Fig. 18.11 Intraoperative clinical montage showing the three critical steps of the lateral canthal resuspension sine canthotomy technique (LCR-SC). (a) Forward pass of a single-armed 6.0 Prolene suture on a P3 needle through the upper eyelid blepharoplasty incision, under the orbicularis oculi muscle but above the lateral canthal tendon, and externalization through the apex of the lateral canthal angle at the mucocutaneous junction (yellow circle). (b) The suture is passed backwards through the same hole but this time under the lateral canthal tendon and externalized through the blepharoplasty incision. (c) The suture is anchored to the periosteum inside the lateral orbital rim (yellow circle)

18.8Conclusion

Lower eyelid retraction remains one of the most dreaded complications of eyelid surgery and occurs in as many as 20% of patients undergoing skin and muscle flap lower eyelid blepharoplasy [1, 2]. Even the most experienced surgeons will occasionally encounter a post-lower eyelid blepharoplasty patient with rounded lateral canthi and retracted lower eyelids. However, the vast majority of cases are the result of skin-focused blepharoplasty procedures and surgical techniques that alter important eyelid structures, such as the orbicularis oculi muscle and the orbital septum, which leads to postoperative eyelid weakening and scarring.

Some techniques that have been proposed for avoiding this complication are proper wound closure to avoid tether of the orbital septum in the operative site, a tight pressure dressing immediately following surgery to prevent hematoma formation, a Frost suture to apply upward traction on the lower eyelid during the early postoperative period, and a transconjunctival approach to fat to avoid violation of the septum and reduce the risk of scar formation [3, 6, 12–14, 48–50].

A thorough preoperative evaluation is essential for determining the pathophysiologic mechanism of eyelid retraction and deciding on the appropriate combination of surgical procedures needed to address the problem. Therefore, a lower eyelid “snap” test, a vertical traction test, and an evaluation for malar descent should be done at a minimum to assess for the contributing factors.

Many different procedures have been proposed for the correction of lower eyelid retraction. Inferior retractor weakening by releasing the sympathetically innervated lower tarsal muscle, recession of the capsulopalpebral fascia, and various horizontal shortening procedures have been used successfully to treat mild cases of eyelid retraction or laxity. For patients presenting with horizontal laxity of the lower eyelid only, without middle lamella scarring and malar descent, studies have shown that a lateral canthoplasty or canthopexy procedure can usually correct the problem [22–25, 51]. However, these lateral canthal resuspension procedures are usually ineffective when used alone in the presence of vertical inadequacy of the lower eyelid [4, 5, 8, 10, 11, 26–35, 40–47]. These patients require correction of the vertical inadequacy by reconstructing all eyelid lamellae involved, in addition to horizontal lower eyelid tightening. We found that, in the majority of patients with severe lower lid retraction, all three factors (lateral canthal tendon laxity, vertical eyelid shortening, and midface descent) are contributing to some extent to the eyelid malposition. For this reason, approaching the problem with any one surgical technique alone is unlikely to lead to optimal correction. Instead, we treat all three components as a functional and cosmetic unit by performing a combined lateral canthopexy, spacer graft placement, and

midface elevation. For the rare case where midface lifting is insufficient for reconstruction of a very short anterior lamella, surgeons may have to place a full-thickness skin graft, albeit at an aesthetic expense. This procedure has very low acceptance among cosmetic patients and should be used only as a last resort.

Although the middle and posterior lamellae are more difficult to reconstruct because of the lack of an ideal and readily available graft material, the cosmetic result is more acceptable to the patient. Thus, conjunctiva and tarsus are often supplemented by “spacers,” which are free grafts of “substitute” tissue that have physical and histologic properties that make them suitable to support eyelid structures and protect the globe [4, 5, 8, 10, 11, 26–35, 40–47]. The required “spacers” provide augmentation by lengthening the lower eyelid retractors and giving vertical height and stiffness to support the lower eyelid following release of the cicatrix.

