Revisional Eyelid Surgery: Treatmentof Severe Postblepharoplasty LowerEyelid RetractionJohn Pak, MD, PhD

a, Allen M. Putterman, MDa,b,*

& Anatomic considerations in lower eyelidmalposition

& Mechanisms in lower eyelid retractionAnterior lamellaMiddle and posterior lamellae

& Treatment of anterior lamella–relatedlower eyelid retraction

Autogenous skin graftsCheek-midface lift

& Treatment of middle posteriorlamella–related lower eyelid retraction

Hard palate grafting& References

Lower eyelid blepharoplasty is a commonly per-formed procedure designed to reduce dermatocha-lasis and herniated orbital fat from the lower eyelid.The procedure can be performed by a transcuta-neous or transconjunctival surgical approach. Onechallenging and potentially disfiguring postopera-tive complication associated with this procedure islower eyelid retraction, defined as a downward mal-position of the lower eyelid margin. Severe lowereyelid retraction after lower lid blepharoplasty canoccur in up to 20% of cases [1–6].On clinical examination, lower eyelid malposi-

tion can present as a spectrum ranging from lateralcanthal rounding and scleral show to cicatricialectropion. Lower eyelid retraction can be measuredby defining the distance between the lower eyelidmargin and the inferior limbus of the eye in pri-mary position, commonly referred to as scleralshow. Under normal conditions, the lower eyelidmargin is positioned at the inferior limbus. Mea-surement of scleral show should be undertaken at

the temporal, central, and nasal positions of thecornea. Another measurement that can be usedis the margin reflex distance-2 (MRD2), definedas the distance from the light reflex reflected fromthe cornea when the eye is in primary gaze to thelower eyelid margin [7]. In severe lower eyelidretraction involving cicatricial attachment of thelower eyelid to the inferior orbital rim, a forcedelevation test can determine the degree of restric-tion [8].Individuals with lower eyelid retraction may

experience ocular irritations manifesting as con-junctivitis, epiphora, blurred vision, foreign bodysensation, and photophobia. Often, medical treat-ment with ocular lubricants can minimize oculardiscomfort; however, in severe cases of lower lidretraction, for example, those that result in lag-ophthalmos, exposure keratopathy may developand result in subsequent visual decline, particularlyin patients who have a poor Bell’s response. Profi-cient ways to manage severe lower eyelid retraction

F A C I A L P L A S T I CS U R G E R Y C L I N I C S

O F N O R T H A M E R I C A

Facial Plast Surg Clin N Am 13 (2005) 561–569

a Division of Oculoplastics, Department of Ophthalmology and Visual Sciences, University of Illinois Eye andEar Infirmary, 1855 West Taylor Street, Chicago, IL 60612, USAb Ophthalmology, Michael Reese Hospital, 2929 South Ellis, Chicago, IL 60616, USA* Corresponding author. 111 North Wabash Street, Suite 1722, Chicago, IL 60602.E-mail address: puttermanmd@hotmail.com (A.M. Putterman).

1064-7406/05/$ – see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2005.06.002facialplastic.theclinics.com

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can improve the functional and esthetic qualities ofthe postblepharoplasty lower eyelid.There are a variety of surgical approaches for

lower eyelid retraction, each tailored to the degreeof retraction and anatomic aberration. In mildlower eyelid retraction with concomitant lowereyelid laxity, a lateral canthal suspension or tarsalstrip procedure can be curative [9]. In cases of mod-erate lower lid retraction, the presence of cicatricialadhesions between the orbital septum and adjacentstructures causes the lower lid to be tethered to theinferior orbital rim. Lysis of the cicatrix and lateralcanthal resuspension can be curative [8,10]. In se-vere lower eyelid retraction, the cicatricial changesof the middle and posterior lamellae typically needstructural support of the lower eyelid after lysis ofadhesions. Clinical evaluation and identification ofthe causes leading to lower eyelid retraction areimportant for a successful surgical outcome. Casesof severe lower eyelid retraction are challenging,particularly those involving cosmetic blepharo-plasty. The corrective approach in these circum-stances must be functionally sound and maintainexcellent esthetic qualities. This article discusses theauthors’ approach to the treatment of severe lowereyelid retraction after cosmetic blepharoplasty.

