Lower Eyelid Reconstruction Case Study

By Joseph Walrath, MD | Jan 3, 2021 | Blepharoplasty, Canthoplasty, Cosmetic, Cosmetic Reconstruction

Lower Blepharoplasty with repair of prior surgical complications

This 68 year old gentleman came to visit me from out-of-state for assistance in managing long-standing lower eyelid problems. His surgical history was complex.

His journey started 15 years prior, starting with a  complicated lower blepharoplasty leading to hollowing and lower lid retraction.  He underwent many surgeries during the last 15 years, including:

1. Primary lower blepharoplasty
2. Hard palate grafting to the lower lids
3. Dermis fat graft placement to the lower lids
4. Debulking procedures on those dermis fat grafts

The Office Evaluation

On my office consultation, I noted that there was lower lid retraction (the lids did not relax or move when the patient looked up, and they were pulled down at rest).  The eyes were slightly prominent, relative to the cheeks.  There were surface contour irregulaties due to prior dermis fat graft placement.

The lids adopted a pulled-down appearance, evoking a sad appearance.  This belied the fact that this gentleman was one of the most pleasant and enjoyable patients to grace our office, and therefore his eyelids were not at all reflective of his demeanor!

The midface was somewhat shallow, with some loss of volume, which made the lumpiness of the lower lids even more noticeable.




3 Month Postoperative

The Surgical Plan for Lower Eyelid Reconstruction

The surgical plan can be summed up as follows: go big, or go home.  There is no half measure to correct problems such as this.

To release scarring and correct lower lid shape and position, cartilage from the ear would be implanted on both side.

To reduce hollowing, fat transfer from the eye socket (either normal fat or previously placed dermis fat graft) to the midface would be done where possible.  Excess dermis fat graft would be excised, particularly on the right side.

To further augment volume around the orbital rims, and to stabilize the eyelids, the midface would be elevated.

The lower eyelid reconstruction procedure was scheduled to take 2.5 – 3 hours.  The patient was examined an additional time before the surgery, and the plan was confirmed.  It was confirmed with that patient that this was not a “lunchtime” surgery: there is significant swelling and downtime, extending beyond one month or longer.  He was on board.

The Lower Eyelid Blepharoplasty Surgery

The surgery was performed in August 2020.  Some of my notes from the procedure:

Right side: Prior DFG placement looks like it was done properly,  and it could be dissected free without damaging other structures. The DFG was dissected free and transferred into subperiosteal plane, across the tear trough,  on the right side.  This was held in place with sutures tied over an external dressing, which was to be removed at the one week postoperative visit. Ear cartilage was secured to the inner layers of eyelid from an internal approach, held in place with full thickness sutures.  A canthoplasty was performed and the lid was anchored with 4-0 prolene suture. The midface was dissected in the subperiosteal plane and elevated, anchoring in the region of the lateral canthus.

One the left side, the procedure was similar, except that the DFG was less prominent, and there was a hard palate graft which was incised when placing the ear cartilage graft into proper position.

The Lower Eyelid Surgery Recovery

As predicted, there were a few months or swelling, mostly in the form of some puffiness and fullness at the outer corners of both eyelids.

There was no postoperative pain.

At our postoperative #3 month visit, he is ecstatic.  The photos demonstrate his outcome and the reason for his happiness!  And, as the final cherry on top, in the future we will get together to left his left upper eyelid a little bit to match the other side — this is a simple office procedure.

Lower eyelid surgery is complex, and there are many different techniques available to use when crafting a custom surgical plan.  A video that describes those options in depth can be seen here.