Reoperative Aesthetic & Reconstructive Plastic Surgery

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This 62-year-old woman presented with bilateral senile ptosis. She underwent bi-
lateral ptosis repair using the levator aponeurosis technique. The right upper lid
level was dif cult to adjust in the initial procedure because of fatty in ltration of the
levator muscle and attenuation of the levator aponeurosis. One to 2 mm of right
upper lid ptosis remained postoperatively.
Secondary adjustment of the levator aponeurosis achieved eyelid symmetry.

527
Chapter 19
Secondary Ptosis Correction
This 21-year-old woman presented after left upper lid levator advancement surgery
for left blepharoptosis. She was referred for consultation because of overcorrection.
It is noteworthy that the patient had mild ptosis of the right upper eyelid, which
was accentuated by a reverse Hering-Breuer re ex:as the patient attempted to close
the overcorrected left upper lid, because of equal innervation, the right lid was
brought to a lower level by decreased neural input to the levator muscle.
She underwent a 4 mm recession and resuturing of the left levator muscle to lower
the overcorrected left upper lid and aponeurosis plication to correct the minimal
right upper lid ptosis.

Secondary correction via contralateral (left) aponeurosis advancement produced
bilaterally symmetrical eyelids.
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This 31-year-old woman presented with right upper eyelid ptosis, which was cor-
rected with aponeurosis plication. Postoperatively, however, a slight drop of the
contralateral right lid resulted. This situation again illustrates the Hering-Breuer
re ex and the law of equal innervation. Preoperatively both eyes received neural
overstimulation to elevate the lids.This neural pattern was abolished with the cor-
rection of the right upper lid ptosis, thus causing the left lid to fall.

529
Chapter 19
Secondary Ptosis Correction
This 52-year-old woman underwent bilateral levator aponeurosis repair under
monitored conditions for severe bilateral blepharoptosis. Intraoperatively eyelid lev-
els were thought to be near-perfect. However, slight overcorrection of the left up-
per eyelid became apparent postoperatively, aggravating dry-eye symptoms. Ap-
proximately 10% of patients demonstrate a satisfactory lid level during a monitored
surgical procedure, but postoperatively manifest a less than perfect result.This out-
come may be the result of oversedating or undersedating, or may result from in l-
tration of the local anesthetic deeply enough to paralyze the levator muscle or stim-
ulate Mailer’s muscle.

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The patient underwent a secondary procedure to lyse the scar adhesions of the left
upper lid and to release the levator aponeurosis of the left upper lid to allow a slight
drop in lid level via a transverse incision.
Postoperatively bilateral symmetry was achieved.The patient was instructed to mas-
sage the left upper lid to maintain the secondary correction,scar lysis,and lid motility.

531
Chapter 19
Secondary Ptosis Correction
This 31-year-old woman presented with left blepharoptosis and strabismus. Ptosis
may be worsened by strabismus because of the patient’s constant attempts to block
vision in the weaker eye to prevent diplopia.The patient underwent correction of
left blepharoptosis with a levator advancement procedure. After surgery the strabis-
mus was more obvious.This possibility had been discussed with the patient preop-
eratively, and she understood that strabismus surgery would be indicated. Surgical
correction of the strabismus was performed, giving a better aesthetic and functional
result. Patients with strabismus and ptosis should be counseled before ptosis correc-
tion so they understand that reoperative surgery will be necessary to achieve an
overall satisfactory outcome.

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This 60-year-old woman presented with severe bilateral ptosis and dermatochala-
sis.Visual elds were severely compromised but she complained of no visual prob-
lems other than the need to wear corrective lenses. After correction of blepharop-
tosis with aponeurosis repair, she reported that her visual acuity had diminished
greatly. No eyelid or corneal complications had occurred during the surgical pro-
cedure;therefore she was referred to an ophthalmologist in hopes of clarifying the
problem. The ophthalmologist was unable to diagnose the cause of the decreased
acuity. A second ophthalmologist was consulted, whose opinion was that the patient
had been compensating for existing diminished visual acuity by relying on the
overhanging lid and skin to create a pinhole lens effect. When this “pinhole vi-
sion” became frustrated by removal of the skin and opening of the lids, visual acu-
ity suffered. Visual acuity improved by reducing the pupil size with parasympa-
thetic eyedrops. Once she adjusted to the corrected elevated lid level several months
postoperatively, the eyedrops were discontinued.

This 65-year-old woman was referred after bilateral upper lid blepharoplasty and
correction of bilateral blepharoptosis by levator aponeurosis resection. Evaluation
revealed persistent left upper lid ptosis and marked right upper lid retraction.
533
Chapter 19
Secondary Ptosis Correction
She underwent left levator aponeurosis repair and lysis of right upper lid adhesions.
Lid level was symmetrical immediately after surgery.
The postoperative result as shown at 4 months was satisfactory, with appropriate bi-
lateral lid level and complete eyelid closure.

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The patient returned 2 years later with the right lid maintained in a low but rela-
tively stable position, but still without levator muscle function. The patient subse-
quently underwent fascia sling suspension of the right upper lid. Optimal lid level
and improved cosmetic appearance were achieved.
This 33-year-old man presented with the inability to open the right eye after sus-
taining a complex nasofrontoorbital fracture. He had complete ptosis as a result of
third cranial nerve paralysis and secondary levator palsy.
He underwent right upper lid suspension with a nylon suture as a temporizing
procedure while waiting for levator muscle function to return. Temporary ptosis
correction was accomplished with this procedure and adequate vision was possible.

After repair of right upper lid blepharoptosis by aponeurosis plication, this 59-year-
old woman presented with obvious overcorrection made evident by lid retraction
and resultant corneal irritation. In addition, she had marked dermatochalasis and
hooding of the left upper eyelid.
535
Chapter 19
Secondary Ptosis Correction
She underwent division and recession of the right levator aponeurosis to allow lid
closure and functional left upper lid blepharoplasty to correct the left upper lid
dermatochalasis.“Hang-back” sutures allowed a drop of the lid margin and the cre-
ation of a gap in the aponeurosis.
These procedures resulted in correction of the right upper lid retraction, lid asym-
metry, and dermatochalasis.