Anatomic considerations in lower eyelidmalposition

Several putative mechanisms and anatomic consid-erations have been implicated in the developmentof lower eyelid retraction after blepharoplasty.A thorough understanding of the lower eyelidstructures and their dynamic interactions witheach other benefits the clinician when evaluat-ing the mechanisms involved in this challeng-ing complication.The lower eyelid can be divided into three sepa-

rate anatomic lamellae: the anterior, middle, andposterior. The anterior lamella consists of skin andorbicularis oculi muscle. The middle lamella con-sists of the orbital septum, which is attached to theinferior orbital rim at the arcus marginalis. Theposterior lamella consists of the inferior retractormuscles (capsulopalpebral fascia and inferior tarsalmuscle), tarsus, and palpebral conjunctiva. Theselamellae are intimately associated, and their inter-actions contribute to the contour and position ofthe lower eyelid.

Mechanisms in lower eyelid retraction

Anterior lamella

The involvement of the anterior lamella in lowereyelid retraction has largely been attributed to

lower eyelid blepharoplasty performed by a trans-cutaneous approach. Retraction after a transcon-junctival approach has not been reported [11,12].Unlike the transconjunctival approach, the trans-cutaneous approach involves an infraciliary skinincision and subsequent dissection into the sub-orbicularis space. Even when no anterior lamellais excised, vertical contraction of the skin maydevelop. The resultant scar can contract the anteriorlamella, leading to an effective deficiency in an-terior lamella and subsequent downward pull ofthe lower lid. This result may be observed morefrequently in the lower eyelid with lateral canthallaxity; however, nearly all cases of lower eyelid re-traction stem from overzealous excision of skin andorbicularis. Inappropriate excision of anterior la-mella may occur without careful attention to thechanging contour of the lower eyelid, particularlyafter the surgeon excises herniated orbital fat.Owing to the unacceptable risk of lower eyelid

retraction, the transconjunctival approach has be-come the preferred surgical method. Techniqueshave been refined to reduce the risk of causinglower eyelid retraction. The authors attempt tominimize lower eyelid retraction in individualswith herniated orbital fat with no dermatochalasisby performing a transconjunctival blepharoplasty[13]. In this approach, an incision through theconjunctiva and inferior retractor muscles is under-taken until the suborbicularis space and prolapsedfat are identified. The prolapsed fat is excisedor repositioned according to the clinical circum-stances. Because no skin is excised, the risk ofinducing lower eyelid retraction is reduced.In the presence of dermatochalasis, the authors

create a skin flap after removing herniated orbitalfat to excise excess skin. This maneuver can poten-tially increase the development of retraction, but atechnique is performed that minimizes the risk.The skin flap procedure has been described else-where [14]. An infraciliary incision is created, andthe lower eyelid skin is dissected from the under-lying orbicularis oculi muscle, thereby creating askin flap. To minimize excessive skin removal andappropriately determine the amount of skin to ex-cise, the assistant applies pressure to the globewhile the surgeon drapes the skin flap over theeyelid. Skin overhanging the eyelid margin is con-servatively excised. The ballottement of the globemimics the position of the eye in its extreme upgazeand determines the outer limit of skin excision.Using this technique, the authors have had excel-lent success avoiding lower eyelid retraction.On clinical examination, the surgeon should

evaluate the anterior lamella to determine whethera deficiency exists. The patient should be instructedto look upward while opening his or her mouth.

562 Pak & Putterman

A lower eyelid with vertically inadequate anteriorlamella will respond by retracting away from theglobe. Furthermore, the scleral show measurementcan be substantially greater when compared withthe contralateral normal lower eyelid. Lastly, theanterior lamella can be palpated to determine anyhint of tautness.

Middle and posterior lamellae

Severe lower eyelid retraction involving the middleand posterior lamellae has been attributed to post-operative cicatricial changes. Cicatricial changesand inflammation involving the orbital septumhave an important role in vertical contraction ofthe lower eyelid. In lower blepharoplasty, the her-niated orbital fat, orbital septum, and inferiorretractor muscles are incised and surgically manipu-lated. This surgical manipulation of the orbitalseptum and herniated orbital fat can induce inflam-matory changes leading to the formation of densescarring between these structures as well as adhe-sion to the orbicularis muscles. As the orbital sep-tum remains attached to the inferior orbital rim,adhesion with the inferior retractors will inducecontraction and retraction of the lower eyelid andtether the lower eyelid to the orbital rim.On clinical examination, lower eyelid retraction

secondary to adhesions of the middle and posteriorlamellae can be assessed by demonstrating resis-tance when attempting to elevate the lower eyelidover the cornea. Under normal conditions, thelower eyelid can be raised superiorly over the cor-nea with ease. With cicatrix of the orbital septumand inferior retractor muscles, the tethering of thelower lid to the inferior orbital rim precludes thelower eyelid from elevating over the cornea. Inmiddle lamella adhesions, the anterior lamellaemay be free to move in a vertical manner; however,the posterior tissue is well adherent and incapableof shifting upward.

