Lower Eyelid Malposition Research Articles

Applied Anatomy of the Lower Eyelid Preseptal Space for Treating Ectropion and Retraction with Soft-Tissue Fillers.

Lower eyelid malposition can result from age-related changes, such as ectropion, or postsurgical changes, such as retraction after lower lid blepharoplasty. The current accepted treatment is surgical, but soft-tissue fillers have been used as well, with good outcome. The underlying anatomy, which is incompletely described, would be useful information for practitioners desiring to provide minimally invasive injections of the lower eyelid. The authors describe a minimally invasive injection technique adjusted to the complex anatomy of the lower eyelid for the treatment of ectropion and retraction of the lower eyelid. A total of 39 periorbital regions of 31 study participants were retrospectively analyzed using photographs before and after reconstruction of the lower eyelid with soft-tissue fillers. Two independent raters assessed the degree of ectropion and lower eyelid retraction (0 to 4, best to worst) before and after the reconstruction and the overall aesthetic improvement using the Periorbital Aesthetic Improvement Scale. The median degree of ectropion and lower eyelid retraction score improved statistically significantly from 3.00 (SD, 1.5) to 1.00 (SD, 1.0) ( P < 0.001). The mean volume of soft-tissue filler material applied per eyelid was 0.73 cc (SD, 0.5). The median Periorbital Aesthetic Improvement Scale score after the treatment was rated as 4.00 (SD, 0.5), indicating improvement of the periorbital functional and appearance. Anatomic knowledge of the lower eyelid and of the preseptal space is of clinical relevance when reconstructing the lower eyelid with soft-tissue fillers. The targeted space provides optimal lifting capacities for improved aesthetic and functional outcome. Therapeutic, IV.

Ageing increases risk of lower eyelid malposition after primary orbital fracture reconstruction

Lower eyelid malposition (LEM) is a common sequela after orbital fracture reconstruction. This study aimed to analyse the development of LEM, specifically ectropion and entropion, following primary orbital fracture reconstruction, to identify predictive factors for LEM, and to assess the effect of the eyelid complication on patients’ daily lives. The retrospective cohort comprised patients who had undergone orbital floor and/or medial wall fracture reconstruction for recent trauma. Demographics, fracture type and site, surgery and implant-related variables, follow-up time and number of visits, type and severity of LEM, subsequent surgical correction, and patient satisfaction, were analysed. The overall occurrence of LEM was 8%, with ectropion in 6% and entropion in 2% of patients. Older age, complex fractures, transcutaneous approaches, preoperative traumatic lower lid wounds, and implant material were associated with the development of LEM. Of all patients, 3% needed surgical correction of LEM. Six of the 13 patients (46%) who developed LEM required surgical correction. The transconjunctival approach and patient-specific implants should be preferred, especially in elderly patients and those with more complex fractures. LEM often requires subsequent surgical correction, and the treatment period is substantially prolonged, with multiple extra visits to the clinic.

A Combination of Three-Step Lower Blepharoplasty to Correct Four Types of Lower Eyelid Deformities in Asian People.

This study aimed to propose a novel four-type deformity and treatment-oriented classification of the lower eyelids that directs the therapeutic combination of three-step lower blepharoplasty for Asian populations. We reviewed 183 patients who underwent a therapeutic combination of three steps of lower blepharoplasty after being diagnosed with four types of lower eyelid deformities between July 2018 and April 2021. The three-step lower blepharoplasty includes: (1) mid-face and lower eyelid augmentation, (2) transconjunctival eye bag removal, and (3) skin pinch removal. Consecutive digital images, detailed fat graft volume, fat removal amount, skin pinch removal amount, complications, and patient's satisfaction and aesthetic improvement score were recorded. The overall patient's satisfy score is 91. Aesthetic improvement score is 80.2 and 83.3 among lay persons and experts, respectively. The volume of the fat graft ranges from 2 to 3 mL per orbit according to the severity of the deformity. The amount of fat removed was 0.53 ± 0.36 and 0.61 ± 0.40 mL per orbit in types II and III patients, respectively. There is no lower lid malposition. Eleven patients had over-correction of fat grafting, and they need steroid injection; 20 patients had under-correction of fat grafting, and they need secondary fat grafting. Ten patients need secondary skin pinch excision due to post-op skin redundancy. Two patients had conjunctiva wound granuloma. The combination of three-step lower blepharoplasty according to the novel classification is a straightforward and effective method to correct lower eyelid deformities. The complication rate was low with high patient satisfaction. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Revisiting Lateral tarsal strip procedure for correction of late lower eyelid malposition following lower blepharoplasty

Revisiting Lateral tarsal strip procedure for correction of late lower eyelid malposition following lower blepharoplasty

Outcomes of XEN Gel Stent Implantation in the Inferonasal Quadrant after Failed Trabeculectomy.

