Summary
Purpose
Lower eyelid scaring and malposition following violation of all three lamellae pose
a significant ophthalmologic reconstructive challenge. The purpose of our study was
to document a staged approach for this problem using: 1) transconjunctival scar release
followed by palatal graft below the tarsal plate and subciliary scar release followed
by full-thickness skin graft superficial to the tarsal plate and 2) subsequent autologous
fat grafting to the lower eyelid.
Methods
Cadaveric anatomic dissections were performed. Post-traumatic and post-surgical lower
eyelid deformities requiring reconstruction were reviewed and outcome assessment was
based on symptomatic improvement, perioperative complications, reoperations and long-term
follow-up (> 1 year).
Results
Cadaver dissections demonstrated consistent lower eyelid tarsal plate and lamellar
anatomy for the use of palatal graft and skin grafting. Clinically, 75% cases resulted
from full thickness traumatic laceration of the lower eyelid or malar region and 25%
of cases occurred after transconjunctival incisions were made for zygomatic maxillary
repositioning following partial lower eyelid laceration.
Preoperative symptoms of: epiphora, tearing, redness, blurry vision and dryness improved in all patients and
complete resolution was seen in 63% of patients. Thirty-seven percent of patients
had complications: Redundancy of palatal graft, Partial FTSG loss, cellulitis after
fat transfer.
Conclusions
We describe an approach for the scarred and displaced lower eyelid following injury
to all three lamellae that provided symptomatic improvement after lower lid scar tissue
release, lengthening of the contracted septum, support of the posterior lamellae with
a palatal graft and a replacement of anterior lamella with full thickness skin graft.
Keywords
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References
- The incidence of lower eyelid malposition after facial fracture repair: a retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions.Plast Reconstr Surg. 2009 Nov; 124: 1578-1586
- Cicatricial entropion: an analysis of its treatment with transverse blepharotomy and marginal rotation.Ophthalmic Surg. 1989; 20: 575-579
- An examination of posttraumatic, postsurgical orbital deformities: conclusions drawn for improvement of primary treatment.Plast Reconstr Surg. 2008 Dec; 122: 1870-1881
- Management of lower-lid retraction with hard-palate mucosa grafting.Arch Ophthalmol. 1990; 108: 1339-1343
- Eyelid complications in trachoma. I. Cicatricial entropion.Ophthalmic Surg. 1989; 20: 800-807
- Repair of cicatricial entropion of the upper eyelid.Am J Ophthalmol. 1975; 80: 302-303
- Repair of entropion of upper lid.Arch Ophthalmol. 1967; 77: 675
- Palatal grafts for eyelid reconstruction.Plast Reconstr Surg. 1985; 76: 411-414
- Tarsotomy for the treatment of cicatricial entropion with trichiasis.Arch Ophthalmol. 1992; 110: 714-717
- The Wies procedure for management of trichiasis or cicatricial entropion of either upper or lower eyelids.Br J Ophthalmol. 2009; 93: 1612-1615
- Update on upper lid blepharoplasty.in: Guthoff R. Katowitz J.A. Essentials in ophthalmology. Oculoplastics and orbit. Springer, Berlin, Germany2006: 123-142
- The evaluation and management of lower eyelid retraction following cosmetic surgery.Plast Reconstr Surg. 2000; 106: 438-453
- Primary infratarsal lower eyelid retractor lysis to prevent eyelid retraction after inferior rectus muscle recession.Am J Ophthalmol. 1996; 122: 331-339
- The lower eyelid retractor consists of definite double layers.Ophthalmology. 2006; 113: 2346-2350
- Extraocular connective tissue architecture.J Vis. 2003; 3: 240-251
- Microscopic anatomy of Asian lower eyelids.Ophthal Plast Reconstr Surg. 2006; 22: 430-433
- Surgical anatomy of the ocular adnexa-a clinical approach.American Academy of Ophthalmology, San Francisco, CA1996 (16,17,26)
- Herniated fat and the orbital septum of the lower eyelid.Clin Plast Surg. 1993; 20: 323-330
- Tarsal grafting for correction of cicatricial entropion.Ophthalmic Surg. 1979; 10: 42-48
- Hard palate and free tarsalgrafts as posterior lamella substitutes in upper lid surgery.Ophthalmology. 2006; 113: 489-496
- Hardpalate mucosa graft in Stevens–Johnson syndrome.Am J Ophthalmol. 1994; 118: 786-791
- Tarsal polishing and mucous membrane grafting for cicatricial entropion, trichiasis and epidermalization.Ophthalmic Surg. 1983; 14: 1021-1025
- A trial of surgery for trichiasis of the upper lid from trachoma.Br J Ophthalmol. 1990; 74: 109-113
- Tarsoconjunctival grafts for upper eyelid cicatricial entropion.Ophthalmic Surg. 1988; 19: 316-320
- The use of mucous membrane from the hard palate in the treatment of trichiasis and cicatricial entropion.Ophthalmic Plast Reconstr Surg. 1986; 2: 129-131
- Graft contraction: a comparison of acellular dermis versus hard palate mucosa in lower eyelid surgery.Ophthal Plast Reconstr Surg. 2003 Jan; 19: 14-24
- Comparison of the efficacy of hard palate grafts with acellular human dermis grafts in lower eyelid surgery.Plast Reconstr Surg. 2005 Sep; 116 (discussion 879–80): 873-878
- Eyelid reconstruction with hard palatemucosa grafts [see comment].Ophthalmic Plast Reconstr Surg. 1992; 8: 183-195
- Hard palate mucosal grafts in oculoplastic surgery: donor site lessons.Am J Ophthalmol. 2004; 137: 1021-1025
- Autogenous hard palate mucosa: the ideal lower eyelid spacer?.Br J Ophthalmol. 2001; 85: 1183-1187
- Cicatricial entropion repair with hard palate mucous membrane graft: surgical technique and outcomes.Clin Exp Ophthalmol. 2008; 36: 348-352
- Surgical treatment of eyelid cancer with special reference to tarsoconjunctival flaps. A follow-up on 193 patients.Scand J Plast Reconstr Surg. 1975; 9: 107-115
- Long-term survival of fat transplants: controlled demonstrations.Aesth Plast Surg. 1995; 19: 421-425
- Facial recontouring with lipostructure.Clin Plast Surg. 1997; 24: 347-367
- Future of fat as raw material for tissue regeneration.Ann Plast Surg. 2003; 50: 215-219
- Fat transfer: current use in practice.Clin Plast Surg. 2000; 27: 545-556
- Fat injection in severe burn outcomes: a new persepective of scar remodeling and reduction.Aesth Plast Surg. 2008; 32: 465-469
- Periocular autologous coleman fat graft survival and histopathology.Ophth Plast and Recon Surg. 2008; 24: 213-217
- Correction of cicatricial ectropion by autologous fat graft.Aesth Plast Surg. 2008; 32: 555-557
Article info
Publication history
Published online: August 29, 2011
Accepted:
July 22,
2011
Received:
April 11,
2011
Identification
Copyright
© 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Inc. All rights reserved.
