Thank you for your question.
You submitted a question with two photos of which appears to be a before and after.
You had undergone lower eyelid blepharoplasty approximately 2 years ago.
And you stated in your question that you developed eyelid retraction and that you’ve gone to
a doctor who recommended a skin graft procedure.
And you’ve asked several questions related to the appearance, the healing, the wrinkles
as well as the weight of the skin graft after the surgery.
Well, I can certainly share with you my approach when it comes to dealing with lower eyelid
retraction after cosmetic eyelid surgery.
A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial
plastic and reconstructive surgeon.
I have been in practice in Manhattan and Long Island for over 20 years.
And I have been well-known for helping people who have complications of eyelid surgery,
in particular, lower eyelid retraction.
In fact, patients come to our practice from around the world with exactly this issue and
many complexities and I’ll discuss with you my overall approach.
So with this understanding, I’d like to help you get a sense of the anatomy that is
relevant to this issue of lower eyelid retraction and how I make the decision about the appropriateness
of the skin graft.
To begin with, lower eyelid surgery has always been a procedure that is deceptively complicated.
And the reason is that traditional eyelid surgery which is basically taught to most
general plastic surgeons as the “go to” operation is the transcutaneous lower eyelid
blepharoplasty.
That means going at the outside, making an incision underneath the eyelashes, extending
it a little beyond or outside of the outer corner lateral canthus and addressing fat
pockets etc. and then taking away some skin with the desirable outcome of improving wrinkles.
Very commonly, patients will have rounding of the under eye or retraction of the lower
eyelid.
So when we look at the structure of the lower eyelid, there are some key elements that essentially
get disrupted routinely in this type of surgery that are usually not addressed in the restoration
of the eyelid after the surgical procedure is completed.
So there are 3 basic elements: one is the lateral canthal tendon which is the tendon
that holds the eyelid to the bone.
Then there’s an area called the posterior and middle lamella of the eyelid which act
like pillars that support the lower eyelid.
And then there’s the anterior lamella which is the skin, muscle in front of the eyelid.
Now the muscle in front of the eyelid is called the orbicularis muscle and acts like a hammock
or sling that keeps the eyelid in place.
When I see what appears to be a younger appearing lower eyelid, I am often challenged by the
issues of placing skin grafts.
When you are dealing with a younger person with eyelid retraction, I try to do everything
I can to avoid the skin graft if possible.
And how is that possible?
Well, one of the ways I approach the eyelid is of course I establish by examination the
elasticity of the lower eyelid.
And what I’ll do is I’ll take the lower eyelid and I’ll push it upward.
If the eyelid is able to move several millimeters as close to the original position without
putting tension on the skin then we’re in a position where we could probably avoid a
skin graft.
So what I would then do is I would do something called a posterior or middle lamella graft
and that’s putting tissue behind the eyelid to act as a support to provide vertical support
to the eyelid.
And then as well as restore the lateral canthal tendon or essentially, re-suspend, fixate
if necessary, the lateral canthal tendon which is usually necessary in order to provide the
remaining support.
Now in some scenarios, when the skin is on a little bit of tension and it needs a skin
graft then skin graft is necessary.
What I try to do is minimize the size of the skin graft.
Now as far as the issue of the physical weight of the skin graft, it’s generally not an
issue.
It’s more about the appearance of the skin graft.
And I always explain to my patients that the skin graft appearance can be prominent in
the beginning and it can be customized and tailored to minimally just the right amount
so you don’t have excess.
And that’s part of the art and that’s part of the strategy.
And once that skin is in, what we do in our practice, we use a lot of different techniques
particularly in the regenerative medicine field where we use something called platelet-rich
plasma (PRP) and extracellular matrix which is advanced wound healing that does help facilitate
the healing process of all the grafts that are all involved in lower eyelid retraction
repair.
And it has been quite helpful in expediting the outcome in terms of the rapidity of healing
as well as improving the aesthetic appearance.
Beyond that, the skin graft can also be improved through additional PRP injections, lasers
and other modalities.
So it becomes a challenge in a situation like yours to decide how much is it worth to bring
the lower eyelid up relative to the aesthetics of adding skin from the outside.
It might be that getting 1 or 2 millimeters of elevation or restoration of shape and getting
a little bit closer may be adequate.
I’ve been impressed certainly by situations where I’ve put a graft behind the eyelid
and I was able to get the vertical height that I wanted.
Now on some people, I’ve done things to help stretch the skin and do things to maybe
reduce the necessity of the skin graft but that requires a physical exam in order to
determine this.
So with due respect to the doctor who you saw for the skin graft, I think it’s advisable
for you to get additional opinions from oculofacial plastic and reconstructive surgeons particularly
surgeons who do a lot of revision eyelid surgery for cosmetic surgery and get that sense of
what would be right for you.
It’s very important that you take the right next step to minimize the number of surgeries
you need.
We’ve had patients who have come to us who had 11 operations before coming to see me
and in those situations, I’ve actually had to do tissue rehabilitation to make the tissue
healthy enough before I was able to do additional surgery and that’s basically unfortunate.
Sometimes what happens, because a lot of operations get done as little patch work approaches,
I’m not saying that the skin graft is not a good definitive operation but it may not
be adequate because when you think of the anatomy, the skin graft is actually approaching
the front but what about what’s happening from behind?
Will that be adequate enough long-term?
A lot of times, the eyelid can look good at the beginning but may sag because of lack
of support in the middle lamella.
Again, this might be getting a little bit overly technical but it’s important to get
at least a better sense of the principles.
So I hope that was helpful, I wish you the best of luck and thank you for your question.