Commentary on: Comparison of Efficacy and Complications Among Various Spacer Grafts in the Treatment of Lower Eyelid Retraction: A Systematic Review.

I want to thank the editor for asking me to address the topic of the surgical management of postblepharoplasty lower eyelid retraction (PBLER). Thanks to the authors for sharing their work with Aesthetic Surgery Journal.1 Lower eyelid retraction following lower blepharoplasty has long been an important topic of interest to aesthetic surgeons, both in terms of its prevention and its treatment. Given the various techniques and numerous types of spacer grafts that have been used, it is obvious that PBLER can be a difficult problem to address. First, it is important to understand that there are various factors involved that can contribute to PBLER. After understanding the possible contributing factors, then one can better understand its treatment. Surgeon’s technique is an obvious reason for occurrence of lower eyelid retraction after lower blepharoplasty, with transcutaneous lower blepharoplasty having far greater risk than transconjunctival lower blepharoplasty.2-4 In addition, there are certainly some patients that are more prone to developing lower eyelid retraction after blepharoplasty, including those with globe prominence, poorly developed lower orbital rim and maxilla, lower eyelid laxity, volume deficit, or combination of the above. Failure to account for these issues will not only lead to lower eyelid retraction but also prevent successful treatment of it after it occurs. For instance, if the globe is prominent (either from true globe prominence or from poorly developed orbital rim/maxilla), it not only contributes to lower eyelid retraction, it can prevent its treatment. Therefore, lower blepharoplasty has to be done more carefully and conservatively in these patients and if lower eyelid retraction does occur, these patients may benefit from more favorable globe position (through orbital decompression surgery) and/or additional orbital rim support (through orbital rim or tear trough implant). The type and/or severity of postblepharoplasty lower eyelid retraction will also determine how it needs to be treated. Orbicularis oculi paresis is treated differently than cicatricial lower eyelid retraction. Not all cicatricial lower eyelid retractions are created equal either, both in terms of severity and layer(s) of eyelid involved. Cicatricial lower eyelid retraction after blepharoplasty has traditionally been surgically addressed with midface lifting to recruit skin, open canthal suspension to suspend and support the lower eyelid, and a posterior lamellar spacer graft to vertically lengthen the lower eyelid and recess the lower lid retractors.4 The authors discussed the various types of spacer grafts reported in the literature and discussed their pros/cons. Importantly, they did not find that one type of spacer graft was superior to another. However, they did note limitations of the study (including variability in surgical technique, severity of retraction, and type of retraction) with suggestion for further studies. In