Causes of Upper Eyelid Retraction, and the Right Time for Specialized Surgical Treatment

Author: Amiya Prasad, M.D.

Thank you for your question. You submitted a question without a photo. So it seems that you’re just trying to get some general ideas about your concern which is upper eyelid retraction surgery. You’re asking how specific it is and how precise and predictable it is. You’re asking what are the risks of blindness and is it possible to just do part of the eyelid or the lateral part next to the pupil or does the whole eyelid have to be brought down. Well, certainly I can give you some general understanding of eyelid retraction and what my thought process is when I meet a patient and evaluate them for eyelid retraction and discuss the options for surgery. A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. Eyelid malposition, whether it’s eyelid ptosis and eyelid retraction, is a significant part of my practice as a cosmetic oculofacial plastic and reconstructive surgeon in practice for over 20 years.

Again, I’ll go down the path of what is the thought process and certainly go over the issues about risk. So to begin with, the first question I have to ask will be: what is the nature of the retraction? When it comes to eyelid retraction, generally, it is associated with something called thyroid eye disease or Graves’ disease or another term is thyroid-related immune orbitopathy. So when that is the cause, you also want to know about the stability of the appearance. Is the appearance stable? There are two phases: inflammatory and fibrotic stage. You want to minimize the chances of operating during the inflammatory stage because that’s an active changing time where the eyelid position can vary or the fibrotic stage which is more stable assuming that is the situation. The other situation that does come up is congenital eyelid retraction which means that you are born with it. So when it comes to eyelid retraction surgery, basically, the first line of procedure is called Muellerectomy where you are actually removing a muscle or releasing a muscle behind the eyelid called Mueller’s muscle and that allows the eyelid to typically descend about 1-2 millimeters.

Often, what I tell my patients is given that once that procedure is performed, I actually want to see the effect. And usually, these procedures I do under local anesthesia with LITE™ sedation. That means that the patient is awake during the critical point of when I’m trying to establish the right height and contour. And so we’ll actually sit the patient up and see how their eyelid level looks. It’s comparable to what we do with ptosis surgery. When it comes to eyelid position, a millimeter can make a difference. So in terms of the other options, there’s also a procedure called levator muscle recession and depending on how much the muscle has to be recessed, you can also require some type of grafting procedure where we actually place a spacer graft such as called a temporalis fascia between the levator muscle and the tarsus, the backbone of the eyelid. When I have this discussion with the patient, we have to be ready with a plan A, B or C depending on what I see during surgery so that I’ll know what’s more likely to be the case but I also want to have an additional option.

So to begin with, in terms of the customization of the procedure, I would say that it is still important to understand that, yes, it is possible to customize and if you’re describing a situation where you just want the part that’s on the outer part, that situation is consistent with a term called lateral flare. And very often, that is associated with thyroid eye disease. So to answer the question, can you do just the part outside of the pupil or the outer aspect or the lateral part? The answer is yes, you can. You can certainly customize this procedure. It just depends on how your eye looks intraoperatively and this is a discussion that you should have with your prospective surgeon. As far as the risk of blindness and other issues, I also explain to my patients that for any surgery, the first level of risk is bleeding and infection.

Causes of Upper Eyelid Retraction, and the Right Time for Specialized Surgical Treatment

The chance of blindness is highly unlikely and you have to also think what would be the cause of the blindness. There are many potential risks that have more to deal with issues with the vision that can be compromised such as eye exposure or corneal abrasion that are more likely than frank blindness. So I would say that in the blepharoplasty- associated or cosmetic eyelid surgery associated risk of blindness, a number that gets thrown around is something like .025% which is very rare and is highly unlikely but it is still something to at least understand and that’s always in the discussion and of course it is part of informed consent. What we try to do to mitigate these risks is to of course do proper preoperative evaluation from both medical and ophthalmic point of view. Medically, we want to make sure the risk of excessive bleeding or potential of infection is minimized and from an ophthalmic point of view, I’ll make sure that the integrity of the eye is optimal so that the patient can tolerate the surgery.

So that being said, I think that you need to actually have a one on one consultation with a doctor to understand specifically what’s your situation is. And once you’re comfortable with that doctor, understand moving on. The biggest concern that I would say for me is about the aesthetic and functional outcome. When you are changing the position of the eyelid, you can overcorrect, you can have an overcorrection or undercorrection which means that the greatest concern that I would have is in addition to those other risk is about the need for revision surgery and that possibility can never be eliminated to zero. Every surgeon has to do a revision for their own work sooner or later. A very famous colleague of mine said that if a doctor claims to never do revisions, they’re either lying or not doing surgery and I think that’s very illustrative of that understanding of the art of surgery.

We are dealing with that the human being. We are dealing with soft tissue and we are trying to maximize the predictability through exceptional high level quality surgery but we are dealing with just the elasticity of the human body and the variability of healing. So understanding that, you have to be prepared and the doctor can give you a guideline of how often the doctor does revision surgery and once you are comfortable, move forward with the operation. So I hope that was helpful, I wish you the best of luck and thank you for your question.

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