The lower eyelid is like a washing line held in position at the inner & outer corners of the eyelid.
Aging changes weaken eyelid tissues and peri-ocular muscles, thus affecting the tautness of this structure, and causing an alteration in its form & function.
What is considered the proper lower eyelid position?
A correctly positioned lower eyelid will protect the eye and help maintain its health and comfort. For a majority of people, this lid margin position in relation to the cornea resembles a “Sun on the horizon”. The outer corner should be two millimeters higher than the inner corner. All four eyelids should interface appropriately with the eye and act as smooth “windshield wipers,” evenly spreading the moisturizing tears we produce across the exposed surface. This bathes the eye continuously, which is essential for eye health and to maintain vision.
A sagging lower eyelid fails to remain in contact with the eyeball and leaves the surface of the eye and eyelid exposed and dry. This causes the tears to pool and the eye to water persistently. Eyelid malposition’s can also occur due to shortage of skin and or scarring of the middle layer of the lower lid, as a complication of cosmetic blepharoplasty, and from scarring of the eyelid skin due to injury, especially burns or road traffic accidents, which causes the lid to turn outwards or sag.
An Ectropion is an outwardly turned or sagging lower eyelid, and an Entropion is a condition in which the eyelid turns inward, resulting in the eyelashes touching the surface of the eye causing discomfort.
What methods are available to correct a sagging or retracted lower lid?
To raise the lower eyelids into the correct position, skin grafts or flaps are placed on the visible skin surface of the lower eyelid to lengthen it, along with tightening the lower lid by stitching it at the outer corner. Skin grafts are almost never well matched to the surrounding eyelid skin and therefore are very rarely aesthetically pleasing, particularly for patients concerned about their appearance. If the eyeball position is prominent, tightening of the eyelid at the outer corner is not usually successful and can cause the lower eyelid to fall even lower, much like a man with a protruding belly, tightening his belt, resulting in his trousers being secured lower on the bulge of his belly rather than higher. Thus to obtain the slack needed to raise the lower eyelid, the entire cheek and mid face is raised. This raising is done through a tiny incision at the outer corner of the eyelid in the natural smile crease. Scarring from the previous surgery or surgeries is removed, and adhered layers are separated. A graft is then placed on the inside of the lower eyelid (rather than placing an aesthetically unpleasing skin graft on the outside of the eyelid). This inner eyelid graft can be an free tarsal graft (from the upper lid) or a hard palate graft and acts as a permanent and supple stent or support. Fat (which is harvested from the abdomen) may be necessary to fill in any hollowness of the lower eyelid area that is not filled in by the raising of the cheek and mid face. The lower eyelid is then reconstructed and redraped in the ideal structural, functional and aesthetic position. The only incision made is the tiny incision at the outer corner of the eye, concealed in a natural smile crease and virtually invisible.
What are the potential risks & complication of eyelid surgery?
Minor bruising or swelling, which settles in 3 -6 weeks can be expected. Bleeding and infection, which are potential risks with any surgery, are very uncommon. Occasionally the outer corner of the eyelid may look a bit smaller than before – the so called “Chinese eyed” appearance, generally this tends to correct itself over 4-12 weeks. The eyelid malposition can recur over time.