Commonly used spacers include autogenous tissue (e.g., hard palate, ear cartilage, nasal septal cartilage, tarsus, periosteum, temporalis fascia, fascia lata, and sclera) as well as alloplastic implants, such as AlloDerm (LifeCell Corp., Branchburg, NJ), Mersilene mesh (Ethicon, Johnson & Johnson, Piscataway, NJ), Enduragen (Porex, Newnan, GA), and DermaMatrix (Synthese, West Chester, PA). AlloDerm has compared unfavorably to palatal grafts in lower eyelid reconstructive surgery. In one series, the use of acellular dermis grafts was associated with a 57% contraction rate as compared with a 16% rate observed with hard palate mucosal grafts [42]. A more recent study using thick AlloDerm grafts showed results comparable to those obtained with hard palate grafts and superior to those obtained with thin AlloDerm grafts [52]. Donor sclera was at one time a popular method; however, it suffers from a number of disadvantages, including postoperative shrinkage and folding, unpredictable final lid position, erythema, bulkiness, and the lack of a mucosal surface. Ear cartilage is also a popular choice but, despite being easy to harvest, it tends to be thicker and stiffer than natural tarsus, resulting in a relatively immobile lower eyelid. Because cartilage is difficult to contour, it can also result in a noticeable bump in the lower eyelid. Furthermore, reepithelialization is unpredictable over cartilage grafts. Free tarsal grafts are certainly ideal but necessitate surgery on the upper lid tarsus, risking possible untoward changes in the normal upper eyelid contour and height. However, this technique is useful in the rare instance when an upper eyelid tarsectomy is performed for the correction of concurrent upper lid ptosis.

The hard palate graft remains the gold standard because it most closely resembles tarsus in terms of consistency and stiffness, and provides a mucosal surface and good ocular comfort. Moreover, as these patients present after previously unsatisfactory or unsuccessful aesthetic surgery, a graft that

provides predictable results is critical. The use of hard palate grafts for the correction of lower eyelid retraction was first described by Kersten et al. in patients with thyroid orbitopathy, with good vertical eyelid splinting achieved even in the setting of advanced proptosis [4]. Cohen and Shorr subsequently reported good results with hard palate grafting for postblepharoplasty lower lid retraction [8]. The dense collagen matrix gives the palatal mucosa a firm consistency to provide adequate support without significant shrinkage.

A variety of approaches to midface elevation have been described in the literature [53–58]. These include upper and lower blepharoplasty incisions, a lateral canthotomy incision, and preauricular techniques. With the aim of maximal superolateral pull, we prefer the upper blepharoplasty approach when combined with a lateral canthopexy and placement of a spacer graft. This allows for well-hidden scars with adequate access to the malar fat pad. Although a subperiosteal malar elevation has been reported to be effective for recruiting skin to the lower eyelid, we have found the preperiosteal dissection quite satisfactory. If the anterior lamellar deficiency cannot be compensated by midface elevation because of the lack of recruitable skin, the patient may require skin grafting to provide adequate external coverage to the eyelid.

While each component of the tripartite procedure can be performed using various techniques described in the literature, we have chosen and modified certain procedures that we feel are most suitable for this patient population. For addressing the lateral canthal laxity, we find our LCR-SC to be an adequate technique for the vast majority of cases. The LCR-SC, a canthopexy-type procedure, is performed through an upper eyelid incision and avoids three common complications seen with the canthoplasy procedures: imbrication of the upper and lower eyelids, postoperative chemosis, and shortening of the horizontal palpebral aperture. In postsurgical patients, avoiding further shortening of the lower eyelid and scarring in the lateral canthal angle is desirable and better achieved with a canthopexy rather than a canthoplasty-type procedure. In addition, our technique is very useful because the same upper eyelid incision is used to perform a midface lift. However, there are certainly cases where a traditional LTS-type procedure is necessary to correct the horizontal lower eyelid laxity by shortening the tarsal plate laterally. Thorough preoperative evaluation should be done to determine the best procedure for each individual patient.

In conclusion, by combining the individual techniques of lateral canthopexy, spacer grafting, and midface suspension into a single tripartite procedure, the moderate to severe lower eyelid retraction found in some post-lower eyelid blepharoplasty patients can be effectively corrected. This approach leads to predictable anatomic results and has a high rate of patient satisfaction.

References

1.Neuhaus R, Baylis H. Complications of lower eyelid blepharoplasty. In: Putterman AM, editor. Cosmetic oculoplastic surgery. New York, NY: Grune & Stratton; 1982.

2.McGraw BL, Adamson PA. Postblepharoplasty ectropion. Arch Otolaryngol Head Neck Surg. 1991;117:852.

3.Patipa M. The evaluation and management of lower eyelid retraction following cosmetic surgery. Plast Reconstr Surg. 2000;106:438.

4.Kersten RC, Kulwin DR, Levartovsky S, et al. Management of lower-lid retraction with hard-palate mucosa grafting. Arch Ophthalmol. 1990;108:1339.

5.Shorr N, Fallor MK. “Madame Butterfly” procedure: combined cheek and lateral canthal suspension procedure for post-blepharo- plasty, round eye, and lower eyelid retraction. Ophthal Plast Reconstr Surg. 1985;1:229.

