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Lower eyelid retraction is a condition where the eyelid sits too low on the eye. Normally, the lower eyelid sits right at the colored part of the eye called the iris or covers it slightly. Retracted eyelid is pulled down, which results in a rounded appearance of the eye rather than a more natural, “almond” shape. Prior surgery, trauma, thyroid disease or facial paralysis can lead to the eyelid sagging exposing more of the white part of the eye called the sclera. This condition is different from ectropion, where the eyelid is pulled outward, away from the eye. Eyelid retraction can cause irritation, discomfort, tearing, crusting and eventual compromise of vision. Lower eyelid retraction can be diagnosed by physical examination and treatments vary depending on how much the symptoms bothers you. Conservative treatment like ointments and taping the eye closed at night may improve symptoms.
Surgery is only treatment that can be used to bring the eyelid back to its normal level. Surgery depends on the cause and amount of scar tissue causing the retraction itself. If there was loss of the inside of the eyelid due to trauma or scar, it may need to be substituted by similar tissue from another site of the body. If scar tissue from prior injury or surgery is contributing to eyelid retraction, grafting of either skin, cartilage or the inner lining of the mouth may be necessary to restore proper eyelid function. Both age-related correction or facial paralysis correction may include lifting the middle third of the face that has fallen (midface lift) and pulled the lower lid inferiorly. Loose tendons can be tightened and repositioned to restore normal eyelid shape and function (lateral tarsal strip, horizontal eyelid shortening, canthopexy and canthoplasty). If tendons cannot be tightened, another tendon can be borrowed from a different location in the body to recreate eyelid support (tendon transfer procedures). Age-related correction may need to lift the middle third of the face that sagged due to aging or facial paralysis if it is contributing to the problem (midface lift). After surgery, the eyelid will feel and look tighter to the eye and symptoms should improve or resolve as the eyelid heals completely.
Some patients may notice your eye feeling drier and more of the white part of the eye below the colored iris showing. This will lead many patients to see their doctor. Severe eye irritation can lead to inflammation and corneal (outer surface of the eye) scratches. Repeat corneal trauma can result in ulcerations, infections and eventually, decreased vision. Conservative medical treatment like eye lubricating drops and ointments may improve symptoms but will not correct the droopy eyelid. When the irritating symptoms of ectropion bother you enough then it is time to go for a surgical evaluation for lower eyelid retraction repair. Likewise, when the increased appearance of white part of the eye begins to bother you, then a surgical evaluation could be performed. If you are bothered by puffy eyes or loose skin under the eyes, then this is a good time to bring this up with the surgeon as they can be addressed at the same time as the lower eyelid retraction.
An eye exam will document the condition of the eyes before surgery. You will need a full vision check from your Ophthalmologist prior to any eyelid surgery. Our doctor will discuss the procedure with you including risks, benefits and alternative treatments. They will review your medications including herbal and over-the-counter drugs and supplements. Many herbal products and pain relievers make it harder for you blood to clot and should be discontinued before surgery. You will sign informed consents and get your instructions for before and after surgery.
You will see your own personal physician for a medical clearance to make sure they feel it is safe for you to have surgery. Your physician may order laboratory blood tests, an EKG or a chest X-ray. You need to stop smoking as this delays healing. You should have nothing to eat or drink after midnight before your procedure. You will be told when to arrive at the surgery center before your surgery. You are signed in, change into a gown, given an IV, and talk to the nurse and anesthesiologist. You will then talk to your surgeon before you get any medication at the hospital so you can ask questions.
You are taken in to the operating room, lie down on your back, and the anesthesiologist will put you to sleep with a breathing tube to make sure your airway is safe. The area to be operated on is sterilely prepared with a cleaning solution and drapes. A local anesthetic is injected to decrease bleeding and discomfort. Both eyes are usually protected with special lubricating ointment and a special contact lens during surgery. Protection of both eyes is necessary because we use the unaffected eye to create symmetry.
Frequently to repair lower eyelid retraction, surgery requires borrowing of the materials from the other sites in the body (donor sites). Borrowing materials from donor sites does not affect their long-term function significantly, but it does add to the recovery time, because each donor site will have its own healing timeline. Common donor sites are the roof of the mouth or the inside of the cheek. During initial recovery time, you may need to consume soft foods only. Sometimes, skin grafts are also required in cases of revision surgery. Skin grafts are usually taken from upper eyelid (upper blepharoplasty) or either in front or behind the ear with a hidden scar.
If the eyelid is loose after elevation, the lower eyelid will need to also be tightened by tightening the tendon support and re-creating eyelid shape and angle of the eye (lateral tarsal strip, canthopexy and canthoplasty). If performed, midface lifting is approached from the inside of the eyelid for a more natural appearance.
Rarely, tendons around the eye cannot be tightened and a substitute needs to be borrowed from another site of the body. These tendons to substitute eyelid support can be borrowed from the non-dominant hand (palmaris longus muscle), outer thigh (tensor fascia lata) or rarely leg (plantaris longus) and transplanted to support the eyelid. Donor site care instructions will be given and usually involve wearing a special wrap around the arm, thigh or leg for 7-10 days.
The outer angle of the eye is purposely repositioned a little higher and always tighter than before surgery to keep the eyelid against the eye so that we account for a natural stretching of the lateral canthal tendon over the 6 months. This restores proper function and a more natural appearance. After eyelid repositioning, the skin is closed and special tapes are placed around the incision to support the eyelids. These tapes have to stay dry for a minimum of 48 hours.
You are taken to the waiting room and watched to make sure you are recovering from anesthesia well. Because lower eyelid retraction surgery is considered a minimally invasive procedure, you may go home the same day. You need someone to bring you home from the surgery center to make sure you get home safely.
The procedure is not very painful, but you may take oral pain medicine the doctor has given you or acetaminophen (Tylenol). If you need a narcotic pain medicine you should take them with food in your stomach and start on a mild stool softener like Senna. You will be often given antibiotic and moisturizing eyedrops for use during the day and an ointment to place between your eyelids at night. Frequently, your doctor will prescribe antibiotics especially if complex repair with borrowing tissues was undertaking. Keeping your head elevated will decrease pressure on the incision.
You should take it easy for at least one week and your doctor will let you know what level of activity you can resume. Call your doctor if you have increasing redness of the incision, sudden change in vision, fever, bleeding, pus, drainage, the incision opens or you have worsening pain. Also, let your doctor know if you have any other concerns. You will see your doctor the week after surgery and sutures will be removed. You usually can be performing normal activities within two weeks of surgery.
The risks of your lower eyelid retraction surgery will vary depending on how severe your condition is, number of donor sites, and what other medical conditions you have. The general risks of any lower lid surgery include bleeding, infection, dry eyes, eye irritation, difficulty with eye closure, visible scarring or skin discoloration, eye muscle injury, the need for additional surgery, chronic pain, numbness, temporary blurry vision or rare vision loss and risks of general anesthesia. Preparing for surgery and following your doctor’s instructions are useful to help minimize risks.
The Surgeons of Norelle Health are highly trained and skilled in the diagnosis, management, and treatment of lower eyelid retraction. Dr. Araslanova can provide the optimal treatment for lower eyelid retraction. Moderate to severe lower eyelid retraction causing symptoms may be covered by your insurance although most insurances consider milder ectropion to be cosmetic . As out-of-network providers, we will check your benefits for you and let you know if there are costs are so there are no surprises. We use an individualized treatment plan for your concerns to provide a personalized holistic plan of care. If you would like assistance, please feel free to contact us.