Treatment of anterior lamella–related lowereyelid retraction

Autogenous skin grafts

Lower eyelid retraction resulting from a deficiencyin the anterior lamella can be treated successfullywith placement of autogenous skin grafts. The skingrafts can be taken from the upper eyelid, posteriorauricular area, or supraclavicular region. In indi-viduals with upper eyelid dermatochalasis, the up-per eyelid is the preferred donor site because ofsimilarities in skin texture and color between theupper and lower eyelids. One should use cautionwhen removing skin from the ipsilateral upper lidbecause of the potential for lagophthalmos on the

side where the retracted lower eyelid may havealready compromised closure of the eyelids. Fur-thermore, excision of upper lid skin will result inan asymmetric margin-to-skin crease and margin-to-skin fold measurements.In cases of lower lid laxity, a tarsal strip procedure

should also be performed. To encourage adhesionbetween the skin graft and recipient bed, suturetarsorrhaphies are placed to stretch the donor sitewhile a nonadherent (Telfa) bolster is placed overthe graft [15]. Although this surgical approach canremedy lower eyelid retraction, it has major dis-advantages. The placement of a skin graft can resultin a disfiguring scar and perceptible differencesin the skin color between the graft and adjacentskin. These qualities can be objectionable to most,if not all, esthetic-minded patients.Lower eyelid retraction owing to lower lid laxity

can be treated proficiently by procedures thattighten the lateral canthal tendon. In contrast, ante-rior lamella–associated lower eyelid retraction can-not be treated properly by this surgical approach.Although some types of retraction are treated usinga spacer such as a hard palate graft, it is not bene-ficial under these circumstances. Adding verticallength to the posterior lamella will exacerbate theasymmetry between the anterior and posteriorlamellae and, in most cases, result in frank lowereyelid ectropion. In light of the esthetic disadvan-tages of autogenous skin grafting for the treatmentof anterior lamella–induced retraction, the cheek/midface lift has proved to be an excellent surgicalapproach for augmenting and vertically lengthen-ing the retracted lower eyelid.

Cheek-midface lift

The cheek-midface lift is an excellent procedure forcorrection of severe lower eyelid retraction owingto a deficiency of anterior lamella [8,16–18]. Theeffectiveness of this procedure rests in the ana-tomic relationship between the lower eyelid andthe midface-cheek. The skin and orbicularis oculimuscle of the lower eyelid extend below the infe-rior orbital rim and constitute part of the midface.In the cheek-midface lift, the midface is suspendedupward to the lateral orbital wall. The upwardsuspension of skin and orbicularis of the midfaceeffectively adds vertical height to the lower eyelid[Fig. 1A, B].Furthermore, this procedure has excellent esthetic

qualities that cannot be undervalued. Most of thedissection occurs in the subperiosteal space and isreached by a transconjunctival approach. A minorexternal incision created at the lateral canthal re-gion is the sole external incision. Eliminating dis-figuring facial scars or skin grafts can be gratifyingfor the postblepharoplasty patient who is seeking

563Revisional Eyelid Surgery

an esthetic solution. By elevating the orbicularisand suborbicularis fat pad, the surgeon can mini-mize any inferior rim hollowing, a common fa-cial feature found in aged faces. If herniatedorbital fat exists in the presence of a tear-trough de-formity, the isolation of the central and nasal fatpads can be repositioned easily in the subperios-teal space during the cheek-midface lift procedure[19–21]. Because of these esthetic qualities, thecheek-midface procedure is an excellent choice forthe treatment of lower eyelid retraction.

