Management of Postblepharoplasty Lower Eyelid Retraction with Hard Palate Grafts and Lateral Tarsal Strip

Abstract

Lower eyelid malposition is the most common long-term complication following transcutaneous lower eyelid blepharoplasty. The malposition may include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, or frank ectropion. The result is cosmetically unacceptable and may be associated with tearing, irritation, and other exposure keratitis symptoms. Multiple factors, including lower eyelid laxity, shortage of skin, and scarring of the middle lamella, may be responsible for this malposition. A systematic examination of the lower eyelid, as presented, helps to assess the degree to which each of these factors is responsible for the malposition. Patients with the most severe degree of lower eyelid malposition generally have middle lamella scarring. If this abnormality is not addressed, lower eyelid procedures aimed at correcting the malposition are doomed to failure. In the presence of significant middle lamella scarring, a spacer is required to provide vertical height and stiffness to support the lower eyelid following release of the cicatrix. A systematic approach aimed at addressing the underlying abnormalities was developed. In patients with significant middle lamella scarring, hard palate mucosa grafts were used as spacers in 29 eyelids (17 patients). A lateral canthotomy and transconjunctival incision allow access to the scarring in the lower eyelid retractors and septum. After careful release of all cicatrix, a hard palate mucosa graft is inserted between the lower border of the tarsal plate and the recessed conjunctiva, lower eyelid retractors, and septum. Horizontal lower eyelid laxity, when present, is corrected by performing a lateral tarsal strip. Most patients do not have a true deficiency of the anterior lamella (skin and orbicularis oculi muscle). When a moderate amount of anterior lamella deficiency is present with significant scarring of the middle lamella, the technique we describe allows correction of the lower eyelid malposition without a skin graft. After a follow-up interval of 6 to 30 months (mean 14 months), excellent results were obtained in all eyelids. Complications included corneal abrasions in two eyes before routine use of bandage cornea contact lenses at the end of surgery and a secondary bleed from the roof of the mouth in one patient. Palate mucosa closely resembles tarsus and provides excellent vertical support to the eyelid. It is stiff enough to maintain eyelid contour without causing a cosmetically unacceptable bump. Tissue can be obtained with ease. The technique, as described, addresses the underlying causes of lower eyelid malposition and gives excellent functional and cosmetic results.

Midface Lifting as an Adjunct Procedure in Ectropion Repair

“…[1][2][3]18 Although these grafts have been used for many years, especially in cases of cicatricial ectropion and postblepharoplasty ectropion, we prefer to avoid the use of spacer grafts whenever possible since they involve donor-site morbidity, increased operative time, or increased operative costs. Three of our patients with recurrence of ectropion after ectropion repair with adjunctive midface lifting, however, required spacer grafts after the primary surgery.…”

Porcine Dermal Collagen in Lower Eyelid Retraction Repair

“…3 Hard palate mucosa has become one of the most commonly used posterior lamella spacer grafts. 1,3,4,22,23,[46][47][48][49] The hard palate is formed by the palatine processes of the maxilla and the horizontal processes of the palatine bones with the overlying soft tissue. 72 It forms the roof of the oral cavity and the floor of the nasal cavity.…”

“…Additionally, the use of synthetic materials including polytetrafluoroethylene 29,30 and porous polyethylene 31-34 has also been described. Autogenous and irradiated tarsus, [35][36][37][38] donor sclera, 39,40 dermis grafts, 41 auricular cartilage, 20,42-45 cadaveric dermal collagen, 1 and hard palate mucosal grafts 1,3,4,22,23,[46][47][48][49][50] have also been used with varying success rates. The auricular cartilage and hard palate mucosal grafts have probably enjoyed the most use.…”

Inferior rectus pulley hindrance: A mechanism of restrictive hypertropia following lower lid surgery

“…14 Comprehensive reviews of other complications have been published. 15,16,17 Functionally disabling diplopia is certainly a tragic postoperative event to be avoided in an elective esthetic procedure such as blepharoplasty or in functional lower eyelid reconstructive surgery. Nevertheless, a series by Alfonso et al and Hayworth et al described cases they interpreted as diplopia due to IR paresis following blepharoplasty 18,19 or lower eyelid surgery.…”