Lower Eyelid Malposition After Blepharoplasty: Ectropion, Retraction and Scleral Show

Lower eyelid malposition is the lower lid sitting too low after blepharoplasty, either pulled straight down (retraction) or rolled outward away from the eye (ectropion), usually showing a strip of white below the iris and leaving the eye dry. It is the complication lower blepharoplasty is chiefly judged on, more likely after the external approach and in lids that were already lax before surgery¹.

This is the risk that made me read the most before I let anyone touch my lower lids. My upper lids were about heavy skin, but the lower ones sit right against the eye, and the difference between a good result and a lid that will not close cleanly is narrow. This is the plain account of what malposition is, why it happens, who it happens to, and what surgeons do to stop it. It sits under the full picture of eyelid surgery and beside lower blepharoplasty, which is worth reading first if you are weighing up the lower operation itself.

What lower eyelid malposition is

Malposition covers two related problems: retraction, where the lid is pulled straight down and exposes a rim of white sclera below the iris (scleral show), and ectropion, where the lid margin turns outward and no longer rests against the eye. Both leave the eye looking rounded rather than almond-shaped, and both stop the lid doing its job of spreading tears, so the eye feels dry, gritty, or waters constantly².

The two shade into each other, and a lid can show a little of both. What matters is that the lower lid is meant to sit at or just below the coloured part of the eye, moving up as you blink to wet the surface. When it drops, the mechanics break down before the appearance does, which is why the dryness and the watering are often the first thing people notice, not the look in the mirror. Dry, gritty eyes are the commonest after-effect of any eyelid surgery, but a lid that stays visibly down is a different matter and is covered alongside the other risks in blepharoplasty risks and complications.

Why it happens

The external (transcutaneous) incision just below the lashes cuts through the lid muscle and can heal with scarring in the middle layer of the lid that tugs it downward, an effect made worse by removing too much skin or by operating on a lid that was already lax. Downward traction on the orbital septum during surgery is one of the mechanisms behind that middle-layer contracture³.

There are really three ingredients, and they compound. The first is the approach: an external, below-the-lashes route disturbs more of the lid’s support than the scarless internal one. The second is laxity: a lid with weak tone before surgery has less spring to resist any downward pull, so the same operation that is fine on a tight lid can drag a loose one down. The third is over-resection: taking too much skin from the lower lid leaves too little to drape without tension. A careful surgeon treats the lower lid as a structure to be supported, not a flap of skin to be trimmed, which is exactly why the transconjunctival route, hidden inside the lid, exists.

Who is most at risk

The highest-risk combination is the external approach on a lid that is already lax, in someone whose lower lid sits low or whose eye is prominent, and where skin has been removed generously. A lax lid, a negative-vector eye where the cheek sits behind the eye, and pre-existing scleral show all raise the odds, which is why they are checked before, not after, the decision on technique¹.

The laxity check was the moment my own consultation turned specific. The surgeon pulled my lower lid gently down and away from the eye and watched how quickly it snapped back against it. Mine returned promptly, which he said was reassuring; a lid that is slow to spring back, or that needs a blink to reseat, is the kind that has to be tightened at the same time or left alone, not simply opened and closed again.

How surgeons work to avoid it

Prevention runs through the whole operation: assess lid laxity with the snap-back and distraction tests beforehand, choose the transconjunctival route where it will do, remove skin conservatively, reposition fat rather than strip it, and tighten the lid corner (a canthopexy or canthoplasty) at the same sitting when the lid is loose. In one prospective series of 200 extended transconjunctival cases, using free fat grafts rather than pulling the septum down, no malposition or scleral show was recorded at long-term follow-up³.

None of that removes the risk, but it stacks the odds. The internal route leaves the lid support largely undisturbed; a skin pinch takes only the millimetre or two of genuinely loose skin without opening the whole lid; and adding a corner-tightening stitch to a lax lid gives it back the tone it was missing. The honest headline, the same one that runs through all lower-lid work, is that the operation is judged on the lid sitting right afterwards, not on how much was taken away⁴.

If it happens: settling, and revision

Mild malposition in the first weeks is frequently swelling and tissue tightness rather than a fixed fault, and it commonly eases as the swelling resolves and the scar softens over weeks to a few months, helped by upward massage, taping, and lubrication for the dryness. A lid that is still visibly down once everything has settled, usually judged around the six-month mark, generally needs a corrective procedure to tighten or support it⁵.

The waiting is the hard part, because an eye that shows white and waters at three weeks is frightening even when it is on its way to being fine. Persistent cases are specialised oculoplastic work: releasing the scarred middle layer, tightening the lid corner, and, where the lid needs lengthening, adding a spacer graft to give it back its height. The dryness in the meantime is treated on its own terms, the same lubrication-first approach set out in dry eyes after blepharoplasty. It is worth knowing before you choose the external route that the revision, if it is needed, is a bigger undertaking than the operation that caused it.