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Original Investigation |

The Minimally Invasive, Orbicularis-Sparing, Lower Eyelid Recession for Mild to Moderate Lower Eyelid Retraction With Reduced Orbicularis Strength

Donald B. Yoo, MD1; Garrett R. Griffin, MD2; Babak Azizzadeh, MD3,4,5; Guy G. Massry, MD6,7
[+] Author Affiliations
1Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles
2Facial Plastic and Reconstructive Surgery, Spalding Drive Cosmetic Surgery and Dermatology, Center for Advanced Facial Plastic Surgery, Beverly Hills, California
3Facial Plastic and Reconstructive Surgery, The Facial Paralysis Institute, Beverly Hills, California
4Facial Plastic and Reconstructive Surgery, Center for Advanced Facial Plastic Surgery, Beverly Hills, California
5Department of Facial Plastic and Reconstructive Surgery, David Geffen School of Medicine at the University of California, Los Angeles
6Ophthalmic Plastic and Reconstructive Surgery, The Facial Paralysis Institute, Beverly Hills, California
7Ophthalmic Plastic and Reconstructive Surgery, Beverly Hills Ophthalmic Plastic Surgery, Beverly Hills, California
JAMA Facial Plast Surg. 2014;16(2):140-146. doi:10.1001/jamafacial.2013.2401.
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Importance  Identifying a procedure to address lower eyelid retraction (LER) in the presence of an orbicularis deficit is a useful tool for aesthetic and reconstructive eyelid surgery.

Objective  To describe and evaluate a surgical technique consisting of a closed canthal suspension and true lower eyelid retractor recession to address LER in the setting of orbicularis weakness.

Design, Setting, and Participants  A retrospective medical record review of patients who underwent the minimally invasive, orbicularis-sparing, lower eyelid recession from January 1, 2010, to October 1, 2012, by one of us (G.G.M.) in an ophthalmic plastic surgical practice. We included 29 patients with reduced orbicularis strength and LER resulting from eyelid paresis related to facial nerve disease, surgical trauma (after blepharoplasty), involutional change, or idiopathic causes.

Interventions  Surgical intervention consisting of closed canthal suspension and lower eyelid retractor recession.

Main Outcomes and Measures  Surgical results, complications, and patient satisfaction.

Results  The 29 patients included 18 women and 11 men. The mean patient age was 52 (range, 6-72) years; mean follow-up, 11 (range, 6-21) months; and mean preoperative orbicularis strength, 2.7 (on a scale of 0-4, where 0 indicates no function and 4, normal function). The causes of orbicularis weakness included eyelid paresis related to facial nerve disease (11 patients), surgical trauma (13 patients), involutional change (4 patients), and an isolated idiopathic finding (1 patient). In 12 patients, the eyelid retraction was unilateral; in 17, bilateral. A small tarsorrhaphy was added to the surgery in 6 patients with facial nerve disease. The mean eyelid elevation after surgery was 1.80 mm, with only minor complications. Patient and surgeon satisfaction were high.

Conclusions and Relevance  Recent publications have demonstrated the utility of closed canthal suspension and true lower eyelid retractor recession as separate procedures. In the setting of LER with reduced orbicularis strength and/or tone, the techniques can be combined to recess the lower eyelid without disturbing the already compromised lower orbicularis muscle (minimally invasive, orbicularis-sparing, lower eyelid recession). The combination technique is safe and effective and yields excellent results.

Level of Evidence  4

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Figures

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Figure 1.
Surgical Series Demonstrating Minimally Invasive, Orbicularis-Sparing (MIOS), Lower Eyelid Recession Procedure

The MIOS procedure combines retractor recession and closed canthal suspension. A, Forceps pointing to the conjunctiva over the cornea (blue) and sclera (white), with the arrow directed at elevated retractors. B, Scissors undermining the retractors. C, Scissors incising the retractors. D, Forceps elevating the recessed retractors. E, Internal lysis of the canthal tendon through incision in the temporal eyelid crease. F, The canthus engaged with the suture and secured to the periosteum at the inner orbital rim.

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Figure 2.
Representative Patients Who Underwent the Minimally Invasive, Orbicularis-Sparing, Lower Eyelid Recession Procedure

Preoperative photographs are given on the left; postoperative photographs from the same patients, on the right. A-D, Two patients who developed lower eyelid retraction bilaterally after lower blepharoplasty. Neither patient has more than a minor cicatricial component. E and F, A young woman with right lower eyelid retraction related to Bell palsy. She declined upper eyelid weight implant before surgery. G and H, A young man with right lower eyelid retraction related to traumatic (surgical) facial nerve paresis. A slight overcorrection in his eyelid height postoperatively did not bother him. No aesthetic deficit was created by the addition of the tarsorrhaphy in the last 2 patients.

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