Shorr FACE Institute
Lower Eyelid Retraction (The Madame Butterfly Procedure)

The Madame Butterfly is a world-renowned procedure developed by Dr. Norman Shorr out of his desire to solve what was a set of impossible problems – lower eyelid retraction (sometimes combined with hollowness, ectropion and entropion), all of which can occur following a routine lower eyelid blepharoplasty. Dr. Shorr and Dr. Taban are particularly skilled in this technique which incorporates both reconstructive and cosmetic components to achieve the best possible structural, functional and aesthetic results. Lower eyelid blepharoplasty is the removal of fat, and sometimes muscle and “excess skin” from the lower eyelids. In many cases, those who undergo the procedure obtain a very satisfactory result. However, the problems known as retraction, hollowness, ectropion and entropion will occur in a percentage of patients. Though these problems can occur randomly, those with large, prominent eyes seem to be at greater risk.

Before: Eyelids are extremely retracted and patient has significant hollowness.
After: Lower eyelids are properly positioned, hollowness is eliminated.
Before the Madame Butterfly Procedure.
After the Madame Butterfly Procedure.

Understanding the problems that can occur following a lower blepharoplasty:

To understand how retraction, ectropion and entropion can occur, one must understand the basic anatomy of the lower eyelid. The lower eyelid is made up of three layers. These three layers, when they are adequate and free to move independently of one another, allow the lower eyelid to function normally, such as rise appropriately, close completely, and interface perfectly with the eye itself.


Following a lower eyelid blepharoplasty, the formation of scar tissue in any one or a combination of these three layers can cause them to adhere to one another and become “tethered,” or to contract. A patient can therefore undergo a perfectly successful lower blepharoplasty, then during the healing process develop retraction, ectropion, entropion or a combination thereof.


  • Lower eyelid retraction – This means that the eyelid is pulled down and the white part of the eye below the iris is showing. This is also known as “round eye” or “scleral show.” Lower eyelid retraction can occur following a routine lower eyelid blepharoplasty due to an inadequacy of the middle layer of the three layers that make up the lower eyelid.
  • Hollowness – This is the gaunt or “sunken in” look which can result from the removal of too much fat of the lower eyelid area during a routine lower eyelid blepharoplasty. See figures below:
Lower eyelids were extremely retracted and patient had significant hollowness.
After surgery the lower eyelids are properly positioned and hollowness is eliminated.
  • Ectropion - The medical term for an eyelid that is “rolled out” or “hanging away” from the eye. Ectropion can occur following a routine lower eyelid blepharoplasty due to an inadequacy of the outermost layer of the lower eyelid which includes the skin. See figures below:
This patient had extreme retraction and ectropion.
After surgery lower eyelid was raised and the proper position restored.
  • Entropion - The medical term for an eyelid that is “rolled in” toward the eye. Entropion can occur following a routine lower eyelid blepharoplasty due to an inadequacy of the innermost layer of the lower eyelid. See figures below:
This patient had extreme retraction and entropion.
After surgery lower eyelid was raised and the proper position restored.

What if these problems go untreated or uncorrected?

If a patient has retraction with or without ectropion or entropion, the eye will be overexposed to air. Air is the enemy of the eye and too much air can immediately or gradually create a myriad of problems such as chronic irritation, tearing, mucous, redness, pain, a gritty sensation, and even the breakdown of the cornea itself. In addition, if a patient has entropion, the rolled in eyelid and lashes can rub against the eye which irritate and can damage the eye’s delicate surface. Hollowness can occur in any of these situations due to removal of too much fat.

What is considered the proper lower eyelid position

A correctly positioned lower eyelid will protect the eye and help maintain its health and comfort. The ideal position is for the lower eyelid margin to just graze the iris. The outer corner should be two millimeters higher than the inner corner. All four eyelids should interface appropriately with the eye and act as smooth “windshield wipers,” evenly spreading the moisturizing tears we produce across the exposed surface. This bathes the eye continuously which is essential for eye health and to maintain vision.

What methods are available to correct retraction?

