TheAmerican Journal of Cosmetic Surgery Vol. 25, No.4, 2008 RICHARD C. WEBSTER RESIDENT PAPER Transconjunctival, Sublabial, and Temporal Subperiosteal Approach Midface-Lift for Persistent Lower Eyelid Retraction After Blepharoplasty Ronald Mancini, MD; Tanuj Nakra, MD; Stanley M. Saulny, MD; Robert A. Goldberg, MD; Norman Shorr, MD 243 Purpose: To define a subgroup of postblepharoplasty patients with persistent lower eyelid retraction despite attempted lower eyelid reconstruction and midface-lifting, and to propose a revisional midface-lifting procedure to address complex cicatricial patterns in these patients. Methods: This is a retrospective observational case series of consecutive patients with bilateral persistent cicatricial lagophthalmos from lower blepharoplasty despite prior lower eyelid reconstruction and midface-lifting. An ap- proach for midface-lifting and lower eyelid reconstruction was designed that consisted of transconjunctival, sublabial, and temporal approaches to the subperiosteal space with manual distraction cicatricial scar matrix lysis. Routine postoperative evaluation of clinical outcome, safety, patient satisfaction, and photographic analysis was performed. Results: A total of 8 patients who underwent revisional midface-lift surgery (15 ipsilateral surgeries) were identi- fied. In all 15 cases, a 3-dimensional cicatricial matrix was identified that involved the lower eyelid and midface and limited visual exposure of the subperiosteal space and mobility of the midface despite complete subperiosteal release to the sublabial incision. Manual anterior distraction of the midface via the sublabial incision provided a mecha- nism for lysis of the cicatricial matrix. Improved midface mobility allowed successful vertical fixation with maximal anterior lamellar recruitment and lower eyelid support. No complications were encountered. All patients reported improvement in cosmesis and ocular comfort. Average improvements in lower margin to reflex distance (MRD2) was 0.9 mm, scleral show was 0.8 mm, palpebral fissure Manuscript received August 27,2008... . From the Division of Orbital and Ophthalmic Plastic Surgery, Jules Stem Eye Institute UCLA Medical Center, Beverly Hills, California (Dr Mancini, Dr Nakra, Dr Goldberg, Dr Storr), Jules Stein Eye Institute, Ophthalmology Associates, Encino, California (Dr Saulny). Winner of the Richard C. Webster Resident Paper Contest, 2008. Corresponding author: Norman Shorr: North Roxbury Drive, Beverly Hills, CA 90210 (e-mail: Manclm@Jsel.uc!a.edu). height at the medial limbus was 1.2 mm, and palpebral fissure height at the lateral limbus was 1.2 mm. Conclusion: Patients who presented with postblephar- oplasty cicatricial lagophthalmos after unsuccessful lower eyelid reconstruction, including midface-lifting, may have a complex 3-dimensional cicatricial matrix involving the lower eyelid and midface. A combined transconjunctival, sublabial, and temporal subperiosteal approach with manual scar matrix release for midface elevation and lower eyelid support is a safe and effective management paradigm. T he "classic" unhappy postblepharoplasty patient with lower eyelid retraction has full-thickness cicatricial vertical inadequacy that extends from the lower tarsus to the inferior orbital rim. 1 Management of these patients has been described in detail and may involve full-thickness eyelid reconstruction with pos- terior lamellar augmentation with or without midface- lifting to recruit the anterior lamella if necessary. 2-4 With the increasing popularity of the midface-lift as a standard oculo-facial procedure for the management of postblepharoplasty lower eyelid retraction.' a new generation of unhappy postblepharoplasty patients has arisen. These patients have undergone 1 or more lower eyelid reconstructions, as well as 1 or more midface- lifting procedures, in an attempt to recruit anterior lamella for the lower eyelid. These patients have a 3-dimensional cicatricial mass continuum that extends beyond the inferior orbital rim to involve the entire extent of the midface. They may not respond to a standard transconjunctival lower eyelid reconstruction and midface-lift. In this study, we describe the findings of this new genre of unhappy postblepharoplasty patients and describe our technique for addressing their complex constellation of problems.