Lower eyelid blepharoplasty: minimizing complications and correction of lower eyelid malposition.

Lid retraction is a feared complication of lower blepharoplasty. Anatomical variations like negative orbital vector, horizontal lid laxity and pre-existing lid retraction are more prone to lid malpositions. Meticulous and precise execution of a series of surgical steps is key to preventing complications. This includes minimising surgical trauma, meticulous hemostasis, preserving innervation to the medial lid and pretarsal orbicularis, safe method of fat excision, septal tightening while maintaining lid traction and conservative and titrated skin excision. Canthal fixation addresses lid laxity and maintains the lid stretched vertically while post-operative healing and fibrosis are taking place. Post-blepharoplasty lid retraction may occur due to failure to address lid laxity and the occurrence of middle lamellar fibrosis. Excessive skin excision may also result in anterior lamellar deficiency. The "sag and drag" concept is useful to evaluate the post-blepharoplasty retracted lid. The treatment of the retracted lid includes lid massage, replacing the anterior lamella or releasing the middle lamellar fibrosis or a combination of techniques. In conclusion, understanding the mechanisms of lid retraction, careful pre-operative assessment and surgical precision will help surgeons to prevent and manage this complication.