I have taken care of several patients referred with the unfortunate problem of excessive skin removal during lower lid blepharoplasty. It can be a very difficult problem for patients, as the lower lid is “retracted” down below the cornea. This leaves the lower segment of the cornea exposed to air, causing dryness. In extreme circumstances, this dryness can even lead to perforation or near-perforation of the cornea, necessitating a corneal transplant.
Strategies for dealing with patients with lower lid skin shortage are varied. A cheek lift, which brings skin into the area from below, can be valuable. Almost always, the lower lid needs support on the inside, in the form of tissue grafts (collagen implants, ear cartilage grafts). In extreme instances, skin grafting will be required.
One element of the examination that many physicians do not appreciate is that inadequate eyelid anchoring can lead to eyelid malfunction, even in the presence of a normal amount of skin. Inadequate eyelid anchoring can result from prior cosmetic blepharoplasty in which the function of the eyelid was not respected or ensured by the surgeon. Instead of a normal blink mechanism, in which the eyelid moves vertically and snaps closed, the result is an eyelid that migrates from side to side during a blink, closing incompletely. This leads to a persistent dry spot on the cornea.
Eyelid biomechanics is discussed in a recent review submitted to the journal Ophthalmic Plastic and Reconstructive Surgery.