration of “microptosis” techniques can help minimize asymmetric outcomes. ¹⁹

In addressing the orbicularis oculi, the trend recently has been to preserve orbicularis rather than perform excision. Preserving orbicularis retains volume and also prevents the possible exacerbation of dry eye. Overexcision of orbicularis oculi may result in temporary dry eye symptoms with or without temporary paralysis. In a study of 40 eyes of 20 patients, those eyes that underwent excision of the orbicularis oculi muscle were more likely to have a temporary increase in reversible dry eye syndromes. ²⁰ Excision of the orbicularis oculi may result in transient lagophthalmos or paralysis, with possible concurrent lagophthalmos. ²¹ While lagophthalmos is usually temporary and should improve with time, lubrication and lid massage can be helpful in the immediate postoperative period. ²¹ In patients in whom this does not resolve, canthal suspension procedures with associated muscle tightening may be used or hyaluronic acid can be injected into the pretarsal space to increase eyelid load. ¹⁷ Preoperative dry eye symptoms should be evaluated completely, and orbicularis should likely be spared in these patients with a very conservative skin excision.

The orbital septum, sometimes referred to as the middle lamella, should not be overly compromised during surgery. In general, the less manipulation of the orbital septum, the better. Suturing of the orbital septum is discouraged due to the risk of causing lagophthalmos. In cases of scarring of the orbital septum to the skin, additional surgery may be needed to release adhesions from the septum to scar tissue. ²²

Fat pads should be assessed during the preoperative assessment. If prominent, excess fat can be excised; however, excessive removal can result in a hollowed, cadaveric appearance. In general, the trends in upper eyelid blepharoplasty have transitioned from excess fat contouring to preservation of fat pads. ²³ The preaponeurotic fat is rarely excised unless in obvious excess, while the medial fat pad is often conservatively debulked. Repositioning of fat pads may be a useful tool in the event of overexcision. ²⁴ Most commonly, the medial fat pad is mobilized to correct cases of excessive excision of the preaponeurotic fat. Alternative options include free fat transfer, or dermal filler, with the understanding that additional treatments may be necessary in the future.

It is critical to pay close attention to the eyelid crease. The eyelid crease is formed by fibrous extensions from the levator aponeurosis to the dermis. There is significant variation in the position and strength of the eyelid crease in the population. The formation, obliteration, or change in the position of the eyelid crease should be discussed with patients preoperatively. The surgically created eyelid crease may be influenced by thick skin, blepharoptosis, sunken eyelids (superior sulcus deformity), younger age, or changes in weight. In cases of an absent lid crease or shallow folds, this can be corrected with resection of connective tissue or extraneous fat in the pretarsal space. ¹⁵

Attention should also be paid to the eyelid fold, which is the fold of skin directly superior to the eyelid crease. In general, a fold does not exist without a crease. Proper evaluation of the eyelid fold should be conducted prior to surgery. In women, the eyelid fold is higher and thinner; in men, the eyelid fold is lower and thicker. ²⁵

A high lid crease may result in an increase in the tarsal platform. ²⁶ Previous studies on the “postblepharoplasty syndrome” suggest that central levator disinsertion may result in high or absent upper lid creases, eyelash ptosis, and loose eyelid platform skin. The presence of “white line” levator disinsertion when evaluating eyelash ptosis following blepharoplasty can help confirm this diagnosis. Treatment includes correction of ptosis and closure of the eyelid with supratarsal fixation. ²⁷ Alternatively, the edge of the levator aponeurosis can be incorporated into the eyelid crease incision.

Complications after upper eyelid blepharoplasty are best avoided, rather than treated. Thorough preoperative evaluation helps identify potential patients at increased risk. Conservative surgery, although at risk of resulting in undercorrection, is encouraged. In patients who have an unfavorable result, appropriate treatments are available to attain patient satisfaction.

Lower Lid Blepharoplasty

Preoperative Evaluation in Lower Lid Blepharoplasty

Preoperative evaluation of patients undergoing lower lid blepharoplasty centers on patient complaints, eyelid skin, eyelid laxity, lower lid position, nasojugal fold (tear trough), fat pads, midface, and globe position.

Thorough evaluation of the presenting complaints of the patient is critical to ensure expectations after surgery are met. Patients should verbalize if it is the wrinkles around the eye, prominent tear trough, or “bags” under the eye that are most concerning, as each of these complaints would be addressed differently.

