Commentary on: Lower Eyelid Retraction Surgery Without Internal Spacer Graft

I want to thank the editor for asking me to address the topic of the surgical management of lower eyelid retraction. I will focus my discussion only on post-blepharoplasty lower eyelid retraction (PBLER), as this is a topic of great interest to me, and because the other causes described in Dr Taban's report are less of a focus to aesthetic eyelid surgeons, although the same principals of treatment certainly apply. I will divide my discussion into four parts: (1) a respectful appreciation of Dr Taban's insight; (2) what the literature currently suggests; (3) what the readership wants to know; and (4) a few words on future efforts. First and foremost, thank you Dr Taban for sharing your work with the Aesthetic Surgery Journal .1 I believe those that see this problem often understand what a difficult and humbling eyelid malposition this is to understand and manage. Clearly Dr Taban has a good feel for it, and any simplification shared will certainly make the process more palatable for others. Let me summarize what I feel Dr Taban is suggesting. PBLER has 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.2 This combined procedure has been the standard for over 30 years. Its component parts make sense, and each may play a vital role in surgical success. However, is each step needed in every case? Can an algorithm be developed which omits unnecessary procedures which, in and of themselves, carry various degrees of potential morbidity? These questions demand a critical reevaluation of this …