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Approximately 20 years earlier this 65-year-old man, with the main complaint of
recurrent ptosis of the left upper lid, had undergone left blepharoptosis repair with
levator advancement. Persistent and progressively worsening ptosis was obvious on
examination. The absence of levator function was especially apparent on upward
gaze.The patient had borderline dry eyes bilaterally, which precluded elevation of
the lid to a normal level.
Because of concerns of producing a frank dry eye and corneal irritation, aggressive
lid elevation was avoided and modest levator aponeurosis repair was again per-
formed to improve, but not completely correct, the severe left eyelid ptosis.

This 43-year-old woman presented approximately 15 years after correction of right
upper lid blepharoptosis with partial tarsal resection. To correct the 2 to 3 mm of
residual ptosis of the right upper lid, she underwent levator advancement. Postoper-
atively she had bilaterally equal upper lid levels and could achieve full eyelid closure.
537
Chapter 19
Secondary Ptosis Correction
Elevation of the left upper lid was accomplished, allowing adequate vision and no
clinical exacerbation of dry eyes. If ptosis had been corrected to a greater degree,
eye closure would not have been adequate to protect the cornea.

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Improved vision without any dry-eye problems resulted. The patient was able to
raise the lid higher by raising the eyebrow.
When she was 10 years of age, this 58-year-old woman underwent a levator
shortening procedure to correct congenital ptosis of the left eye. She presented for
consultation because she had minimal levator function of the left upper lid, resid-
ual ptosis, and obstructed visual elds. Evaluation and examination revealed dis-
ruption of the lateral canthal tendon, ptosis of about 3 mm, marked dermatocha-
lasis, and borderline dry eyes. The ptosis was significant enough to cause visual
impairment. Only a moderate amount of lid lift was thought to be appropriate for
this older patient because of her reduced tearing function.
The patient underwent ptosis repair of
the left upper lid with a frontalis sling
procedure using Gore-Tex suture for
the sling.The defect was undercorrected
to avoid exacerbating the patient’s dry-
eye syndrome.

539
Chapter 19
Secondary Ptosis Correction
This 47-year-old man with a history of myotonic dystrophy presented for cor-
rection of bilateral ptosis. He had undergone bilateral aponeurosis advancement for
blepharoptosis repair approximately 8 years previously. Examination revealed good
levator function.
Operative repair was undertaken with levator aponeurosis advancement and rein-
sertion to the tarsus bilaterally.

540
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Postoperatively the patient had bilateral equal upper lid levels, adequate bilateral
levator function, and the ability to achieve full closure of both eyes.

541
Chapter 19
Secondary Ptosis Correction
This 35-year-old man presented after right periorbital trauma. Preoperative evalua-
tion revealed absence of the right upper lid crease and mild right upper lid ptosis.Op-
erative repair included revision of the forehead and upper lid scars,and anchor bleph-
aroplasty to rede ne the right upper lid fold. Partial tarsectomy was performed to
correct the mild lid ptosis. After correction, symmetry of the lid folds was achieved.

542
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References—With Key Annotated References
1. McCord CD. The evaluation and management of the patient with ptosis. Clin Plast Surg
15:169-184, 1988.
The author discusses the fundamentals of evaluating and correcting ptosis for a variety of patients. He
emphasizes that there are many types of patients with ptosis who require surgeons to have a exible
approach and a repertoire of surgical procedures. In a certain percentage of patients, results will remain
unpredictable, and surgeons must always be prepared to perform reoperative surgery.The author also
stresses that formulas are only a starting point for each surgeon to develop individual variations to ob-
tain the best and most predictable ptosis correction.
2. Leone CR, Shore JW. The management of the ptosis patient. Part II. Surg Rev 16:720-727,
1985.
3. Shore JW, Bergin DJ, Garrett SN. Results of blepharoptosis surgery with early postoperative ad-
justment. Ophthalmology 97:1502-1511, 1990.
4. Dortzbach RK, Kronish JW. Early revision in the of ce for adults after unsatisfactory bleph-
aroptosis correction. Am J Ophthalmol 115:68-75, 1993.
The most common complications of levator palpebrae superioris muscle blepharoptosis repair are un-
dercorrection, overcorrection, and abnormalities of the eyelid contour. Previously described nonsurgical
as well as surgical methods delay the repair of such complications and introduce the same confound-
ing factors that can affect judgment of the eyelid level as during the initial surgical procedure.The au-
thors present their technique and results in 22 patients who underwent a highly predictable surgical
technique to revise unsatisfactory postoperative eyelid positions.
5. Crawford JS. Congenital blepharoptosis. In Smith BC, Della Rocca RC, Nesi FA, et al, eds.
Ophthalmic Plastic and Reconstructive Surgery. St Louis: Mosby, 1987, pp 631-653.
6. Fasanella RM, Servat T. Levator resection for minimal ptosis: Another simpli ed operation.
Arch Ophthalmol 65:493-496, 1961.
7. Baylis HI, Shorr N. Anterior tarsectomy reoperation for upper eyelid blepharoptosis or con-
tour abnormalities. Am J Ophthalmol 84:67-71, 1977.
8. Anderson RL, Beard C. The levator aponeurosis: Attachments and their clinical signi cance.
Arch Ophthalmol 95:1437-1441, 1977.
9. Carraway JH. Correction of ptosis—A simple technique. Perspect Plast Surg 3:100, 1989.
10. Jones LT, Quickert MH,Wobig JL.The cure of ptosis by aponeurotic repair. Arch Ophthalmol
93:629-634, 1975.
11. Jones LT.The anatomy of the upper eyelid and its relation to ptosis surgery. Am J Ophthalmol
57:943-959, 1964.
12. Linberg JV,Vasquez RJ, Chao GM. Aponeurotic ptosis repair under local anesthesia. Ophthal-
mology 95:1046-1052, 1988.
13. McCulley TJ, Kersten RC, Kulwin DR, et al. Outcome and in uencing factors of external le-
vator palpebrae superioris advancement for blepharoptosis. Ophthalmol Plast Reconstr Surg
19:388-393, 2003.
This article discusses levator advancement success and surgical failure risk factors in patients with ac-
quired good-function blepharoptosis.After levator advancement for acquired good-function blepharop-
tosis, 77% of patients had ideal results and 8.7% underwent reoperation. Patients with bilateral or
severe blepharoptosis have increased risk of undercorrection.
14. Carraway JH, Vincent MP. Levator advancement technique for eyelid ptosis. Plast Reconstr
Surg 77:394-402, 1986.
15. Carraway JH, Denk MJ. Re nements in ptosis surgery using frontalis sling technique. Opera-
tive Tech Plast Reconstr Surg, 1:113-119, 1994.

