Transconjunctival, Sublabial, and Temporal Subperiosteal Approach Midface-Lift for Persistent Lower Eyelid Retraction after Blepharoplasty

Abstract

Purpose: To define a subgroup of postblepharoplasty patients with persistent lower eyelid retraction despite attempted lower eyelid reconstruction and midface-lifting, and to propose a revisional midface-lifting procedure to address complex cicatricial patterns in these patients. Methods: This is a retrospective observational case series of consecutive patients with bilateral persistent cicatricial lagophthalmos from lower blepharoplasty despite prior lower eyelid reconstruction and midface-lifting. An approach for midface-lifting and lower eyelid reconstruction was designed that consisted of transconjunctival, sublabial, and temporal approaches to the subperiosteal space with manual distraction cicatricial scar matrix lysis. Routine postoperative evaluation of clinical outcome, safety, patient satisfaction, and photographic analysis was performed. Results: A total of 8 patients who underwent revisional midface-lift surgery (15 ipsilateral surgeries) were identified. In all 15 cases, a 3-dimensional cicatricial matrix was identified that involved the lower eyelid and midface and limited visual exposure of the subperiosteal space and mobility of the midface despite complete subperiosteal release to the sublabial incision. Manual anterior distraction of the midface via the sublabial incision provided a mechanism for lysis of the cicatricial matrix. Improved midface mobility allowed successful vertical fixation with maximal anterior lamellar recruitment and lower eyelid support. No complications were encountered. All patients reported improvement in cosmesis and ocular comfort. Average improvements in lower margin to reflex distance (MRD2) was 0.9 mm, scleral show was 0.8 mm, palpebral fissure height at the medial limbus was 1.2 mm, and palpebral fissure height at the lateral limbus was 1.2 mm. Conclusion: Patients who presented with postblepharoplasty cicatricial lagophthalmos after unsuccessful lower eyelid reconstruction, including midface-lifting, may have a complex 3-dimensional cicatricial matrix involving the lower eyelid and midface. A combined transconjunctival, sublabial, and temporal subperiosteal approach with manual scar matrix release for midface elevation and lower eyelid support is a safe and effective management paradigm.