Cosmetic Reconstruction: Identify the Real Problem!

This case report is very illustrative of the importance of a careful assement of eyelid position and mechanics, as well as careful image analysis.  The role of the lateral canthus in upper and lower lid appearance and function is critical to understand when embarking on cosmetic reconstruction, as this case report demonstrates.

The patient here came to me first in March of 2016.  She had a history of Grave’s disease of the thyroid, which led to right upper eyelid retraction: the lid was scarred internally from the disease and was too high.  Prior to the diagnosis of Grave’s disease, her surgical history included a cosmetic lower lid blepharoplasty, which went fine.  The upper lid retraction started several years before she saw me, and she had three surgeries to try to correct it.  The outcome was similar to a cat chasing its tail:  postoperatively,  the lid was too high, then too low, then too high, etc.   She had surgeries performed by oculoplastic specialists in Florida and Alabama, and in the end she decided to make the 5 hour trip to Atlanta for a consultation with me.  By the time she saw me, the lid was too low, and the contour was too flat, and she was uncomfortable.  There was chronic discomfort at the outer corner of the right eye.  Her preoperative photo is seen below, in Figure 1.

Figure 1. Initial visit to Dr. Walrath, March 2016.  

The upper lid is flat, and low, and there is significant asymmetry.  The contour abnormality is due to surgical treatment of lid retraction due to Grave’s disease.   However, there is another subtle abnormality in this initial photo that is the key to correcting her problem!

Figure 2. Initial visit, image analysis

The image is rotated so as to be level, and a horizontal line is run across the image.  It is clear that the attachment point of the upper lid on the right side is 2-3 mm too high (Expand the image to verify for yourself.).  This is the key piece that explains her discomfort, because the abnormally placed attachment point at the lateral canthus impairs normal lid closure.  This incomplete lid closure will later be demonstrated in a photo from the operating room.  This is also easily visible in a profile photo (Figure 3):  the lids attach too high up at the outer corner.

Figure 3. Initial visit, side view.  

Looking back, we can see that the lower lid / lateral canthal malposition was present the whole time as multiple upper lid surgeries were being performed, as demonstrated in Figures 4 and 5.

Figure 4. Prior to first upper eyelid surgery, it is clear that the lateral attachment point is too high.

Figure 5.  After upper eyelid surgery, the lateral canthal issue persists.

It is important to note that all of the upper lid surgical procedures in the world will not lead to an optimal outcome without correction of this lateral canthal abnormality.  The most interesting feature of this case is that a large part of her problem was due to her previously uncomplicated lower lid blepharoplasty and was never appreciated subsequently!

I did finally correct this problem, although it took me two surgeries to get it right.  The second surgery was on 12/30/16, and involved a complete release of all scarring in the upper lid, advancement of the upper lid muscles to lift the lid, complete release of the lateral canthal tendons, and drill hole fixation of the lateral canthus.

Preoperatively, in the operating room, the eye is slightly gapped open (Figure 6).  This is the reason for her discomfort. 

Figure 6.  Eyelid gapping open while under general anesthesia.  Intraoperative photos demostrating the scar release of the upper lid, and the drill hole fixation of the lateral canthus, can be seen here.

At our 6 week postoperative visit (Figure 7), it can be seen that the lateral canthal position has been corrected and the upper lid contour is improved (Also note that a left upper lid blepharoplasty has been performed as well for symmetry).   The the eyelid now closes completely (Figure 8).

Figure 7.  Postoperative correction.

Figure 8.  Postoperatively, the eyelid closes.

I am happy to report that this patient is finally comfortable.  She has had an excellent functional and cosmetic outcome, and at this point is ready to turn on the page on this tricky functional and cosmetic issue!