Revision blepharoplasty

What it treats

• Postblepharoplasty lower lid retraction: in a review of 111 patients after lower-lid blepharoplasty, 15% showed some degree of lower-lid retraction, linked to preoperative lid laxity and the amount of skin excised (PMID 1892615).
• Retraction is multifactorial: vertical shortage of the anterior lamella, scarring of the middle lamella, or posterior lamella deficiency can each contribute, and surgical correction is difficult and unpredictable (PMID 31587762).
• Sunken upper eyelid after a primary operation is common in Asian patients, usually from aging combined with excessive orbital fat removal during the original blepharoplasty (PMID 28619482).
• Asian blepharoplasty carries a relatively high complication rate; of 168 revisions by one surgeon, 36 (21%) were revisions of a previously failed revision, most often for ptosis, asymmetric creases, supratarsal depression, or a high or short crease (PMID 15457048).
• Patients are dissatisfied after upper eyelid surgery for a range of reasons: scar, a low or high fold, a shallow or deep fold, triple folds, pretarsal fullness, ptosis, and asymmetry (PMID 26306087).
• High placement of the lid crease is a common complication of upper eyelid surgery and a frequent reason for revision (PMID 30276454).
• See canthal anatomy and prevention of retraction in canthoplasty and canthopexy, and primary-operation technique in upper blepharoplasty and lower blepharoplasty.

How it is done

Spacer grafts for lower lid retraction

• Graft materials include autogenous hard palate mucosa, acellular dermis, conchal cartilage, dermis-fat, and porcine dermal collagen matrix (PMID 1390426), (PMID 2648423), (PMID 20562664), (PMID 30817645).
• Contraction differs by material: mean graft contraction was 57% for acellular dermis against 16% for hard palate mucosa in 19 grafts placed in 14 patients (P<0.005) (PMID 12544789).
• A comparison of 35 acellular dermis and 25 hard palate grafts found no statistically significant difference in eyelid elevation, with a trend toward better elevation and a lower failure rate with hard palate (P=0.121, P=0.092) (PMID 16141830).
• Dermis grafts and conchal cartilage grafts gave similar reduction in scleral show, lagophthalmos, and keratitis in 25 eyelids of 23 patients (PMID 32530712).
• An American Academy of Ophthalmology review of bioengineered acellular dermal matrix spacer grafts found a surgeon-reported success rate of 75-100% across studies, with reoperation in 27 of 526 implants (5%) (PMID 31899031).
• Some surgeons omit the internal spacer graft: in 11 patients (17 procedures) treated without one, mean marginal reflex distance improved 2.2 mm, with a midface lift performed in 14 of 17 eyelids (PMID 27590867).
• Placing a spacer graft at the time of the primary lower lid blepharoplasty in 15 high-risk patients (exophthalmometry over 17) resulted in retraction at 2 years in 2 patients, none immediately (PMID 37326309).

Midface lift

• A preperiosteal midface lift with canthoplasty via a lateral canthal incision in 28 patients (56 eyes) reduced average inferior scleral show from 1.96 mm to a postoperative position of +0.07 mm above the limbus; 2 patients needed canthal revision (PMID 20489542).
• An endoscopic subperiosteal midface lift in 22 patients (39 sides) was graded excellent in 61% and good in 26%; 26% of sides were operated for postblepharoplasty retraction (PMID 12352817).
• Supraperiosteal fat repositioning with midface lift in 1,152 Asian patients (2,304 eyes) over 18 years produced lower lid ectropion needing lateral tarsal strip in 0.6% and revision for residual fat in 0.7% (PMID 38353810).
• A cheek-midface lift is described as the corrective method for iatrogenic ectropion after excessive lower lid blepharoplasty, replacing free skin grafting (PMID 30519739).
• Endoscopic orbicularis repositioning combined with midface elevation in 300 patients treated the difficult lower lid with no cases of postoperative retraction; additional suture points were needed in 12% (PMID 22929253).

