Blepharoplasty, or eyelid surgery, improves the appearance or function of the eyelids by removing or repositioning excess skin, muscle, and fat. A potential complication following this surgery is lagophthalmos, the inability to fully close the eyelids. This condition ranges from a slight opening noticeable only during sleep to a significant gap that leaves the eye surface exposed. When the eyelid cannot fully close, the exposed cornea is susceptible to drying out. Protecting the surface of the eye is the immediate concern when lagophthalmos occurs after blepharoplasty.
Immediate Management and Observation Period
The immediate goal following the onset of lagophthalmos is rigorous corneal protection to prevent dryness and damage to the eye’s surface. This involves frequent application of lubricating agents, which temporarily substitute for the protective function of a closed eyelid. Artificial tears are used throughout the day to keep the exposed eye moist.
For extended eye closure, especially at night, thicker lubricating gels or ointments provide a longer-lasting moisture barrier. These formulations are necessary because the natural blink reflex is reduced during sleep, increasing the risk of exposure keratitis. Individuals may also be advised to use moisture chambers, specialized goggles, or to gently tape the eyelids shut overnight.
An observation period is required before any permanent corrective treatment is considered. Post-surgical swelling, inflammation, and the tightening of early scar tissue can temporarily restrict eyelid movement. Surgeons recommend waiting at least six months, and sometimes up to a full year, for the tissues to soften, swelling to subside, and scar contracture to relax. Many mild cases of lagophthalmos resolve naturally as the healing process completes.
Identifying the Source of the Complication
Successful long-term management of lagophthalmos depends on accurately diagnosing the underlying structural cause of the eyelid closure deficit. The problem is generally categorized into three main sources related to the initial blepharoplasty procedure. The most common cause is the over-resection of skin and muscle, meaning too much tissue was removed, resulting in a physical shortage that prevents the eyelids from meeting.
Another contributing factor is the formation of dense scar contracture or fibrosis within the eyelid tissue, which physically restricts movement. This internal scarring can pull the eyelid open even if the skin quantity is sufficient. The third major cause, particularly following lower blepharoplasty, is the malposition or laxity of the lateral canthal tendon, leading to lower lid retraction (ectropion).
An experienced oculoplastic or facial plastic surgeon performs a detailed examination, measuring the skin deficiency and assessing the position and tension of the canthal angle. They evaluate the degree of scleral show, the visibility of the white part of the eye below the iris, which is associated with lower eyelid retraction. This diagnostic phase dictates whether the problem is a tissue shortage, a scarring issue, or a structural support failure.
Non-Surgical and Minimally Invasive Treatments
If lagophthalmos persists after the observation period but is mild or moderate, non-surgical and minimally invasive treatments offer improvement without immediate revision surgery. These techniques primarily aim to soften scar tissue and restore tissue balance. Gentle eyelid massage, performed multiple times daily, can help stretch and relax early scar tissue, promoting better elasticity and movement.
Steroid injections, specifically triamcinolone, may be administered directly into dense scar tissue or fibrosis to soften the scar and reduce inflammation restricting movement. This is an effective strategy when the primary cause is internal scar tightness rather than a severe skin shortage.
Neuromodulators, such as botulinum toxin, can be injected into the orbicularis oculi muscle of the lower eyelid to relax tension pulling the lid downward. Dermal fillers, typically hyaluronic acid-based, provide structural support when placed in the cheek or lower eyelid area. This elevates the lower eyelid margin and reduces the vertical tension contributing to lagophthalmos. These options can serve as a bridge to surgery or provide a definitive solution for less severe issues.
Definitive Surgical Correction Procedures
When non-surgical methods fail or lagophthalmos is severe due to a structural defect, surgical correction is necessary to restore full eyelid function. The specific procedure selected is tailored to the underlying cause identified during diagnosis. For cases involving skin deficiency, often from over-resection, a full-thickness skin graft is the standard treatment.
The graft, usually harvested from the opposite upper eyelid or behind the ear, is placed into the area of skin shortage to physically lengthen the eyelid and allow closure. When the issue is lower lid retraction or laxity, procedures supporting the lower eyelid are used. The lateral tarsal strip procedure tightens and repositions the lateral canthal tendon, the anchor point for the lower lid, to elevate the eyelid margin.
For more complex lower eyelid issues, a canthopexy or a midface lift may provide vertical support to the cheek and lower lid complex, reducing tension. In instances of severe, persistent lagophthalmos that threatens corneal health, a temporary or permanent tarsorrhaphy may be performed. This procedure involves partially suturing the upper and lower eyelids together at the outer corner, narrowing the opening to protect the eye surface. These complex revision surgeries require consultation with a specialist oculoplastic surgeon experienced in reconstructive techniques.