6.Jordan DR, Anderson RL. The tarsal tuck procedure: avoiding eyelid retraction after lower blepharoplasty. Plast Reconstr Surg. 1990;85:22.

7.Wolff E. Anatomy of the Eye and Orbit. 7th ed. Philadelphia, PA: Saunders; 1976.

8.Cohen MS, Shorr N. Eyelid reconstruction with hard palate mucosa graft. Ophthal Plast Reconstr Surg. 1992;8:183–95.

9.McCord Jr CD, Ellis DS. The correction of lower lid malposition following lower lid blepharoplasty. Plast Reconstr Surg. 1993;92:1068.

10. Shorr N. Madame Butterfly procedure with hard palate graft: management of post-blepharoplasty round eye and scleral show. Facial Plast Surg. 1994;10:90.

11. Patel BC, Patipa M, Anderson RL, McLeish W. Management of post-blepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip. Plast Reconstr Surg. 1997;99:1251.

12. McCord Jr CD, Shore JW. Avoidance of complications in lower lid blepharoplasty. Ophthalmology. 1983;90:1039.

13. Edgerton Jr MT. Causes and prevention of lower eyelid ectropion following blepharoplasty. Plast Reconstr Surg. 1972;49:367.

14. Tenzel RR. Complications of blepharoplasty, orbital hematoma, ectropion and scleral show. Clin Plast Surg. 1981;8:797.

15. Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol. 1979;97(11):2192–6.

16. Anderson RL. Tarsal strip procedure for correction of eyelid laxity and canthal malposition in the anophthalmic socket. Ophthalmology. 1981;88(9):895–903.

17. Jordan DR, Anderson RL. The lateral tarsal strip revisited. Arch Ophthalmol. 1989;107(4):604–6.

18. Karesh JW, Nirankari VS, Hameroff SB. Eyelid imbrication. An unrecognized cause of chronic ocular irritation. Ophthalmology. 1993;100(6):883–9.

19. Donnenfeld ED, Perry HD, Schrier A, Zagelbaum B, Rodgers R. Lid imbrication syndrome. Diagnosis with rose bengal staining. Ophthalmology. 1994;101(4):763–6.

20. Vagefi MR, Anderson RL. The lateral tarsal strip mini-tarsorrhaphy procedure. Arch Facial Plast Surg. 2009;11(2):136–9.

21. Webster RC, Davidson TM, Reardon EJ, Smith RC. Suspending sutures in blepharoplasty. Arch Otolaryngol. 1979;105(10):601–4.

22. Whitaker LA. Selective alteration of palpebral fissure form by lateral canthopexy. Plast Reconstr Surg. 1984;74(5):611–9.

23. Hamra ST. The role of the septal reset in creating a youthful eyelidcheek complex in facial rejuvenation. Plast Reconstr Surg. 2004;113(7):2124–41; discussion 2142–4.

24.Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg. 1998;102(5):1646–57.

25. Rizvi M, Lypka M, Gaon M, Kovacev T, Eisemann B, Eisemann MJ. Minimally invasive lateral canthopexy (MILC). J Plast Reconstr Aesthet Surg. 2010;63(9):1434–6.

26. Shorr N, Perry JD, Goldberg RA, et al. The safety and applications of acellular human dermal allograft in ophthalmic plastic and reconstructive surgery. Ophthal Plast Reconstr Surg. 2000; 16:223.

27.Rubin PA, Fay AM, Remulla HD, Maus M. Ophthalmic plastic applications of acellular dermal allografts. Ophthalmology. 1999;106:2091.

28. Fay AM, Pieroth L, Rubin PAD. An animal model of lower eyelid spacer grafting with acellular dermis. Ophthal Plast Reconstr Surg. 2001;17:270.

29. Patipa M, Patel BC, McLeish W, Anderson RL. Use of palate grafts for treatment of post-surgical lower eyelid retraction: a technical review. J Craniomaxillofac Trauma. 1996;2:18.

30. van der Meulen JC. The use of mucosa-lined flaps in eyelid reconstruction: a new approach. Plast Reconstr Surg. 1982;70:139.

31. Marks MW, Argenta LC, Friedman RJJ, Hall JD. Conchal cartilage and composite grafts for correction of lower lid retraction. Plast Reconstr Surg. 1989;83:629.

