Eyelid malpositions after either an upper or lower blepharoplasty unfortunately are not uncommon. However, measure can be taken to prevent further damage, so it is extremely important to recognize pre-existing conditions, such as lid laxity and brow ptosis, prior to a blepharoplasty.
After upper blepharoplasty, eyelid malpositions include lagophthalmos, lid retraction and ptosis. Ways to avoid these problems include careful measurements of the skin that is to be removed. Gently pinch up the excess skin until the lashes start to evert. Leave at least 11 mm between the lower brow hairs and the upper incision to prevent worsening brow ptosis and potential lagophthalmos.
Overaggressive cautery of the septum and/or levator can create lid retraction, and reckless dissection beyond the preaponeurotic fat can lead to damage of the levator, which can result in ptosis. Repair of these eyelid malpositions may require a skin graft in the case of lagophthalmos, release of the retractors or repair of ptosis.
Eyelid malpositions after lower blepharoplasty are a bit more common and include ectropion, lower lid retraction, chemosis and entropion. Many of these issues can be avoided by supporting the lateral canthal tendon during the blepharoplasty.
A significant number of lower blepharoplasty patients have pre-existing lower lid laxity. If this goes unrecognized, post-operative ectropion, retraction and dehiscence of the lateral canthal tendon are likely. During the blepharoplasty, exposure of the lateral canthal tendon is simple, and plication to the periosteum over Whitnall’s Tubercle inside the lateral orbital rim will help support the lower lid and prevent malposition during the healing process.
Postoperative support is also important. Use of anti-inflammatories is essential, including arnica in the form of topical, oral or pads, ice packs and suspension of the lid in an upward/lateral direction with steri-strips. If malposition occurs post operatively, a lower lid tightening procedure can be performed by plicating the tendon, horizontally shortening the lower lid margin or performing a lateral tarsal strip.
In general, it is best to do a thorough exam and recognize any eyelid laxity before the blepharoplasty. Address these issues during the procedure to help avoid post-operative problems. If malpositions occur after the blepharoplasty, there are many techniques that can be used to fix the problem, including the two written in my last article.