Normal upper eyelid rests just below the upper border of the cornea/iris, while normal lower eyelid rests at the lower border of the cornea/iris. Eyelid retraction is abnormal elevation of the upper eyelids and abnormal lowering of the lower eyelids.
What Causes Eyelid Retraction?
There are various causes of eyelid retraction, including congenital, thyroid eye disease (Graves’ disease), trauma, and prior surgery. Most common cause of upper eyelid retraction is thyroid disease followed by genetics. The most common cause of lower eyelid retraction is from complications from prior lower blepharoplasty (post-blepharoplasty eyelid retraction), where either scar tissue developed and/or if too much skin was excised from the lower eyelid. Lower eyelid retraction can appear as rounding of the eyes and scleral show and very importantly it results in surgical (unnatural) eye and facial appearance. It can lead to chronic eye conditions including dry eyes, excessive tearing, redness, burning and blurred vision. Another common cause of lower eyelid retraction is genetics, where the lower eyelids are too low with scleral show. These patients often complain about their eye shape while desiring more almond shape eyes. They want surgery to correct the scleral show. It is important to understand that sometimes large eyeballs or bulging eyes can force the lower eyelids to be too low, which means sometimes the eyeballs have to be set back (through orbital decompression) to allow the lower eyelids to come up. A good analogy to consider is someone’s pants can fall down if the belly is too big!
The first line of therapy is ocular protection using frequent ocular lubrication (drops and ointment), bandage contact lens, etc. Surgery is inevitably needed since the eyes will get more dry as time progresses. Upper and lower eyelid retraction surgery are done differently. For upper eyelid retraction, the levator muscle (responsible for lifting the upper eyelid) is cut to lower the upper eyelid. Lower eyelid retraction surgery works differently. There are various surgical techniques, usually performed via a posterior (hidden) eyelid approach. At times, grafts and/or midface (cheek) lift may be needed to help elevate the lower eyelid and reduce the scleral show. Tightening of the lower eyelid is usually concurrently performed through canthoplasty where the outer corner of the eye is tightened. Lower eyelid retraction surgery can help achieve more almond shape eyes. At times, orbital decompression may be necessary as an initial step (prior to lower eyelid retraction surgery) if big eyeballs or bulging eyes are forcing the lower eyelids too low. Going back to the previous analogy, if someone’s big belly is reduced, the their pants can come up higher !
Dr. Taban is an expert eyelid retraction surgeon, using minimally invasive techniques, helping patients locally and around the world with this difficult problem, in his 2 offices in the greater Los Angeles area (Beverly Hills and Santa Barbara). He has written several articles on eyelid retraction surgery, including:
Efficacy of “Thick” Acellular Human Dermis (AlloDerm) For Lower Eyelid Reconstruction
Comparison of AlloDerm and Hard Palate grafts
“En-Glove” Lysis of Lower Eyelid Retractors With AlloDerm and Dermis-Fat Grafts in Lower Eyelid Retraction Surgery
New minimally invasive, scarless technique for lower eyelid retraction surgery
See Dr. Taban’s article: Minimally Invasive Englove Approach For Eyelid Retraction Surgery
Young male with congenital rounded eyes and lower eyelid retraction with scleral show who underwent lower eyelid retraction surgery with internal Alloderm graft and canthoplasty, resulting in elevation of the lower eyelids in a more natural position. He also had tear trough silicone implants placed.
Middle age male, with thyroid eye disease, who underwent orbital decompression followed later by lower eyelid retraction surgery and canthoplasty.
Before (left) and after (right) bilateral lower eyelid retraction surgery with internal dermis-fat graft.
Before (left) and after (right photo) of right upper eyelid ptosis surgery, left upper eyelid retraction surgery and bilateral lower blepharoplasty.
Before and 3 months after LEFT lower eyelid retraction surgery without graft, under LOCAL anesthesia.
Before (left) Middle age woman with multiple prior eyelid surgeries and blepharoplasty, resulting in right lateral canthal angle distortion and lowering, unnatural right lower eyelid contour, and droopy upper eyelid. After (right) 2 months after revisional eyelid surgery, right canthoplasty, right lower eyelid retraction surgery (internal, with midface lift, without graft) and lower eyelid contour surgery. Fat injection in upper eyelids.