Monday was just another typical day in my office: two more patients, unable to close their eyes after having eyelid surgery done elsewhere.
There are many reasons why people cannot close their eyes after surgery. Some of it is predictable, and in fact, there are certain complicated conditions in which I inform patients that there is a good chance that their eyes will not be able to close all the way after surgery. These are generally people who were born with abnormalities in eyelid function (“congenital ptosis”), people with neuromuscular (myasthenia gravis) or mitochondrial disorders (chronic progressive external ophthalmoplegia), or people who has significant scarring in the upper eyelid “glide planes” of the main lifting muscle of the upper lid, the so-called levator muscle. In these people, the lids are generally so droopy that the cannot see unless surgery is performed. In these people, the modest risk of impaired eyelid closure is worth taking, so that I can help them see!
On the other hand, it is obviously not acceptable for eyelid closure to be affected during routine cosmetic surgery of the eyelids. This happens far too often. I am surprised by the number of people who are treated for severe “dry eye” years after cosmetic eyelid surgery… often, eyelid mechanical problems are the root of the problem, as detailed below.
The first patient underwent upper blepharoplasty many years ago and has been unable to properly close her eyes for several years. Surgery was performed by a general ophthalmologist, as opposed to a fellowship-trained oculoplastic surgeon. Fellowship-trained oculoplastic surgeons are board-certified ophthalmologists who complete 1-2 years of additional training in diseases and surgery of the eyelids, eye sockets, and tear drains. It was clear immediately that the incision and scarring from the previous surgery were responsible for the patient’s symptoms: The incision was not placed in the native eyelid crease and was constructed so poorly that the resultant scarring was contracting the lid skin and preventing closure. This sort of problem would never happen with a properly constructed incision.
There are a few ways to consider fixing this problem: a skin graft (which would work, but would not look good), or a horizontal lid tightening (which would work, but would have a higher risk of reoperation in the future). In the end, the simplest procedure the horizontal upper lid tightening, was chosen. The horizontal tightening (canthoplasty) will improve the mechanics of eyelid closure by placing the main closing muscle (the orbicularis oculi) on stretch, improving the muscle function. Muscles in the body have overlapping filaments (myosin and actin) that need to be on proper tension to allow optimal contraction. We learn about this in medical school, often in the realm of cardiology. The phenomenon is well-known, and this stretch / function relationship is known as the Frank-Starling curve. This approach, the horizontal tightening, is also often utilized in patients with some mild to moderate paralysis of lid closure, as well in patients who have had careless cosmetic surgery.
The second patient is much more complex, having had at this point 6 or 7 surgeries. The initial procedures were cosmetic, and the rest have been corrective. The root of the problem is that, somewhere along the way, the upper lid attachment point (to the bone) has been improperly raised. The lid simply cannot close with this geometry. There have been several attempts to correct his eyelid problems, but all were destined for failure, since this single anatomic abnormality was not addressed. The patient had well-regarded plastic surgeons and oculoplastic surgeons work on him, from all over the country. Tempting as it might be to a surgeon, a simple office procedure cannot fix this sort of problem. In fact, it is quite likely that the patient will require independent drill hole fixation of the upper and lower lids on each side to restore form and function. The definitive approach to complex eyelid problems such as these was detailed in a review article that we wrote a few years ago.
Independent upper and lower eyelid fixation is something that I do on a weekly basis to correct eyelid position abnormalities. There are perhaps 6-7 different variations on how I fixate the lateral eyelids during cosmetic and reconstructive cases. Usually a drill is not required, but in this case, it is quite unlikely that the tissue will provide a solid enough anchor, given the sheer number of prior surgical procedures.
These patients underscore the need to give careful thought when choosing an eyelid surgeon. It is always more preferable to get the surgery done right the first time!