32. Holt JE, Holt GR, Van Kirk M. Use of temporalis fascia in eyelid reconstruction. Ophthalmology. 1984;91:89.

33. Obear MF, Smith B. Tarsal grafting to elevate the lower lid margin. Am J Ophthalmol. 1965;59:1088.

34. Baylis HI, Rosen N, Neuhaus RW. Obtaining auricular cartilage for reconstructive surgery. Am J Ophthalmol. 1982;93:709.

35. Siegel RJ. Palatal grafts for eyelid reconstruction. Plast Reconstr Surg. 1985;76:411.

36. Vecchione TR. Palatal grafts for lip reconstruction. Ann Plast Surg. 1983;10:301.

37. Yoshimura Y, Nakajima T. Tracheoplasty with palatal mucoperiosteal graft. Plast Reconstr Surg. 1990;86:558.

38. Hall HD, O’Steen AN. Free grafts of palatal mucosa in mandibular vestibuloplasty. J Oral Surg. 1970;28:565.

39. Holck DE, Foster JA, Dutton JJ, Dillon HD. Hard palate mucosal grafts in the treatment of the contracted socket. Ophthal Plast Reconstr Surg. 1999;15:202.

40. Doxanas MT, Dryden RM. The use of sclera in the treatment of dysthyroid eyelid retraction. Ophthalmology. 1981;88:887.

41. Karesh JW, Fabrega MA, Rodrigues MM, Glaros DS. Poly tetrafluoroethylene as an interpositional graft material for the correction of lower eyelid retraction. Ophthalmology. 1989;96:419.

42. Sullivan SA, Dailey RA. Graft contraction: a comparison of acellular dermis versus hard palate mucosa in lower eyelid surgery. Ophthal Plast Reconstr Surg. 2003;19:14.

43. Wainwright DJ. Use of an acellular allograft dermal matrix (AlloDerm) in the management of full-thickness burns. Burns. 1995;21:243.

44. Tobin HA, Karas ND. Lip augmentation using an AlloDerm graft. J Oral Maxillofac Surg. 1998;56:722.

45. Kridel RW, Foda H, Lunke KC. Septal perforation repair with acellular human dermal allograft. Arch Otolaryngol Head Neck Surg. 1998;124:73.

46. Jones FR, Schwartz BM, Silverstein P. Use of a nonimmunogenic acellular dermal allograft for soft tissue augmentation. Aesthet Surg Q. 1996;16:196–201.

47. Patrinely JR. Application of acellular dermal allografts. Ophthalmology. 2000;107:1966.

48. Zarem HA, Resnick JI. Expanded applications for transconjunctival lower lid blepharoplasty. Plast Reconstr Surg. 1991;88:215.

49. Kim JW, Ellis DS, Stewart WB. Correction of lower eyelid retraction by transconjunctival retractor excision and lateral eyelid suspension. Ophthal Plast Reconstr Surg. 1999;15:341.

50. Goldberg RA, Lessner AM, Shorr N, Baylis HI. The transconjunctival approach to the orbital floor and orbital fat: a retrospective study. Ophthal Plast Reconstr Surg. 1990;6:241.

51.Baylis HI, Nelson ER, Goldberg RA. Lower eyelid retraction following blepharoplasty. Ophthal Plast Reconstr Surg. 1992; 8:170.

52. Taban M, Douglas R, Li T, Goldberg RA, Shorr N. Efficacy of “thick” acellular human dermis (AlloDerm) for lower eyelid reconstruction: comparison with hard palate and thin AlloDerm grafts. Arch Facial Plast Surg. 2005;7(1):38–44.

53. Spinelli HM. Atlas of aesthetic eyelid and periocular surgery. Philadelphia: Saunders; 2004. p. 23–57, 120–35, 163.

54. Anderson RDA, Lo MW. Endoscopic malar/midface suspension procedure. Plast Reconstr Surg. 1998;102:2196.

55. Hinderer UT. Vertical preperiosteal rejuvenation of the frame of the eyelids and midface. Plast Reconstr Surg. 1999;104:1482.

56. Hester TR, Codner MA, McCord CD. The “centrofacial” approach for correction of facial ageing using the transblepharoplasty subperiosteal cheek lift. Aesthet Surg Q. 1996;16:51.

57. Edelstein C, Balch K, Shorr N, Goldberg RA. The transeyelid subperiosteal midface-lift in the unhappy postblepharoplasty patient. Semin Ophthalmol. 1998;13(3):107–14. Review.

58. Patel MP, Shapiro MD, Spinelli HM. Combined hard palate spacer graft, midface suspension, and lateral canthoplasty for lower eyelid retraction: a tripartite approach. Plast Reconstr Surg. 2005;115(7): 2105–14; discussion 2115–7.