543
Chapter 19
Secondary Ptosis Correction
1. What is the most important determinant of successful blepharoptosis repair?
a. Lid level
b. Levator function
c. Status of cornea
d. Status of the lid margin
2. Initial management for a retrobulbar hematoma includes all the following except:
a. Mannitol
b. Acetazolamide
c. Trendelenburg
d. Suture removal
3. Causes of postoperative vision changes include all of the following except:
a. Elimination of the pinhole effect
b. Eye ointment
c. Dry corneas
d. Exophthalmus
4. To resolve overcorrection of previous aponeurosis plication and reinsertion,
which of the following are true?
a. 1 mm of shortening of the aponeurosis leads to 1 mm of lid elevation
b. 2 mm of shortening of the aponeurosis leads to 1 mm of lid elevation
c. 3 mm of shortening of the aponeurosis leads to 1 mm of lid elevation
d. 4 mm of shortening of the aponeurosis leads to 1 mm of lid elevation
5. What level should the operated lid be set during aponeurosis reinsertion under
awake conditions?
a. At the level of the opposite lid
b. 1 mm above the level of the opposite lid
c. 2 mm above the level of the opposite lid
d. 3 mm above the level of the opposite lid
6. Which statement regarding ptosis is most correct?
a. If a patient has minimal levator function and moderate ptosis, good results
can be achieved in at least 90% of cases
b. Near-perfect lid level corrections are best achieved with the patient under
general anesthesia
c. With ptosis repair, form must be balanced against function
d. Reoperations are relatively uncommon with ptosis surgery
e. The most aesthetically important parameter by which patients judge pto-
sis repair results is levator function.
R EVIEW QUESTIONS

544
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7. Important factors to consider for reoperative ptosis surgery include:
a. Lid level (measure ptosis)
b. Levator function
c. Lower lid position
d. Schirmer’s test result
e. All of the above
8. Regarding lid margin irregularities in ptosis surgery, which of the following
statments is most correct?
a. Peaking is usually caused by the aponeurosis, levator muscle, or fascial sling
being sutured to just one area of the tarsal plate
b. Correction involves tightening of the repair at the point of attachment
c. The most common lid margin irregularity is lifting of the medial seg-
ment
d. If a fascial sling was used for the inital repair, shortening of the sling is the
treatment of choice
e. None of the above is correct
9. If the lid level seems undercorrected in the rst week after a levator aponeu-
rosis ptosis repair, one should:
a. Return to the operating room for tightening of the repair
b. Reoperate for the addition of medial and lateral sutures in the tarsus
c. Shorten the levator muscle
d. Wait until all the swelling subsides to determine the degree of undercor-
rection
e. Consider early addition of a fascial sling
10. The Fasanella-Servat perocedure:
a. Is performed through a lid crease incision
b. Is not indicated for secondary ptosis correction
c. Will not cause corneal abrasion if absorbable interrupted sutures are used
d. Can make the lagophthalmos of the upper lid worse
e. None of the above

545
Reoperation and
Avoidance and Treatment of
Complications in Eyelid Surgery
Clinton D. McCord, Jr., and Foad Nahai
C ha pter 2 0
Reoperative Problems
Standard eye prominence
Upper lid complications
Deep-set eyes
Ptosis
Prominent eyes
Levator dehiscence
Complications of autologous
Postoperative lagophthalmos
fat injections
Sulcus abnormalities
Lower lid complications
Do the dif cult things while they are easy and
do the great things while they are small.
Lao Tzu
C omplications that occur after blepharoplasty can be divided into two cate-
gories: aesthetic complications, in which the basic protective mechanisms of the
eyelid are unimpaired but the patient is realistically displeased by surgical changes,
or lack of surgical changes, in the eyelid;and functional complications, in which the
patient suffers postoperatively from eyelid malposition or is left with faulty eyelid
mechanics so that the eyelid fails to protect the eye. These two categories are not
mutually exclusive, and both may have to be addressed.