Surgical techniqueThe cheek-midface procedure can be performedusing local anesthesia with intravenous sedation[16]. Local anesthetic consisting of a mixture of li-docaine and bupivacaine hydrochloride (Marcaine)(40 mL of 0.5% lidocaine with 1:200,000 units ofepinephrine plus 4 mL of 0.5% bupivacaine hydro-chloride) is injected above the inferior orbital rimin a slightly downward motion that prevents in-advertent penetration of the eye. Approximately0.5 to 1.0 mL of local anesthetic (1% lidocainewith 1:100,000 units of epinephrine) is injectedin the nasal, central, and temporal fat pads in thelower eyelids. The local anesthetic used for the mid-face is injected in the subperiosteal space overlyingthe maxilla to the nasolabial folds and upper gumregion. The infraorbital foramen should be identi-fied and marked using a methylene blue pen andlocal anesthetic injected around this area.A lateral canthal incision is created extending

1.5 to 2.0 cm from the lateral canthal angle usinga No. 15 Bard-Parker blade. A lateral canthotomyand inferior lateral cantholysis are performed usinga handheld cautery device. A 4-0 silk traction sutureis placed through the skin, orbicularis muscle, andsuperficial tarsus at the center of the lower eyelid.A Desmarres retractor is used to evert the lower lid,and anesthetic is injected into the subconjunctivalspace. With the use of a Colorado needle, the con-junctiva and inferior retractor muscles are incised

from the medial to temporal end of the eyelid. Theassistant grabs the superior edge of the incisedtissues as the surgeon grabs the inferior edge tofacilitate exposure of the orbital fat. The incisionis performed until fat is observed. At this junc-ture, if fat repositioning of the central and nasalfat pads is planned, the fat capsule is not pene-trated; rather, a Desmarres retractor is used to pullthe lower lid downward to expose the inferior or-bital rim. By not opening the herniated fat capsule,the surgeon will not obscure the exposure to theinferior orbital rim. Fat repositioning and excisionof temporal herniated orbital fat are performedlater in the procedure and have been describedelsewhere [19–21].Blunt dissection down to the periosteum is per-

formed using a Tenzel periosteal elevator. Incisionof the periosteum can be performed with a Colo-rado needle or No. 15 Bard-Parker blade. The Des-marres retractor is used to retract nasally, centrally,and temporally along the lower eyelid until theperiosteum has been incised along the entire infe-rior orbital rim. The sharp end of the Tenzel peri-osteal elevator reflects the periosteum from theincision site in a downward direction over themaxilla; however, the dissection does not involvethe area containing the infraorbital nerve and ves-sels. Cotton-tipped applicators can be used forgentle dissection in this area. Leaving this area ofthe periosteum intact allows the nasal area to serveas the fulcrum for the cheek-lift. In cases that re-quire the addition of anterior lamellae, such as incicatricial ectropion or postblepharoplasty lowerlid retraction, gentle dissection nasal to the infra-orbital foramen may be necessary. The periosteumis dissected from the maxilla inferiorly to the naso-labial folds and upper border of the upper gum.Blunt dissection with fingers in the subperiostealspace can improve the dissection. Once the dissec-tion is complete, the inferior border of the dissectedperiosteum is incised with a No. 11 Bard-Parkerblade. After the incision, a Ramirez endoforehead

Fig. 1. (A) Patient with preoperative lower eyelid retraction secondary to deficiency of skin after cosmeticblepharoplasty. (B) Same patient after cheek-midface lift and tarsal strip to provide external lamellae. (FromMauriello JA. Techniques of cosmetic eyelid surgery. 1st edition. Philadelphia: Lippincott, Williams, and Wilkins;2004. p. 104; with permission.)

564 Pak & Putterman

periosteal spreader is used to reflect the dissectedperiosteum superiorly away from the inferior edgeof the periosteum.Once the periosteum has been dissected suffi-

ciently, hemostasis is achieved by cautery and tam-ponade using cotton gauze soaked in localanesthetic. By performing tamponade, the surgicalteam can prepare the other side of the face, allow-ing time for hemostasis to develop. At this juncture,the lower eyelid is horizontally shortened and tem-porally elevated by a tarsal strip procedure. Thisstep is critical to reduce the risk for cicatricial ectro-pion. As the lower eyelid is placed superiorly andtemporally, the margin of the lower lid that meetsthe temporal upper lid is marked on the skin sur-face with a scratch incision using a No. 15 Bard-Parker blade. After the tarsal strip is created, a4-0 polypropylene double-armed suture is placedinternally to externally in a locking fashion. Thesuperiorly placed end is plicated to the internalaspect of the lateral orbital wall, usually the peri-osteum. Under some circumstances, the suture isattached to the upper eyelid lateral canthal tendonor upper eyelid temporal tarsus. Regardless of theplacement of the superior suture, the inferior endis placed slightly inferior. The suture is temporarilytied over a 4-0 silk suture using a surgeon’s knot.After the procedure is repeated on the other side