Aim and objectiveTo evaluate the efficacy and safety of XEN stent implantation in the inferonasal quadrant after prior failed trabeculectomy.Materials and methodsFourteen open-angle glaucoma patients with prior failed trabeculectomy were recruited to this retrospective study. Implantation of the stent was performed as a stand-alone procedure. The mean follow-up duration was 14.2 months. Best-corrected visual acuity, intraocular pressure (IOP), number of medications, complications, and the requirement for additional procedures were among the outcome measures recorded.ResultsMean IOP reduced by 49.3% from 24.14 ± 2.74 mm Hg preoperatively to 12.23 ± 2.89 mm Hg at month 12 (p < 0.001). Medication usage reduced from 3.71 ± 0.47 medications preoperatively to 1.31 ± 1.55 at month 12 (p = 0.003). Adverse events included transient slight intracameral hemorrhage (5 eyes, 35.7%), second trabeculectomy required (2 eyes, 14.3%), and numerical hypotony (IOP <5 mm Hg, in 3 cases, 21.4%), all of which resolved spontaneously. Six eyes (42.8%) required postoperative bleb needling to further reduce IOP. There were no cases of vision loss, stent exposure, hypotony, lower eyelid malposition, bleb dysesthesia, or bleb-related infection.ConclusionXEN gel stent implantation in the inferonasal quadrant can be considered a viable surgical option for patients with a history of previously failed trabeculectomy requiring further IOP lowering.Clinical significanceTo the best of our knowledge, this is the first case series describing the outcome of inferonasal implantation of XEN gel stent following failed trabeculectomy.How to cite this articleDüzgün E, Olgun A, Karapapak M, et al. Outcomes of XEN Gel Stent Implantation in the Inferonasal Quadrant after Failed Trabeculectomy. J Curr Glaucoma Pract 2021;15(2):64–69.

An Update on Subciliary Lower Eyelid Blepharoplasty.

The subciliary lower eyelid blepharoplasty has evolved considerably to create a more harmonious natural appearance with a fuller and unoperated look and also to minimize the complications. While lower eyelid malposition was very common in the past, now this complication is significantly reduced by attention to preoperative evaluation, meticulous surgical planning, precise surgical technique, and postoperative care. Various prophylactic maneuvers maintaining/strengthening lower lid support can be utilized to prevent lower lid malposition including preservation of the pretarsal orbicularis oculi muscle, conservative resection of skin and muscle, and suspension of the orbicularis oculi muscle and/or tarsus to the periosteum of the lateral orbital rim. The release of the orbicularis retaining ligament and surgical transposition of orbital fat over the rim rather than excision allows for smoothing of the lid-cheek junction, filling the tear trough deformity, and reducing the appearance of bulging fat in the lower eyelid. In this article the reader will find a comprehensive approach for achieving a smooth contour with gradual blending at the lower eyelid-cheek junction while maintaining/restoring normal lower lid support. A descriptive outline of postoperative care is also provided to help in optimal healing for the patient.

Lower eyelid malposition following repair of complex orbitofacial trauma

ABSTRACT Purpose To compare the incidence of lower eyelid malposition following repair of isolated orbital floor fractures with that of complex orbitofacial fractures (defined as multi-wall fractures or prior orbital fracture repairs requiring revision) by oculofacial plastic surgeons via a transconjunctival or swinging eyelid approach. Methods Retrospective review of 175 patients who underwent surgical repair of orbital fractures at our institution. The primary outcomes were the occurrence of lower eyelid malposition (ectropion, entropion, and eyelid retraction) and the need for subsequent surgical correction. Results Of 95 patients with isolated orbital floor fractures, 4 developed eyelid malposition (4.2%), 1 of which required surgical repair (1.1%). Of 80 patients with complex orbitofacial fractures (48 multi-wall fractures, 32 secondary revisions), 10 had pre-operative eyelid malposition and were excluded from further analysis. Fourteen of the remaining 70 patients developed postoperative eyelid malposition (20%), 3 of which required surgical repair (4.3%). The difference in the occurrence of eyelid malposition between groups was statistically significant (p = .001), but the difference in rates of those requiring subsequent repair was not (p = .182). There was no statistically significant difference in the occurrence of eyelid malposition when considering other surgical factors including lateral canthotomy, conjunctival closure, implant material, or anterior rim screws. Conclusions The incidence of lower eyelid malposition following orbital fracture repair via a fornix-based approach was significantly higher for the repair of complex orbitofacial fractures than for isolated floor fractures. However, very few patients in either group required surgical repair for eyelid malposition. Surgical factors including implant material did not affect outcomes.