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Awareness of the complications that may occur after aesthetic eyelid surgery can
help a surgeon avoid them. In many cases, postoperative complications are visible
and obvious;however, on occasion, a patient may look acceptable from an aesthetic
standpoint but still have eyelid dysfunction from subtle changes in eyelid exibil-
ity, position, or movement. For example, even mild lower lid retraction, if accom-
panied by reduced upper lid closure from excessive skin removal, can produce se-
vere exposure problems, particularly if there are coexisting conditions such as eye
dryness or poor eye movement.
Most patients with no preoperative history of eye symptoms or those who have a
history of a “normal” eye examination in the recent past are generally good candi-
dates for eyelid surgery. It is safe to assume that contact lens wearers, because of the
adequate moisture that is required by the lenses for wear, will be tolerant of the
usual stiffness that occurs after blepharoplasty, but there may be exceptions.
Patients who have suspicious symptomatology or unusual ndings on
an eye examination and those with a history of eye problems should
be evaluated by means of slit-lamp examination, tear tests, or consul-
tation with an ophthalmologist.
All patients undergoing blepharoplasty are asked if they have had a Lasik proce-
dure. Blepharoplasty should be delayed if the patient has had a Lasik procedure
within the last 6 to 12 months. Blepharoplasties performed after a Lasik procedure
sooner than 6 to 12 months may lead to symptoms of dry eyes.
EYELID MECHANICS AND INNERVATION
Eyelid mechanics are multipart and complicated and dependent on contributing to
orbicularis muscle function. Contraction occurs in different parts of the muscle,
depending on the function needed.There is interplay between orbicularis contrac-
tion and counterpull at the eyelid attachment at the lateral canthus.This interplay
affects eyelid blinking and eye ssure shape.
EYELID MOVEMENT: DIVISION OF LABOR
IN THE O RBICULARIS
From previous studies involving segmental surgical removal of the orbicularis mus-
cle in a large series of patients with blepharospasm,1 it was shown that only the or-
bicularis muscle in the inner canthus is responsible for routine eyelid tone, move-
ments associated with blinking, and everyday eyelid closure. This section of the
orbicularis also provides the “motor” for the lacrimal pump mechanism for tear
drainage.The rest of the orbicularis, the extracanthal orbicularis, is responsible only
for emergency and emotional eyelid closure, such as squeezing, squinting, and an-
imations of expression.

547
Chapter 20
Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
Anatomic classi cation of the orbicularis into the orbital, preseptal, and pretarsal or-
bicularis is convenient for surgical labeling, but a functional classi cation of the or-
bicularis into an inner canthal orbicularis and an extracanthal orbicularis should
be adopted for better understanding of eyelid function.
These drawings illustrate the division of function (division of labor) seen in the
orbicularis muscle. The extracanthal orbicularis is primarily responsible only for
accessory squeezing movements and expression of the eyelid. The inner canthal
orbicularis (purple-shaded area) is responsible for normal blinking movements, eye-
lid tone, and the lacrimal pump mechanism. The larger areas in the drawing at
lower left show the vector of pull of the inner canthal orbicularis toward the nose
and the counterpull on the eyelids by xation of the lateral canthal tendon.
Extracanthal orbicularis
Inner canthal orbicularis
Responsible for:
Eyelid closure/blinking
Lower lid tone for position
Tear pump
Responsible for:
Squeezing
Animation
Expression
Protection from flying objects

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EYELID INNERVATION: DIVISION OF INNERVATION
OF THE ORBICULARIS
It follows that because there is a division of labor in orbicularis muscle function,
there would also be a dual of innervation of the orbicularis. Electromyographic
(EMG) studies, clinical observations, and anatomic studies have shown that to be
the case.The extracanthal orbicularis is supplied by the zygomatic branch of the fa-
cial nerve, whereas the inner canthal orbicularis is supplied by a vertical extension
of the buccal branch of the facial nerve.
The dual innervation of the orbicularis muscles is illustrated. Branches of the zygo-
matic portion of the facial nerve supply the extracanthal orbicularis, and vertical
branches of the buccal branch of the facial nerve supply the canthal orbicularis and
corrugator muscles.
Loss of innervation from the zygomatic branch of the facial nerve to the extracan-
thal orbicularis can occur, but in the absence of lower lid laxity it will produce lit-
tle change in eyelid position or tone as long as the buccal branch innervation to the
inner canthus remains intact. Standard surgical incisions in the pretarsal or presep-
tal orbicularis external to the inner canthus cause no abnormalities in lower eyelid
position or tone.With regard to the effect of subciliary incisions, recent EMG stud-
ies show that microdenervation of the pretarsal orbicularis muscle does not occur,
even if the recording electrode is placed directly into the surgical incision line.
Loss of eyelid innervation from the buccal branch of the facial nerve
to the inner canthal area, however, will cause profound changes in
eyelid function, with reduction or absence of blinking, poor lower lid
tone and position, and a weakening of the lacrimal pump mechanism
causing tearing.
EXTRACANTHAL ORBICULARIS
CANTHAL ORBICULARIS
Zygomatic branches VII
Buccal branch VII

549
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Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
LATERAL CANTHAL ANCHORING2
The mechanics of eyelid closure, the normal blinking movements of
the upper and lower lid, require rm attachment at the insertion of the
lateral tendon for counterpull.
Because contraction of the orbicularis in the inner canthus is responsible for blink-
ing of the eyelids, if it is unopposed, an abnormal nasally directed eyelid movement
occurs with each blink. Firm anchoring laterally is needed for counterpull against
canthal contraction to convert the vector of the blink movement into a vertical
one for proper eyelid closure. Patients who lack lateral canthal anchoring suffer
from faulty eye-blinking mechanics.The nasal movement of the eyelids that occurs
with each blink results in “ sh-mouthing” of the eyelids with attempted eyelid clo-
sure, causing lagophthalmos and eye exposure of varying degrees.
The structures in the eyelids responsible for blinking movements are depicted
above.The inner canthal orbicularis, with its contraction, provides the motor for the
eyelid blink but can only be effective if there is rm counterpull of the eyelids lat-
erally at the outer canthus.The top illustration demonstrates normal closure in the
presence of rm lateral canthal anchoring. The lower one shows reduced closure,
to the point of sh-mouthing, in the presence of weak or dehisced lateral canthal
attachments.
Counterpull of
lateral canthal
attachment
Loosening of
lateral canthal
attachment

