As with the upper eyelid, if insufficient skin has been removed, the most direct remedy is to excise a little more. Be aware, however, that skin excision will not go far in eliminating wrinkles, while overzealous removal of lower eyelid skin will cause substantial problems (see below).
The most common "cosmetic problem" is insufficient removal of fat resulting in a noticeable bulge (or, in the case of fat transfer, an unacceptably irregular shape and contour). If objectionable, most such irregularities can be addressed by revision from a transconjunctival approach.
Excessive removal of lower eyelid fat can create a hollowness within the orbital cavity that is difficult to restore. Orbital fat grafting seems to offer the best solution.
Hematoma, orbital hemorrhage, loss of vision (see upper lid complications).
The most common functional complication of lower eyelid blepharoplasty is an alteration of the position of the lower eyelid ("malposition"), thus interfering with its relationship with the eyeball. Malposition may be due to:
• lower eyelid retraction, or
• cicatricial ectropion
While similar in some ways, these conditions are not the same and require different treatments.
Lower eyelid retraction is a pulling down of the eyelid thus exposing excessive sclera ("white of the eye") and creating an obvious "surgical look". This mild to very serious complication is exclusively associated with blepharoplasty performed via a transcutaneous (skin) approach. The retraction is caused by excessive scarring in the middle layers of the eyelid, which are more "violated" during the more invasive transcutaneous version of lower blepharoplasty. Patients with prominent eyes sitting in shallow bony sockets are at significantly greater risk, but the risk is present to some degree in all patients undergoing the skin approach operation.
Surgical correction of lower eyelid retraction is challenging and may incorporate severing of scar tissue, tightening procedures at the lateral canthus, grafting of ear cartilage or hard palate tissue into the middle layer of the eyelid, and/or a midface lift.
Cicatrical ectropion is an eversion of the lower eyelid (a pulling away of the eyelid from the eyeball). Ectropion is caused by excessive removal of lower eyelid skin, and, again, is a not uncommon complication of transcutaneous lower blepharoplasty. Patients with stretched and weakened supporting tendons are at higher risk (the elderly, smokers) because any tightness at all is poorly tolerated and may result in eyelid eversion.
Surgical correction of cicatricial ectropion is, likewise, a difficult reconstructive operation and may require full-thickness grafting of donor skin (most commonly, taken from behind the ear) and/or horizontal reinforcement of the eyelid by advanced shortening and/or tightening techniques at the lateral canthus.