Canthal support and crease revision

• Lateral canthal support (canthopexy, canthoplasty, orbicularis suspension) added routinely to primary transcutaneous lower blepharoplasty in 264 patients still left lid malposition needing correction in 3.5% (PMID 18176227).
• A modified lateral tarsal strip restored canthal anatomy in 15 patients (25 eyelids) after failed aesthetic lateral canthoplasty, with a significant improvement in palpebral aperture and canthal angle (P<0.001) (PMID 37622520).
• Correction of the high eyelid fold with a pretarsal orbicularis oculi flap in 31 patients gave satisfactory results in 83.9%; 12.9% had mild asymmetry and 3.2% needed further revision (PMID 30245018).
• Retro-orbicularis oculi fat (ROOF) transposition corrected the high fold in 58 of 206 secondary blepharoplasty cases classed as difficult, with 89.66% satisfaction and no infection, dehiscence, or levator dysfunction (PMID 36913561).
• A free-style design for low in-fold or out-fold creases in 297 secondary blepharoplasty patients gave 89.6% satisfaction; complications included complete crease loss (1.0%), partial crease loss (1.7%), and asymmetric creases (2.4%) (PMID 37027031).
• An orbicularis-fascia-aponeurosis fixation approach treated the "sausage phenomenon" of pretarsal bulge in 68 patients; FACE-Q scores rose from 66 to 90 (P<0.01), and 6 patients needed further revision (PMID 37991537).

Hollowing and fat grafting

• An orbital fat transposition flap or dermofat graft corrected sunken upper eyelids in 60 patients; 3 patients underwent further revision surgery (PMID 28619482).
• Microfat injection into the infraorbital groove after lower blepharoplasty in 50 patients left 46 satisfied or very satisfied; 5 developed mild ectropion that recovered without treatment (PMID 31866148).
• Combined orbital fat repositioning and microfragmented fat grafting for upper eyelid hollowing in 35 patients (70 eyelids) gave 97.14% satisfaction with no major complications (PMID 41939494).
• A "pendulum" technique moving orbital fat and retro-orbicularis oculi fat corrected sunken eyelid deformity after Asian upper blepharoplasty in 49 patients; 95.9% had improved aesthetic rating and 93.9% were satisfied (PMID 38315230).
• A preseptal orbicularis oculi muscle flap corrected superior sulcus hollowness in 45 of 481 upper blepharoplasty patients; in the conventional-technique comparison group, 16 patients developed medial canthal scarring (4 needing revision), while the flap group had transient supraorbital hypoesthesia in 71%, resolving within months, with no flap necrosis (PMID 42332315).

Results and evidence

• A systematic review of 15 studies (709 patients, 855 eyelids) on lower eyelid malposition found modifications of the lateral tarsal strip had the highest success and lowest recurrence among the techniques studied (PMID 39631150).
• "Standard" surgery for postblepharoplasty retraction is described as the combination of midface lift, posterior lamellar spacer graft, and canthal suspension, producing variable functional and cosmetic gains (PMID 31587762).
• A hand-carved expanded polytetrafluoroethylene implant fixed with microscrews plus a hard palate graft is proposed to avoid the tension on lateral canthoplasty that causes other techniques to fail (PMID 33906761).
• Lowering a high lid crease in 69 patients (100 eyes) reduced moderate-or-severe crease asymmetry from 81.1% preoperatively to 6.7% at 2 years, and moderate-or-severe lid height asymmetry from 64.5% to 4.5% at 1 year (PMID 30276454).
• Conchal cartilage or composite auricular grafts gave stable lower lid support in all 33 patients in the original 1989 series, with reepithelialization of exposed cartilage complete by 3.5 weeks (PMID 2648423).