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AESTHETIC GOALS IN THE MIDFACE AREA
THE LOW ER LID: A MIDFACE AESTHETIC UNIT
Normally the inferior arc of the orbicularis oculi muscle and the underlying sub-
orbicularis oculi fat (SOOF) span the eyelid and orbital rim area in the midface.
With aging there is sagging or ptosis of the orbicularis muscle accompanied by
loosening of the orbitomalar ligament, which causes a downward descent of the
SOOF and malar fat.This facial descent results in the loss of padding over the in-
ferior orbital rim and a loss of cheek fullness that is inconsistent with a youthful ap-
pearance. This descent is usually accompanied by herniation of fat as well as skin
laxity in the eyelid. Loss of volume seen with aging also contributes to this process.
The skeletonization of the orbital rim area associated with age is a
major contributor to the aging appearance in the midface area. Sur-
gery that fails to address the eyelid and cheek area as an aesthetic unit
falls short of a true reversal of aging changes in this area.3
Techniques that use supraplacement of the inferior arc of the orbicularis muscle to
reposition the midcheek upward correct the underlying problem of ptosis of the
orbicularis. In patients undergoing primary cosmetic surgery, as the skin of the
lower lid and midface is recruited upward, the resulting skin redundancy is ex-
cised.4,5 In patients undergoing reoperation with lower lid retraction caused by ex-
cessive skin removal, the additional skin recruited by upward movement of the or-
bicularis introduces needed skin into the lower lid. In corrective surgery, the
technique of orbicularis redraping is a valuable tool and allows the surgeon to avoid
skin grafts in patients with a shortage of skin in the lower lid.

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Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
EYE FISSURE SHAPE
In patients undergoing aesthetic eyelid surgery, a youthful con guration of the eye-
lid ssure is needed to reduce the appearance of aging in the eyelids.6 The ele-
ments that de ne eye ssure shape are the position of the eyelid margins and the
shape of the exposed white triangles (scleral triangles) on either side of the cornea.
The size of the cornea is uniform in all persons, but the shape of the scleral trian-
gles may vary. Generally the nasal scleral triangle is smaller, and the lateral scleral tri-
angle is larger and more pointed. In most individuals, the position of the lateral
canthus is slightly higher than the inner canthus and is at the level of the inferior
edge of the pupil.
The youthful eye ssure shape, pictured above, is de ned by the position of the
eyelids and the exposed sclera on either side of the iris, the nasal scleral triangle, and
the lateral scleral triangle.The standard position of the lateral canthus is in line with
the inferior edge of the pupil and is slightly higher than the inner canthus. Eye s-
sure changes that occur with age are shown in the eyes at right. In a deep-set eye,
the eye ssure becomes smaller, with a reduction in the size of the lateral scleral tri-
angle. In a prominent eye, downward bowing of the lower lid is evident.
The shape of the scleral triangles and eye ssures is depicted in the eyes of these
young women.With aging there is relaxation of lateral canthal attachments, which
may cause the eye ssure to change in shape according to eye prominence. In in-
dividuals with normal or deep-set eyes, the ssure tends to become rounder and
smaller.
Lateral scleral
triangle
Deep-set eye
Prominent eye
Nasal scleral
triangle
AGE
YOUTH

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In individuals with prominent eyes, a downsliding of the lower lid,
scleral show, and enlargement of the lateral scleral triangle may occur.
Proper canthal anchoring restores a more youthful look to the eye s-
sure by changing the shape of the ssure and the shape of the lateral
scleral triangle.
This woman is shown before and after a lateral canthopexy and midface lift. The
eye ssure has been changed from rounded and small with age, as depicted on the
left, to a more open elliptical youthful shape, as shown on the right.
A change in eye ssure shape is demonstrated in this man. After canthal anchoring,
the shape of his eye ssure changed from rounded on the left to a more youthful
elliptical shape on the right.
It has been shown mathematically that protrusion of the eye against
the eyelid affects the shape of the eye ssure.
Upper lid curvature is determined almost exclusively by indentation of the globe
on the eyelid. Lower lid curvature is determined by a combination of globe in-
dentation and the position and tone of the lateral canthal tendons. Lateral canthal
anchoring has a powerful in uence on lower lid position and curvature.

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Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
TECHNIQUES OF LATERAL CANTHAL ANCHORING
Strengthening the eyelid attachments at the lateral canthus may include a pexy pro-
cedure with plication of the canthal tendons or canthoplasty, cantholysis, and short-
ening of the lower lid with reattachment to the lateral periosteum.
In cases of lower lid laxity, reinforcement with shortening of the lower
lid is necessary.
The two common methods of lateral canthal anchoring are illustrated. With can-
thopexy,a mattress-like suture attaches both the upper and lower tendons to the peri-
osteum inside the orbital rim.With canthoplasty, the lower lid is shortened to com-
pensate for laxity. In both cases the upper lid is included in the anchoring to the
orbital periosteum.Whichever procedure is used, the axial vector of lid anchoring
must travel inside the lateral orbital rim so that the lower lid will be ush with the
curvature of the globe.
This illustration shows the normal vectors of attachment of the lateral canthal ten-
dons and the orbicularis muscle.The lateral canthal extension of the tarsoligamen-
tous sling inserts well inside the orbital rim, whereas the orbicularis muscle inserts
externally on the orbital rim.
Canthal
tendon
vector
Muscle
suspension
vector
Eisler’s pocket
Lateral
canthal
tendon
Pretarsal orbicularis
Orbital septum
CANTHOPEXY
CANTHOPLASTY

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INDICATIONS FOR CANTHOPLASTY VERSUS CANTHOPEXY
Significant laxity of the tarsoligamentous sling must be addressed surgically by tight-
ening or horizontal shortening the lower lid to stabilize it and prevent postopera-
tive ectropion or buckling when blepharoplasty is performed.
This patient, who had lower lid laxity after blepharoplasty, demonstrates outward
buckling of the lower lid with ectropion. No shortening of the tarsoligamentous
sling was performed.There is a disparity in tone between the anterior lamella (or-
bicularis) and the posterior lamella (tarsoligamentous sling) causing the lid to buckle
outward.
The intraoperative distraction test is the best method for detecting lower lid laxity.
Preoperative eyelid distraction tests have been described in the past, but we believe
it is more meaningful to apply the distraction test intraoperatively. No more than
1 to 2 mm of distraction from the globe should be seen with outward traction on
the lower lid with the patient in the recumbent position intraoperatively. In addi-
tion, there should be a rm “snap back” to the globe after distraction. If this amount
of tension is not seen in the lower lid, then a tightening procedure of the tarsoliga-
mentous sling of the lower lid must be performed.