Lateral Canthopexy in Lower Blepharoplasty: A Review Literature

Background: Lower eyelid malposition is a known complication of lower (lid) blepharoplasty surgery.The prevention of this complication is easier than its treatment. Over the past 10 years lot of patients havehad lower blepharoplasties with a canthopexy procedure and in some cases a tarsal strip canthoplasty. Thecriterion for a lateral tarsal strip canthoplasty was a lid distraction distance greater than or equal to 10 mm.Lid distraction distance is the distance the eyelid can be pulled away from the globe after the initial skinincision has been made and measured with calipers. If the eyelid can be pulled away from the globe less than10 mm, then a canthopexy is performed, which occurred in 98% of cases. Patients had lateral canthopexiesregardless of age or preoperative assessment. Herein, we describe a simple method of canthopexy that canbe performed on most patients having a lower blepharoplasty, to not only achieve a cosmetically superiorresult but also to prevent eyelid malposition or ectropion.Conclusion: We have described a simple prophylactic canthopexy suturing technique that all surgeonsperforming lower blepharoplasty can do to prevent rounding or ectropion. Naturally, the more cases that aredone, the more accurate will be the eyelid position and adequacy of eyelid tension achieved. Lateral tarsalstrip canthoplasty is also used in more advanced cases of lid laxity.

Horizontally oriented v-y flap may diminish lower lid retraction

Introduction: lower lid malposition following malignancy surgery in infra- orbital area is often challenging and any way to reduce its chance is appreciated. Case presentation: 36 years old women with confirmed Basal Cell Carcinoma (BCC) of left cheek underwent tumor excision with free margins and remained skin defect reconstructed with adipocutaneous v-y advancement flap, which designed in a horizontally orientation. Patient had no signs of ectropion with good wound repair and obscured scar. Conclusion: v-y flaps are commonly used local flaps with minimal donor site morbidity, and if designed horizontally, not only may reduce chance of lower lid malposition, but also can remain more acceptable scars.

Ophthalmic Changes Following Maxillectomy With or Without Postoperative Radiation Therapy.

To evaluate ophthalmic complications and quantitatively assess anatomic changes following maxillectomy with or without adjuvant radiotherapy in patients with midface malignancy. Twenty-four patients who underwent maxillectomy for sinus and/or paranasal cancer were included for retrospective review. Patients with complete ophthalmic examinations were evaluated for postoperative findings corresponding to sequelae of treatment. When available, anatomical changes including eyelid position were quantified from preoperative and postoperative full-face photos using computer software. The most common complications identified in patients after maxillectomy were retraction/ectropion (50%), epiphora (29%), and exposure keratopathy/dry eye syndrome (25%). Patients treated with maxillectomy with adjuvant radiation therapy were more frequently found to have ophthalmic complications following treatment. In patients with available postoperative photos (n = 10), the mean ipsilateral margin reflex distance (MRD)2 and inferior scleral show were 8.4 mm and 2.4 mm, respectively. In patients with available preoperative photos (n = 5), the mean change in MRD2 and inferior scleral show following maxillectomy was 3.4 mm and 2.8 mm, respectively. Patients undergoing maxillectomy for the treatment of head and neck malignancy may be at significant risk for development of specific periocular complications. Lower eyelid malposition was the most significant postoperative quantitative eyelid change following maxillectomy, which may be exacerbated by adjuvant radiotherapy and inferior orbital rim removal.

Medial canthoplasty for the management of exposure keratopathy.