Risks and complications

• The McCord lateral canthal tendon procedure for ectropion, used after blepharoplasty, required lid position revision in 6 of 77 patients and produced a canthal granuloma in 4 (PMID 6342584).
• Acellular dermis used for a mildly contracted socket had a high failure rate: more than 60% of 5 such cases had only partial success or failure from graft contraction, against consistent success with hard palate mucosa in the same indication (PMID 12544789).
• Complications after primary lower blepharoplasty with routine canthal support in 264 patients included chemosis in 12.1% and minor revisions unrelated to lid malposition in 11.7% (PMID 18176227).
• Revision after upper blepharoplasty with ptosis correction was 9.2%, against 3.8% for blepharoplasty alone, in a 278-patient series (PMID 38315110).
• New dry eye lasting 3 months or longer affected 0.8% of 533 upper blepharoplasties in the same series (PMID 38315110).

Recovery

• Functional gains after spacer-graft and midface-lift revision (scleral show, epiphora, corneal staining) were assessed at 12-18 months of follow-up and had resolved in all eyes by that point in one series (PMID 20489542).
• Reepithelialization of an exposed conchal cartilage graft against the conjunctiva was complete within 3.5 weeks in nearly all cases (PMID 2648423).
• Crease-revision series followed patients from 6 months to 4 years; results were graded stable by 8.2 months' mean follow-up in one pretarsal-flap series and by 12.3 months in an individualized-design series (PMID 30245018), (PMID 37027031).

Combined procedures

• Postblepharoplasty lower lid retraction repair is commonly combined with midface lifting and canthal suspension in the same operation (PMID 31587762).
• Endoscopic subperiosteal midface lift indications included facial rejuvenation (41% of sides), postblepharoplasty retraction (26%), midfacial-ptosis-related retraction (15%), severe cicatricial ectropion (13%), and paralytic ectropion (5%) in the same 39-side series (PMID 12352817).
• Brow position and tear trough anatomy, both relevant when planning a revision, are covered in upper blepharoplasty and tear trough and lid-cheek junction surgery.

Current questions

• Graft material for lower lid spacers remains unsettled: hard palate contracts less than acellular dermis in one trial (PMID 12544789), but a separate comparison found no significant difference in final elevation (PMID 16141830).
• Whether an internal spacer graft is required at all is debated: a small series without one showed improvement in all patients (PMID 27590867), while a bioengineered acellular dermal matrix review still reported 5% reoperation (PMID 31899031).
• Individualized crease design tailored to in-fold versus out-fold preference is a recent focus in secondary Asian blepharoplasty (PMID 37027031).
• Superior sulcus hollowing after upper blepharoplasty is increasingly treated with local orbicularis flaps instead of fat grafting to avoid graft atrophy and embolic risk, though the supporting series remains small (45 patients) (PMID 42332315).

Terms

• Lower lid retraction: the lower eyelid margin pulled below its normal position, exposing sclera (PMID 1892615).
• Spacer graft: tissue placed in the posterior lamella of the lower lid to lengthen it and correct retraction (PMID 31899031).
• Hard palate mucosa graft: a firm, keratinized graft taken from the roof of the mouth, used as a spacer (PMID 1390426).
• Acellular dermal matrix (ADM): processed donor or bioengineered dermis used as a spacer graft (PMID 31899031).
• Midface lift: elevation of the cheek soft tissue to support the lower lid and reduce the gravitational pull on it (PMID 20489542).
• Canthopexy/canthoplasty: suture suspension or surgical shortening of the lateral canthal tendon to support the lower lid (PMID 18176227).
• Sunken (hollow) upper eyelid: volume loss in the upper lid, often from excess fat removal during the original blepharoplasty (PMID 28619482).
• High crease: an upper eyelid crease positioned higher than intended, a common reason for revision (PMID 30276454).
• Marginal reflex distance (MRD): distance from the corneal light reflex to the eyelid margin, used to measure lid position (PMID 27590867).
• Retro-orbicularis oculi fat (ROOF): a fat layer beneath the orbicularis muscle used in some revision techniques to restore volume (PMID 36913561).

Papers