What the research shows
A lower lid pulled down after cosmetic surgery shows white below the iris and makes the eye look round and sad. Its causes are scarring, a loose tendon at the outer corner and a midface that has dropped (Patipa 2000). Patients referred for repair often also had a weak lid muscle, too little lid skin, too little volume under the eye and a cheek that sits behind the eye; scar inside the lid was less common. The authors advise checking for these before the first operation (Griffin 2014).
Canthal support lowers the risk. In a ten-year series of lower eyelid surgery through the skin with routine canthal support, about 1 in 30 needed another operation for lid position (Codner 2008). A study followed for at least five years used the eye exam to choose between a simple stitch (canthopexy) and resetting the corner (canthoplasty), and about 9 in 10 rated the result a success (Tepper 2015). Across published lower eyelid series, lid malposition and repeat surgery are rare (Wilson 2018).
There are trade-offs. After eyelid surgery, dry eye symptoms and swelling of the white of the eye (chemosis) each affected about 1 in 4 in one surgeon's series, and canthopexy raised the chance of chemosis (Prischmann 2013).
When the lid has already been pulled down, repair usually lifts the midface along with the canthus. A vertical midface lift with canthal strengthening improved the lid in nearly every patient, and most of those cases followed earlier cosmetic eyelid surgery (Pascali 2017). A cheek lift that moves tissue toward the eye brought new skin into the lower lid with little risk of a new malposition (Le Louarn 2018). When a graft is placed inside the lid to hold it up, no graft material has proven better than another (Park 2017).
Corner surgery also treats lids that turn in or out with age. For a lid that turns in, a tarsal strip combined with stitches deep in the lid rarely recurred, while either step alone recurred far more often (Rougraff 2001). Modified tarsal strip operations had high success and low recurrence in a 2025 review (Sbitan 2025).
Where surgeons disagree
- Canthal support every time. Some surgeons add a canthopexy to every lower eyelid operation regardless of age (Jacobs 2003, Codner 2008). Others point to the added chemosis (Prischmann 2013) or use a technique without canthal procedures and report few complications and high satisfaction (Klinger 2023).
- A graft inside the lid. A hard palate graft with a midface lift raised the lid more than the lift alone (Ben Simon 2006). Repair without a graft, mostly with a midface lift, also improved lid position in selected patients (Taban 2017).
What is new
- Fat injection alone raised a pulled-down lower lid, and the gain held at one year (Pascali 2023).
- Raising the outer corner of the eye lowered how attractive and trustworthy a face looked to raters and made it look more dominant and threatening, a finding the authors want discussed before surgery (Kempa 2025).
What is still unknown
- How long results last. Published lower eyelid series rarely show photographs beyond two years (Wilson 2018).
- The best graft and the best repair for each cause. Reviewers found too little high-quality evidence to choose (Park 2017, Sbitan 2025).
Key papers
- Patipa 2000: set out the causes of a pulled-down lid after cosmetic surgery and how to evaluate it.
- Rougraff 2001: tarsal strip plus deep stitches gave lasting repair of an in-turned lid.
- Codner 2008: ten years of lower eyelid surgery with routine canthal support.
- Prischmann 2013: linked canthopexy to swelling of the white of the eye.
- Griffin 2014: found less obvious causes of lid retraction worth checking before surgery.
- Tepper 2015: matched the canthal procedure to findings on the eye exam.
- Park 2017: found no graft material clearly better for lid retraction.
- Pascali 2017: vertical midface lift corrected lid retraction in nearly all patients.