To report the surgical technique and functional outcomes of the medial canthoplasty for the treatment of exposure keratopathy. An IRB approved, retrospective review of patients who underwent medial canthoplasty for exposure keratopathy was performed. Patient demographics, reported symptoms, and clinical examination findings were collected and analyzed from pre-operative and follow-up visits. The study included 73 consecutive cases in which the medial canthoplasty was performed in patients with exposure keratopathy. The average follow-up period was 7.9 months (median: 4.7 months; range: 1-150 months). Complete or partial improvement in ocular symptoms (dryness; pain/irritation; tearing) was achieved in 95% (69/73). Clinically, 85% (41/48) of patients demonstrated a post-operative reduction in lagophthalmos and 90% (60/67) showed improvement in ocular surface findings. Complications were rare (1/73) and reversal of medial canthoplasty was not required in any case. The medial canthoplasty appears to be a safe and effective technique to narrow the palpebral fissure, provide lower eyelid support, and improve keratopathy. It is an uncomplicated procedure that may be considered for the treatment of exposure keratopathy caused by facial paralysis and lower eyelid malposition.

Minimal Incisions Vertical Endoscopic Lifting (MIVEL) for the Management of Lateral Canthal and Lower Eyelid Malposition.

The purpose of this article is to describe the necessary steps to correct both primary and postblepharoplasty lateral canthal and lower eyelid malpositions at the time of endoscopic face lifting. Endoscopic surgery is traditionally considered only for brow and forehead lifting. However, in our practice we have successfully expanded the indications of the minimal incision vertical endoscopic lifting technique from being primarily indicated for forehead/brow elevation to also treating both primary and secondary lower eyelid and lateral canthal malpositions. This has eliminated the need for direct lateral canthal manipulation in primary cases and any need for open canthoplasty and posterior spacers in secondary cases. In our series of 63 patients with a mean age of 54 years, overall subjective satisfaction was high in 92% of patients, and there were no long-term side effects or complications.

Controversies in periocular reconstruction for facial nerve palsy.

Periocular rehabilitation of the patient with a facial nerve palsy has evolved over time. Although protection of the ocular surface is paramount, application of disfiguring tarsorrhaphies should be utilized only in special situations. The purpose of this review is to discuss current surgical and medical strategies in treatment of the periocular area in patients with facial nerve palsy to give maximal functional and cosmetic results. Upper lid lagophthalmos is preferentially treated with upper eyelid weights. Platinum has distinct advantages over gold. A supratarsal position of the upper lid weight is preferred over a pretarsal location. Lower lid malposition should be treated as a retraction, rather than an ectropion. Recalcitrant ocular surface disease can be effectively managed with a scleral lens. Tearing in the patient with a facial nerve palsy is often multifactorial; small lumen Jones tubes and botulinum toxin injection to the lacrimal gland should be considered to treat epiphora in these patients. A facial nerve palsy can be devastating for patients from both a functional and cosmetic perspective. Although seismic shifts in treatment of the periocular subunit have not occurred, there are a number of small, yet significant, changes in treatment that should be adopted in taking care of these patients.

Direct Excision of the Lower Eyelid: A Safe and Effective Method for Treating Dermatochalasis and Pigmentation.

The subciliary and skin pinch approaches are the most widely accepted techniques for treating dermatochalasis of the lower eyelid. Direct excision (DE) is an accepted method for treating festoons; however, it is not a popular technique for the treatment of dermatochalasis and pigment of the lower lid. DE of the lower lid offers a safe and excellent aesthetic result for dermatochalasis and pigment of the lower lid, without causing lower lid malposition, which can occur with more traditional methods. In addition to being able to remove significantly more skin without risking lower lid malposition, this procedure allows for removal of the most pigmented and poorly textured skin overlying the nasojugal groove. It is an effective alternative to the conventional subciliary and skin pinch approaches.

Reconstructive subperiosteal midface lift: A three nonvisible incision approach

ABSTRACTThis article describes our surgical technique for subperiosteal midface elevation in patients with paralytic lower eyelid malposition or cicatricial inferior eyelid retraction. Nineteen patients with paralytic lower eyelid malposition and 15 patients with cicatricial inferior eyelid retraction underwent a subperiosteal midface lift (n = 34). The procedure was performed under local anesthesia through three nonvisible incisions. A transconjunctival incision allows preseptal dissection to the orbital rim, followed by a subperiosteal dissection of the midface. An oral incision is useful to achieve complete subperiosteal dissection and to perform the distal periostomy, which allows complete release of the midface soft tissues. A temporal incision provides access to the temporal fascia for fixation of the elevated tissues and gives the surgeon the possibility of removing redundant skin from the scalp instead of the lower eyelid. Additional posterior lamellar grafting was performed in 24 patients. There was a statistically significant reduction in the distance from the pupil centre to the lower eyelid (margin reflex distance, MRD2) 1 month after surgery (preoperative MRD2 9.62 ± 4.52 mm, postoperative MRD2 5.28 ± 2.62 mm). The ectropion and lower eyelid retraction was resolved in all patients, except for one recurrence. Midfacial elevation is a safe and effective surgical technique in the treatment of static lower eyelid malposition after chronic facial nerve palsy or posttraumatic or iatrogenic lower eyelid retraction.

