MANAGEMENT OF POSTBLEPHAROPLASTY LOWER EYELID RETRACTION WITH HARD PALATE GRAFTS AND LATERAL TARSAL STRIP

Lower eyelid malposition is the most common longterm complication foll owing 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 cosmeti cally 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, m ay be responsible for this malposition. A systematic examination of th e lower eyelid, as presented, helps to assess the degree to which each of these factors is responsible for the malposition. Patients with th e 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 re quired to provide vertical height and stiffness to support the lower e yelid following release of the cicatrix. A systematic approach aimed a t addressing the underlying abnormalities was developed. In patients w ith significant middle lamella scarring, hard palate mucosa grafts wer e used as spacers in 29 eyelids (17 patients). A lateral canthotomy an d 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, a nd 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 wi th significant scarring of the middle lamella, the technique we descri be allows correction of the lower eyelid malposition without a skin gr aft. After a follow-up interval of 6 to 30 months (mean 14 months), ex cellent results were obtained in all eyelids. Complications included c orneal abrasions in two eyes before routine use of bandage cornea cont act lenses at the end of surgery and a secondary bleed from the roof o f 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 unacceptabl e 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.