Eyelid skin is evaluated for texture and laxity. Thinner eyelid skin with wrinkles would respond well to transcutaneous incisions, while thicker skin may respond unfavorably to incisions. Laxity of the lower lids should be assessed in any patient undergoing lower lid surgery. A loose lower lid is an unstable lid and prone to postoperative malposition if not addressed. ²⁸ Distraction testing or snap-back testing is useful to evaluate lower lid laxity. If laxity is detected, this is addressed intraoperatively with lateral canthoplasty/canthopexy procedures.

Prominence of the fat pads and assessment of the nasojugal fold will dictate how the fat pads will be addressed during the surgery. The lateral fat pad is usually debulked if prominent on preoperative evaluation; however, prominent central and medial fat pads are often conserved and repositioned depending on the appearance of the tear trough. Specific discussion should address the wishes of the patient; if the complaint and findings are consistent with excessive “bags,” then debulking of the fat pads would be preferable to repositioning. However, similar to the upper eyelids, the current trend in lower lid blepharoplasty is to retain volume.

The position of the lower lid is evaluated for entropion, ectropion, and retraction. If frank entropion or ectropion is present, this should be addressed primarily with a functional procedure and cosmetic concerns should be secondary. Retraction may be secondary to lower lid laxity, previous surgery with cicatricial changes, midface descent, or a negative vector. Negative vector refers to a posterior positioning of the orbital rim related to the lower lid. ²⁹ Negative vector may be associated with unrecognized globe prominence (hemiproptosis), and may occur in combination with inferior orbit volume deficits or orbicularis weakness. ³⁰ Negative vector can be recognized with scleral show, prominent medial fat, and prominent nasojugal crease; it may be associated with generalized maxillary hypoplasia, and must be considered when planning for lower lid blepharoplasty. ³¹

Descent of the midface can result in a loss of an even transition from lower lid margin to the lid/cheek junction. ²⁸ Previous studies evaluating the lid length in individuals at each decade show there is an increase in lid length with age when measured from the lid margin to the orbital rim, owing to weakening in the orbital septum, atrophy in the orbicularis, and increasing laxity. ³²

Thyroid eye disease, prior lower blepharoplasty, or chronic facial palsy all may present with lower lid retraction. ³³ It is critical to recognize this distinction from laxity in the preoperative evaluation, as these patients may need an internal eyelid spacer graft or midface lift to achieve an optimal postoperative result. ³³ It is also critical to recognize patients in the active phase of thyroid eye disease and delay any surgical procedure. Additional preoperative considerations should include assessment of anticoagulation status, prior ophthalmic surgery and/or history of dry eye, and assessment of facial nerve function. ³⁴

Complications of Lower Lid Blepharoplasty

Despite a thorough preoperative evaluation, with careful attention to skin integrity, the midface position, nasojugal fold, and presence or absence of negative vector, lower lid blepharoplasty still has multiple potential complications.

Overcorrection or excessive excision of anterior lamella can result in cicatricial ectropion. Horizontal lid tightening can be performed, with or without retractor plication. ^{35 36} For cases of severe foreshortening in the anterior lamella, skin grafting or local flaps with full-thickness canthotomy with lateral canthal reconstruction may be needed. ³⁷ In cases where a ptotic midface contributes to lower lid malposition, midface lift is a safe and effective adjunct to ectropion repair. ³⁸ Multiple combined procedures may be needed to restore the lid margin shape and position of lower lid. ³⁹

Undercorrection of the anterior lamella following lower lid blepharoplasty may result in patient dissatisfaction. Transconjunctival approach to lower lid blepharoplasty can be safely combined with a skin pinch excision technique in patients regardless of age, addressing both lower eyelid fat prolapse and dermatochalasis. ⁴⁰ To allow for maximal fat preservation and minimal skin excision, laser resurfacing can also serve as a useful adjunct. ⁴¹ Further skin resurfacing can be performed with mild peeling agents, such as 30% trichloroacetic acid. ⁴¹

Asymmetry can occur following lower lid blepharoplasty. It is the most common complication of lid retraction and can occur unilateral or bilaterally. In a study of 204 patients assessed through standardized measurements with Photoshop Extended, 90.2% had some degree of asymmetry preoperatively. ⁴² Careful attention to preoperative lid position can help in detecting asymmetries to optimize postoperative results. ⁴²