To raise the lower eyelids into the correct position, surgeons have used skin grafts placed on the visible skin surface of the lower eyelid to lengthen it and/or have tried to raise and tighten the lower lid by suturing it at the outer corner. Skin grafts are almost never well matched to the surrounding eyelid skin and therefore are very rarely aesthetically pleasing, particularly for patients concerned about their appearance. Likewise, the tightening of the eyelid at the outer corner is not usually successful and can cause the lower eyelid to fall even lower, much like tightening the belt of a man with a protruding belly will result in his trousers being secured lower on the bulge of his belly rather than higher.

How is the Madame Butterfly Procedure performed? 

The Madame Butterfly procedure along with its many variations was developed by Dr. Norman Shorr to correct the challenging problems of retraction, ectropion, entropion and hollowness and is a better, more predictable option than skin grafts or eyelid tightening in almost all cases.

In the Madame Butterfly procedure, to obtain the slack needed to raise the lower eyelid, the entire cheek and midface is raised. You can see how a few millimeters of “excess” tissue is generated to accomplish this by pushing up on your own cheek with your fingers. This raising is done through a tiny incision at the outer corner of the eyelid in the natural smile crease. Scarring from the previous surgery or surgeries is removed, and adhered layers are separated. A graft is then placed on the inside of the lower eyelid (rather than placing an aesthetically unpleasing skin graft on the outside of the eyelid). This inner eyelid graft can be an alloderm graft or a hard palate graft and acts as a permanent and supple stent or support. Fat which is harvested from the abdomen (through a tiny belly button incision) may be necessary to fill in any hollowness of the lower eyelid area that is not filled in by the raising of the cheek and midface. The lower eyelid is then reconstructed and redraped in the ideal structural, functional and aesthetic position. The only incision made is the tiny incision at the outer corner of the eye, concealed in a natural smile crease and virtually invisible.

The Medical Result of the Madame Butterfly procedure: restored eyelid structure and function. The Cosmetic Bonus of the Madame Butterfly procedure: More beautifully shaped eyes and a higher, fuller, more youthful lower eyelid and cheek continuum.

Dr. Shorr performs the Madame Butterfly procedure routinely for patients referred to us for revision surgery from all over the country and around the world.  He has continued to evolve the concepts of the procedure and incorporate his own ongoing, cutting edge innovations as well as the most up to date developments of the most talented professors and advanced surgeons in the disciplines of ophthalmic plastic surgery, facial plastic surgery and dermatologic plastic surgery. Dr. Shorr and his colleagues add the entire spectrum of the Madame Butterfly procedures to the midface lift and endoscopic forehead lift procedures and thus provide the patient with all the synergistic benefits of combinations of sophisticated reconstructive and aesthetic facial rejuvenating options. Our surgeons carefully define the problem and then customize a surgical plan with each individual patient, to deliver maximum structural, functional and aesthetic benefit.
Who Should Perform the Madame Butterfly Procedure?
When choosing a surgeon to perform the Madame Butterfly Procedure, look for a cosmetic and reconstructive facial surgeon who specializes in the eyelids, orbit, and tear drain system. It’s also important that he or she has completed an American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) fellowship. This indicates your surgeon is not only a board certified ophthalmologist who knows the anatomy and structure of the eyelids and orbit, but also has had extensive training in ophthalmic plastic reconstructive and cosmetic surgery. Dr. Shorr is Director of the Fellowship in Ophthalmic Plastic Reconstructive and Cosmetic Surgery at the Jules Stein Eye Institute, UCLA School of Medicine. He and his associates are board certified ophthalmologists as well as ophthalmic plastic reconstructive and cosmetic surgeons who have completed an ASOPRS fellowship.

Dr. Norman Shorr is an early pioneer and innovator of many cosmetic and reconstructive eyelid, eyebrow, forehead and midface procedures performed today worldwide. He and his associates continue to innovate and contribute to the specialty of cosmetic and reconstructive facial surgery. Call today to schedule your personal consultation!


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We specialize in cosmetic and reconstructive surgery of the eyelids and face, as well as non-surgical cosmetic treatments and services. Our office is conveniently located in Beverly Hills near Los Angeles and bordered by Orange and Ventura Counties. Contact us today!


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