Patient dissatisfaction with the final result (see Chapter 29).
As with upper eyelid lift, if insufficient skin has been removed, the most direct remedy is to excise a little more. Be aware, however, that skin excision will not go far in eliminating any wrinkles, while overzealous removal of lower eyelid skin will always cause substantial problems (see below).
The most common "cosmetic problem" is insufficient removal of fat resulting in a noticeable bulge (or, in the case of fat transfer, an unacceptably irregular shape and contour). If objectionable, most such irregularities can be addressed by revision from a transconjunctival approach. It is, however, best to be conservative with fat removal.
Excessive removal of lower eyelid fat can create a hollowness that requires grafting of fat obtained from elsewhere on the body.
Hematoma, orbital hemorrhage, loss of vision (discussed in Chapter 29).
Lower eyelid malposition: The most common functional complication of lower eyelid blepharoplasty is an alteration of the position of the lower eyelid, thus interfering with its relationship with the eyeball. Malposition may be due to:
While the appearance of these three conditions may be similar in some ways, they are not the same and so require different treatments. What works for one will not work for the other. Unfortunately, eyelid collapse is frequently underdiagnosed, which can account for (or at least be a major factor) in some failed "retraction repairs."
• Lower lid retraction is a pulling down of the eyelid thus exposing excessive sclera ("white of the eye") and creating an obvious "surgical look". This mild to very serious complication is more commonly associated with blepharoplasty performed using a transcutaneous (skin) incision. The retraction is usually caused by excessive scarring in the middle layers of the eyelid, which are more "violated" during the more invasive transcutaneous version of lower blepharoplasty, as well as by excessive skin and fat removal. Patients with prominent eyes sitting inside of shallow bony sockets are at significantly greater risk, but the risk is present to some degree in all patients undergoing the skin approach operation.
• severing of scar tissue
• tightening procedures at the lateral canthus (canthoplasty)
• grafting of ear cartilage, hard palate tissue, decellularized tissue matrix (Alloderm - LifeCell Corp.), or a dermal fat graft, sometimes called a spacer graft
• cheek lift,
• placement of a silicone cheek/orbital rim implant.
Such classicial approaches are often only partially successful and for a short duration only. Only recently has orbital fat deficiency has been recognized as a major contributor to eyelid collapse.
• Cicatrical ectropion is an eversion of the lower eyelid (a pulling away of the eyelid from the eyeball). Ectropion is caused by excessive removal of lower eyelid skin, and, again, is a not uncommon complication of transcutaneous lower blepharoplasty. Patients with stretched and weakened supporting tendons are at higher risk (the elderly, smokers) because any tightness at all is poorly tolerated and may result in eyelid eversion.
Surgical correction of cicatricial ectropion is, likewise, a difficult reconstructive operation and may require full-thickness grafting of donor skin (most commonly, taken from behind the ear) and/or horizontal reinforcement of the eyelid by advanced shortening and/or tightening techniques at the lateral canthus and/or midface.
• Eyelid collapse is discussed in the next chapter.
Repairs based on "lifting" procedures such as canthoplasty, midface lift, and SOOF lift may help in the short term but are at high risk for eventual failure, sometimes within a matter of years. As with a face lift, gravity and tension will eventually nullify the effect. If substantial skin is missing and creating a downward pull, the only lasting solution (although not cosmetically easy to accept) may be a full-thickness skin graft.
All spacers materials used to lengthen the middle layer of the lower eyelid are problematical. Ear cartilage and hard palate grafts are relatively stiff and may distort the eyelid over time as they contort . Decellularized tissue matrix (a commercial product) may absorb and lose effect. We generally favor use of a dermal fat graft obtained from the patient's flank, waist, or buttocks. No material is perfect.
Perhaps the most important point to take away from this chapter is that the risk of experiencing a serious complication necessitating substantial corrective surgery is much increased in the transcutaneous version of lower eyelid blepharoplasty. Even when coupled with modern reinforcement techniques (Chapters 19, 21), the classical subtractive approach to standard blepharoplasty introduces additional risk that may or may not be warranted by the chance of achieving any small (potential) additional correction.
Many cases of lower eyelid retraction may be helped only partially with more surgery. After several attempts, some cases can become essentially untreatable.