Retraction of the lower lid due to middle lamella overcorrection or septal scarring can be addressed conservatively with massage, if recognized early. Proper technique with application of the index finger to the affected lid in a horizontal direction and pushing upward is critical to success of massage. ⁴³ Of note, some experts suggest that while the middle lamella is frequently implicated as a source of postblepharoplasty eyelid retraction, consideration of this scar as a multilamellar scar may be more accurate. ⁴⁴

With early recognition, lid malposition due to middle lamella or septal scarring may not resolve with massage alone (Carraway exercises), and may require injection of wound modulators. Triamcinolone and 5-fluorouracil have both been used in an off-label fashion to minimize further scar formation. ⁴⁵

For more severe lid retraction, a spacer may be needed. Options include acellular dermal matrix, ear cartilage, or hard palate grafts. ⁴⁶ For patients who seek an alternative to spacer, suborbicularis oculi fat lifting and scar lysis in combination with canthoplasty and temporary tarsorrhaphy can be considered. ³³

In combination with a spacer, addition of surgical correction of lower lid malposition with lateral canthal suspension and midface suspension may be needed. ⁴⁷ Previous review of 17 patients with inferior scleral show and dry eye found resolution with the combination of hard palate spacer grafting, lateral canthoplasty, and midface suspension. ⁴⁷ In some patients, a lateral canthotomy with a Frost suture may be used to reattach the lateral eyelid back to the normal eyelid position and address a lower lid retraction. ⁴⁸

Orbicularis denervation may occur following lower lid blepharoplasty; patients undergoing inferior transcutaneous blepharoplasty without canthal support may have lower lid malposition in up to 20%. ⁴⁹ Evaluation of the lower lid with blink, particularly watching for movement of the lid medially with blink, can help provide crucial information regarding viable remaining muscle. Previous studies have suggested that a preservation of a minimum of 5 mm of pretarsal muscle is needed to prevent eyelid denervation. ⁵⁰ Studies of electroneuromyography of the lower lid following inferior transcutaneous blepharoplasty show viable muscle. ⁴⁹ In the experience of the authors, massage can be used to stimulate the region with careful observation for improvement over time.

Overcorrection with excessive excision of fat may result in a hollowed eye appearance with skeletonization. ²⁸ Lower lid fat can be reposited back into the orbit in patients with skeletonization of the inferior orbital rim. ³⁴ Advancement of intraorbital fat over the bony rim may result in a smoother contour of the inferior periorbital area. ³⁴ Regardless of the procedure used (retroseptal or preseptal approach), release of the arcus marginalis is required to mobilize orbital fat. ^{51 52} Dissection can also be performed above the arcus marginalis if a ptotic suborbicularis oculi fat pad is to be lifted. ^{51 53} Free fat transfer can also be performed with autologous fat to fill the tear trough and create a smooth transition from lower lid to midface. ⁵¹

For patients who do not desire additional surgery for fat reposition, dermal filler with hyaluronic acid is an alternative for hollowing of the lower lid, and filler in the tear trough may have a longer duration than when used in other regions of the face. ⁵¹ Dermal filler, when used functionally, allows for a titratable and potentially reversible (depending on the filler selected) method for augmenting orbital volume and correction of hollowing. ⁵⁴

Undercorrection following lower lid blepharoplasty can be treated with re-excision; asymmetry can also be addressed as needed with repeat surgery. Careful assessment at preoperative visits for determination of any asymmetry can be useful in avoiding a postoperative surprise in lid position. ⁵⁵

The position of the lateral canthus and resultant iatrogenic lateral canthal dystopia can be addressed through graded surgical rehabilitation. ⁵⁶ Canthal angle changes (such as positive or negative slant) can have a great effect on lid appearance and may require revision. Canthal webs may occur when upper and lower lid blepharoplasty are performed concurrently, and may require revision no sooner than 6 months after the first surgery with Y-V- or Z-plasties. ⁵⁷

Dysfunction of the lateral canthus can also result in “fishmouthing” syndrome, associated with medial displacement of the lateral canthus. ⁵⁸ This is thought to be related to laxity of the lateral tendon with rounding of the lateral canthus, and any attempt at repair must address the lateral canthal attachments. ⁵⁸

Conclusion

While upper and lower lid malpositions may occur following aesthetic blepharoplasty, these can best be prevented through careful preoperative assessment. Careful assessment for any comorbid conditions is mandatory, as well as understanding and communicating patient expectations. When unfavorable results do occur, determining the anatomic variables that contributed to the malposition allows the surgeon to create an appropriate plan for revision.

Funding Statement

Funding None.