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Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
In patients who have laxity of the tarsoligamentous sling, tightening only the orbic-
ularis muscle will not correct internal lower lid laxity and can produce outward
buckling of the lid because of redundancy in the posterior lamella. Tightening of
the tarsoligamentous sling itself must be performed.
Either canthopexy or canthoplasty is used until the proper tension is obtained. If
canthopexy is tried rst and the tension of the lower lid against the globe does not
seem adequate, or there seems to be redundant tissue at the lateral canthus, then the
lower lid should be resected and canthoplasty performed.
VARIATIONS IN PLACEMENT OF LATERAL
CANTHAL ANCHORING
The pull of lateral canthal anchoring on the eyelids against the globe will in uence
the shape of the eyelid ssure according to the prominence of the eye.To produce
the desired youthful shape of the ssure, variations in placement of the anchoring
are made according to eye prominence. Because the lateral pull of canthal anchor-
ing of the lower lid results in changes in the size, shape, and position of the lateral
scleral triangle, different placements of anchoring must be used in patients with
differences in eye prominence.

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The position of the lower lid changes in response to traction at the lat-
eral canthus.
The lower lid position will either remain stationary, “clothesline” downward, or
“clothesline” upward in response to the lateral pull of canthal anchoring, with dif-
ferences in eye prominence. Lower eyelid movement depends on whether the eye
is deep set (less than 15 mm), standard position (15 to 18 mm), or prominent (more
than 18 mm). In an eye with standard prominence, a lateral pull in line with the in-
ferior edge of the pupil will maintain good lower lid position. In a deep-set eye, this
same vector of pull will result in upward “clotheslining,” resulting in a small eye s-
sure postoperatively. In a prominent eye, the same pull will cause downward
clotheslining.
Prominent eye
Deep-set eye
18 mm
Standard eye prominence
15 mm
Stationary
Clothesline downward
Clothesline upward

557
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Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
For lower lid blepharoplasty, failure to take these factors into account, and failure to
modify lateral canthal anchoring accordingly, may result in abnormalities of the eye
ssure. Preoperatively the proper placement of canthal anchoring can be planned
according to measurement of eye prominence with an exophthalmometer.
This approach to treatment is offered as a general guideline with the nal determi-
nation on anchoring made after the behavior of the lower lid has been assessed in-
traoperatively. During surgery, if the nal resting position of the edge of the lower
lid is at the desired level in relation to the cornea (usually just inside the lower lim-
bus), then the position of anchoring can be deemed adequate.
15 mm
15-17 mm
21 mm
Prominent eyes
Deep-set eyes
Standard
measurement

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The proper vectors of canthal anchoring are demonstrated in patients with deep-
set eyes, eyes with standard position, and prominent eyes. In patients with deep-set
eyes, canthal anchoring should be directed more downward and internally to com-
pensate for globe curvature. For patients with standard eye prominence, canthal an-
choring should be placed at the level of the inferior edge of the pupil inside the or-
bital rim. For patients with prominent eyes, there should be a more upward vector
of anchoring with mild supraplacement.
Prominent eye
Deep-set eye
18 mm
Standard eye prominence
15 mm

Standard Eye Prominence
Lateral anchoring for an eye with Standard prominence (16 to 18 mm) is usually
best accomplished by placement at the level of the inferior edge of the pupil.
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Chapter 20
Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
Deep-set eye
Prominent eye
Standard eye
Improper
fixation
Proper
fixation
The image on the right depicts positioning of canthal anchoring in the various sit-
uations of eye prominence.The highest placement is for a prominent eye.The low-
est placement is for a deep-set eye. In the left image, the proper vector of xation
is indicated by the black arrow.The red arrow indicates a placement that is too an-
terior in most cases.

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The Deep-Set Eye
In a patient with deep-set or inwardly recessed eyes, a lower lid clotheslining up-
ward may occur that narrows the ssure and reduces the size of the lateral scleral
triangle. This may cause the patient to complain of “little, squinty eyes” postoper-
atively. In patients with deep-set eyes (less than 15 mm), anchoring is placed more
inferiorly and more internally to prevent the upward clotheslining of the lower lid
that may occur (see the preceding two gures).This also prevents narrowing of the
lateral scleral triangle and postoperative patient complaints of “small eyes.”
This patient with deep-set eyes (15 mm) is shown before a cheek lift (top). Because
she was at risk for narrowing of the eye ssure with standard placement of canthal
anchoring, a modi ed approach was used. On the bottom, the patient is shown af-
ter a midface lift and canthal anchoring, which was modi ed with downward and
inward placement to compensate for her enophthalmos.