Surgical rehabilitation for anophthalmic sockets devoid of orbital implant

PurposeTo determine the necessity of rehabilitative surgical procedures for no implant anophthalmic sockets, and predictive factors of corrective operations after secondary orbital implantation. Material and methodsNineteen unilateral anophthalmic patients without orbital implant were included. The distance of eyebrow, upper eyelid margin, and lower eyelid margin from the horizontal medial canthal line (BM, UM, and LM, respectively) was measured using photographs. The anophthalmic orbit anatomy was compared with that of the healthy side using CT scans. ResultsFive (26.3%) patients showed satisfactory results with the secondary implantation alone. Fourteen (74%) patients needed additional surgeries for ptosis, shallow inferior fornix, enophthalmos, or lower eyelid malposition. Separated superior muscle complex and prominent intermuscular septum connecting the levator and the lateral rectus muscles were noticeable in CT scans. Predictive factors for ptosis surgery included longer BM (p = 0.04), shorter distance from the superior orbital wall to the upper margin of the prosthesis (p < 0.01), and a longer height of the prosthesis (p = 0.04). ConclusionMost patients needed multiple operations after secondary implantation for rehabilitation. Additional ptosis operation may be required for patients with a high brow on the anophthalmic side, a vertically long prosthesis, and an impinged prosthesis against the superior orbital wall.

Observations on Prostaglandin Orbitopathy.

To present the various orbital soft-tissue changes that can result from the use of topical prostaglandin analogs. A case series of patients seen in a referral oculoplastic practice with presumed prostaglandin orbitopathy. Thirty-five patients were found to have a variety of disorders, including deepening of the superior sulci (24/35), hypertrichosis (32/35), periocular erythema (24/35), and meibomian gland dysfunction (18/35). Marginal eyelid thinning with posterior migration of the lash line was commonly present (34/35). Increased eyelid margin tension with horizontal eyelid shortening (32/35) was often associated with lateral canthal deformity or displacement (15/35). Lower eyelid retraction (18/35) seemed to contribute to ptosis in some patients, secondary to apparent tethering at the lateral canthus. Functional conditions resulting from the above structural abnormalities included tractional ptosis (n = 4), cicatricial entropion (n = 3), cicatricial ectropion (n = 2), trichiasis (n = 2), eyelid subluxation (n = 1), and chalazia (n = 1). While topical prostaglandin analogs are well-tolerated by many patients with glaucoma, some individuals using these medications develop structural changes of the orbital soft tissue resulting in a variety of cosmetic and functional eyelid disorders. The eyelid margins can thin, causing posterior migration of the lashes. Increased horizontal tension of the eyelids may result in acquired blepharophimosis and upper or lower eyelid malposition. These orbital changes may be partially reversible in some patients. When possible, it is reasonable to withhold the prostaglandin and allow a period of observation before proceeding with surgical correction.

How to avoid from an ectropion complication by using motor innervation prevention at lower eyelid blepharoplasty surgery

The subciliary incision is the most commonly used approach for lower eyelid blepharoplasty because of the advantages like ease of combining with other periocular and midface rejuvenation techniques. However, the most common reported major complication is lower lid malposition. In this article we described our subciliary dissection technique to protect the motor branches of tarsal orbicularis oculi to avoid from ectropion.

Ocular surface disease in patients with involutional lower eyelid malpositions

Ocular surface disease in patients with involutional lower eyelid malpositions

Lateral canthopexy - a simple addition to lower lid blepharoplasty

Rejuvination of the lower lid is a challenging procedure. Lower lid malposition and ectropion are serious postoperative complications. Therefore presurgical assessment of the lower lid function and laxity are a must before performing a blepharoplasty. Lateral canthopexy is an effective procedure to minimise the risk of postsurgical ectropion. Its necessity increases with rising age of the patients. The canthopexy supports the lower lid postion in the case of increasing vertical tension.