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Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
The Prominent Eye
In a patient with prominent eyes, tightening the lower lid in the standard vector can
cause a clotheslining effect that produces a bowing downward of the lower lid or,
in more severe cases, scleral show. Currently we depend on slight supraplacement
of lateral canthal anchoring to position the lower lid upward to counteract this ef-
fect in milder cases.We have found that the position of the canthal anchoring in the
prominent eye should not be higher than the center of the pupil, particularly in pa-
tients with more severe eye prominence.7
This illustration graphically depicts the limitations of supraplacement of the lateral
canthal tendon, which can result in the weakening of upper lid closure because of
the mechanical factors involved. Canthal anchoring should not be supraplaced
above the midlevel of the pupil. Leverage of upper lid closure is lost as the canthus
is supraplaced.This is particularly true in patients with prominent eyes.
Weakens
upper lid
closure

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LIMITATIONS OF CANTHAL SUPRAPLACEMENT
If certain limits of lateral canthal supraplacement are exceeded in patients with in-
creasingly prominent eyes, there is an adverse effect on upper lid closure.This is be-
cause the fulcrum of upper eyelid movement may slide upward past the vertex of
the cornea as lateral anchoring moves upward, which causes reduced closure of the
upper lid with lagophthalmos. Increased tightening of the upper lid can aggravate
this situation and is analogous to the clotheslining effect that occurs with tighten-
ing of the lower lid in these patients. Excessive manipulation of the lateral tendons
upward may also intrinsically weaken the upper tendon attachment.
This patient with prominent eyes and preexisting scleral show is shown preopera-
tively (top) and postoperatively (bottom). Excess supraplacement of the canthal angles
is evident because of the retinacular suspension to elevate the lower lid margin.
Note the weakening of upper lid closure.
Preoperatively
Postoperatively

OTHER COMPENSATORY PROCEDURES IN PATIENTS
W ITH PROMINENT EYES
If mild lateral canthal supraplacement does not elevate the lower lid enough, the
rst surgical step to counteract any clotheslining tendency is a release or recession
of the inferior retractors, capsulopalpebral fascia (CPF), in the lower lids. A gain of
1 to 2 mm in the lower lid position against scleral show can be achieved with CPF
recession.
563
Chapter 20
Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
This illustration demonstrates recession of the inferior retractors (CPF) of the lower
lid to elevate the lid margin.
Capsulopalpebral fascia

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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
A patient with prominent eyes (greater than 18 mm) is shown before and imme-
diately after canthal anchoring with slight supraplacement combined with recession
of the CPF in the lower lid.There is normalization of the lateral scleral triangles.
In patients with more severe eye prominence, loosening the CPF may not provide
enough lid elevation to prevent postoperative scleral show, and insertion of spacer
material in the posterior lamella of the lower lid is indicated. For spacer placement
we prefer a full-thickness blepharotomy in the posterior lamella 6 mm below the
lower lid margin (sparing the inferior arcade, which is approximately 4 mm below
the lid margin). Most of the blood ow to the lower lid is based on the nasal arte-
rial complex, so care is taken not to dissect or cauterize unnecessarily in this area.
It is convenient to use AlloDerm, of suf cient thickness, as spacer material in pre-
viously unoperated patients. For secondary or complex cases we prefer ENDURA-
Gen (porcine acellular dermis; Porex Surgical Products, Newnan, GA).

This patient with prominent eyes (greater than 19 mm) is shown before and after
midfacial lid surgery combined with upper lid brow surgery in which a primary
spacer of AlloDerm was used to prevent downward clotheslining and scleral show.
565
Chapter 20
Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
Spacer
Incision of the inferior retractors (CPF) and conjunctiva is depicted here, with full-
thickness blepharotomy of the posterior lamella of the lower lid and insertion of
spacer material to elevate the lid margin.

566
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Our present approach for preventing postoperative problems in patients who have
prominent eyes is a progression from conservative lateral canthal supraplacement to
recession of the inferior retractors followed by insertion of a spacer to produce de-
sirable eye ssure shape.
Complications of Autologous Fat Injections into the Lower Lid
Correction of aging lower lids and blending of the lid-cheek junction with autol-
ogous fat microinjections is becoming increasingly popular. Although some of the
results have been impressive, we have seen a number of patients where the fat has
been injected super cially, subcutaneously or in the super cial layers of the orbic-
ularis leading to unsightly “beading” of the lower lid.These problems may be dif-
ficult to deal with. The fat may be removed through the transcutaneous or
transconjunctival approach. As with any complication or problem, avoidance is
preferable to correction. Injection of the fat deep directly over the periosteum is
best in preventing postoperative irregularities and beading.
This woman had undergone autologous fat injections into the lower lid in an at-
tempt to improve lower lid aging and lower lid-cheek junction descent.The excess
super cially injected fat is easily seen. She also had bilateral lid retraction that was
worse on the right than the left.

567
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Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
Through the skin-muscle ap approach, the autologous fat within and super cial
to the orbicularis muscle was easily located. The excess fat was dissected and re-
moved. After all the excess fat was successfully removed, the orbicularis was mobi-
lized and redraped.
Injected autologous fat
10 mm
Preoperative and postoperative views demonstrate improved lid appearance, more
effective lid-cheek junction blending after removal of the injected fat, orbicularis
muscle ap, redraping, and canthopexy.The split view shows the improvement on
the left side.

568
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LOWER LID COMPLICATIONS AND
THEIR TREATMENT
Through a thorough understanding of eyelid innervation and closing mechanisms
and awareness of the aesthetic goals, complications following lower lid blepharo-
plasty may be minimized.
Cognizance of the risk factors including globe position, lid tone, and pre-existing
lid retraction will contribute to the prevention of postoperative complications.
Abnormalities of eye ssure shape and lower lid retraction or ectropion are the
most common problems seen after aesthetic lower lid surgery. Shape deformities
range from a simply undesirable eye shape (i.e., rounding, bowing, or narrowing of
the lateral scleral triangle) to lid malposition. Commonly these problems are the re-
sult of inappropriate canthal anchoring. Patients with poor anchoring may also
have poor eyelid closure mechanics.The causes of ectropion or downward retrac-
tion of the lower lid are as follows:
Overzealous skin removal
Failure to surgically anchor supporting elements of the eyelid (that is, lateral
canthal tendons or orbicularis muscle ap)
Failure to recognize preexisting lower lid laxity
Failure to recognize signi cant variation in eye prominence
Lower lid malposition may have medical consequences in addition to aesthetic
ones.8 Postoperative exposure can be particularly intensi ed if lagophthalmos in
the upper lid is present as well.
CORRECTIVE SURGICAL PROCEDURES9,10
Common procedures to correct lower lid complications are anchoring (or rean-
choring) of the lateral canthus and anchoring (or reanchoring) of the inferior arc
of the orbicularis muscle. Both structures offer support for repositioning the lower
lid and each, if appropriately anchored, can restore an undesirable eye ssure shape.

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Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
This is an example of a patient with eye ssure narrowing after blepharoplasty.The
patient complained of “little bitty eyes” after blepharoplasty;note the narrowing of
her eye ssures. After canthal reanchoring modi ed with downward and inward
placement, she was pleased with the enlargement of her eye ssures and thought
that her eyes had a more normal shape.
In the photo on the left, note the close-up of a patient with deep-set eyes after a
lower lid blepharoplasty in which the proper type of canthal anchoring was not
performed. She had a marked reduction in the size of the lateral scleral triangles
in both eyes. In the photo on the right, after canthal anchoring with downward,
inward placement to compensate for the deep-set eye, enlargement of the lateral
scleral triangle is shown.
If skin shortage is a signi cant factor in lower lid retraction, canthal
vertical anchoring of the inferior arc of the orbicularis muscle will re-
cruit skin upward into the lower lid and will, in most cases, correct re-
traction without a skin graft.

570
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
Spacer insertion into the posterior lamella of the lower lid is particularly useful in
patients with prominent eyes and in patients with retraction caused by middle
lamella scarring. Spacer material, interposed after scar release, acts as a barrier against
postoperative scar contracture. Autogenous material such as dermis, ear cartilage, or
hard palate and ENDURAGen is best used in reoperative cases.
Canthal Anchoring (Reanchoring)
In patients who have minimal scarring and an intact lateral rim periosteum, canthal
reanchoring may be performed as one would in an unoperated patient. In patients
with unusual scarring or tissue de ciency in the canthal area, extra tissue may be
needed for lateral reinforcement. In milder cases, a periorbital rim–based periosteal
strip can be used for support.
Techniques of canthal anchoring using reinforcement with additional tissue are de-
picted;periosteal strip on the left and free fascia graft on the right. A re ected ap
of lateral rim periosteum can be used as a reconstructive procedure at the lateral
canthus and can act as additional support. In lieu of periosteum, free grafts of fas-
cial tissue, either temporalis or fascia lata, can be used for additional support of can-
thal reanchoring.
A free fascia patch graft may also be used. This approach, in which additional soft
tissue is introduced, is particularly helpful in cases where there is a shortage of eye-
lid tissue in the lateral lid.
Periosteal strip
Free fascia graft

After an earlier eyelid surgery, this patient had a loss of normal lateral canthal attach-
ments in the right eye and phimosis from tissue loss in the left. Both lateral canthi
were reconstructed with reanchoring and periosteal ap placement, as shown on
the right.
Our procedure of choice for the most secure canthal anchoring is re xation of the
lateral canthus through a drill hole in the lateral orbital rim. This is a useful tech-
nique in patients with poor periosteum and weakness of soft tissue support at the
lateral canthus. It is best for patients with severe distortion of the eye ssure or pa-
tients who have poor eyelid closure caused by lateral anchoring de ciency. Drill-
hole xation enhances the permanency of anchoring.
571
Chapter 20
Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
The technique of canthal anchoring using drill-hole xation to the lateral orbital
rim is demonstrated. A single drill hole can be used.The double-armed suture (4-0
Mersilene) is passed through the single drill hole and secures the canthus inside
the lateral orbital rim. The double-armed suture can then be fixed to the deep
temporal fascia. The use of a single drill hole allows greater precision in canthal
placement and possibly a more secure attachment to the orbital bone.

572
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
The doubled-armed suture attached to the canthal structures is brought out
through the drill hole and secured to the deep temporal fascia.
On the left, this patient shows deformity of the right canthus that had resisted con-
ventional forms of canthal reanchoring; on the right, the same patient is seen after
drill-hole canthal anchoring.
The need for drill-hole canthal xation commonly occurs in patients with promi-
nent eyes who also have eyelid retraction and stiffness of the upper and lower lids.
In these patients a double drill-hole xation is necessary in which the lateral ten-
dons of the upper and lower lid are independently xed to drill holes in different
positions.

To obtain the proper vectors of pull at the lateral canthus to ensure good lid clo-
sure, a criss-cross attachment can be used.This is particularly important in patients
with prominent eyes and poor closure.The vector of pull that improves closure in
the upper lid is obtained by placing it in the inferiorly placed drill hole. A can-
tholysis is performed, and the edge of the upper lid is attached to the lower drill
hole. The lateral tendon of the lower lid can be placed in the superiorly placed
drill hole, allowing a higher supraplacement of the lower lid without affecting up-
per lid closure.This improves the upper lid closure mechanics and also allows more
supraplacement of the lower lid. This criss-cross drill-hole xation is commonly
used in conjunction with the other reconstructive procedures.
Vertical Reanchoring of the Inferior Orbicularis Muscle
The redraping upward of the inferior arc of the orbicularis, with tightening and
rm attachment to the temporal fascia, will add support to the lower lid.11
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Chapter 20
Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
The skin is recruited upward into the lower lid with vertical reanchoring of the in-
ferior arc of the orbicularis muscle.

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PART III
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Vertical reanchoring of the orbicularis muscle is demonstrated, with recruitment of
skin into the lower lid. Reanchoring the orbicularis also acts as the supportive sling
for lower lid repositioning.The vector of orbicularis anchoring is performed in ac-
cordance with eye prominence. A more vertical vector of xation, to the temporal
fascia and periosteum, is used when more skin recruitment is required and in pa-
tients with more prominent eyes.
Orbicularis reanchoring is usually combined with canthal reanchoring as described
above. One may use a more limited orbicularis dissection and reanchoring in milder
cases of lower lid retraction in which the skin shortage is not severe.