if necessary, the patient is placed in the sitting posi-tion to evaluate the symmetry of the lateral canthi.At this point, the position and symmetry of thelateral canthi are evaluated by placing a millimeterruler aligning the medial canthi. If asymmetryexists, the surgeon’s knot is untied, and the sutureis repositioned into a more favorable position.Once the positions of the lateral canthi are deemed

appropriate, the sutures are loosened, and the4-0 silk sutures are removed. The lateral canthalangles are reconstructed by placing a 5-0 chromicgut suture through the upper and lower eyelidmargin. The suture is placed approximately 2 mmfrom the lateral edge of each eyelid within the grayline. After the suture is tied, the 4-0 polypropylenesutures are tied with permanent knots. A 4-0 poly-glactin (Vicryl) suture is placed through periosteumand the lateral tarsal strip to further secure thelower eyelid to the periosteum. Excess tarsal stripcan be excised.By this time, the gauze has been removed from

underneath the cheek tissue, and hemostasis hasbeen achieved with cautery. With the use of forceps,the orbicularis flap that is lateral to the lateralcanthus is elevated superiorly and temporally.This movement induces an elevation of the cheekand reduces the nasolabial folds. A 4-0 polypro-pylene suture is placed from internal to external ofthe orbicularis muscle and then placed to the peri-

osteum over the lateral orbital wall. Similar to thelateral tarsal strip construction, the suture is tiedwith a surgeon’s knot over a 4-0 silk suture.After the same procedures are completed on the

contralateral side, the patient is placed in a sittingposition in which one can evaluate the relativeposition of the elevated cheek tissue. If the positionis satisfactory, the patient is placed back in thesupine position, and the knots are released toremove the 4-0 silk sutures and then permanentlytied. A second 4-0 polypropylene suture secures theorbicularis flap to the temporalis fascia over thelateral orbital, providing additional support thatmaintains the elevation of the cheek tissue. Anyexcess orbicularis is excised using Westcott scissors.The superior and inferior edges of the orbicularisare sutured together using a 6-0 polyglactin su-ture, and the orbicularis and skin are approximatedusing 6-0 polyglactin and silk sutures.

Treatment of middle posteriorlamella–related lower eyelid retraction

An approach for correcting lower eyelid malposi-tion involving cicatrix of the middle and posteriorlamellae involves lysis of the adhesions and place-ment of a spacer within the posterior lamella[21–26]. Severing the adhesions between the or-bital septum and adjacent structures without theaddition of a spacer can lead to readhesion ofthe same internal eyelid structures and result inno change in lower lid retraction. Donor-bankedsclera, acellular dermis grafts (AlloDerm), nasalseptal cartilage, and ear cartilage have been usedas lower eyelid spacers.Based on surgical experience involving many pro-

cedures with different spacers, the autogenous hardpalate graft has proved to be an excellent choice forthe lower eyelid in the treatment of postblepharo-plasty lower eyelid retraction. A key attribute of thehard palate graft is its tissue composition. The hardpalate consists of two tissues that resemble thetarsus of the lower eyelid. Its mucosal surface isnonabrasive similar to conjunctiva, whereas itscollagenous component provides tensile strengthwith flexibility similar to tarsus. Furthermore, un-like other potential spacers, the autogenous hardpalate does not undergo severe contraction. Con-traction of the spacer can minimize the long-termeffectiveness of treating lower eyelid retraction. Inone report, the mean graft contraction rate was57% for thin acellular dermis and 16% for hardpalate mucosal grafts (P < .005) [27]. Recently, astudy evaluating thick Alloderm as a spacer re-ported less contraction in a comparison with thinAlloderm [28]. The advantage of using Allodermis primarily the avoidance of the morbidities asso-

565Revisional Eyelid Surgery

ciated with obtaining the hard palate graft. Oral dis-comfort, the formation of oronasal fistulas, bleed-ing, and salivary mucous production from the graftare known postoperative complications associatedwith the hard palate graft [29,30]. Despite thesepotential disadvantages, the use of autogenous tis-sue is superior to allogeneic sources, particularly inpreventing the transmission of infectious agentssuch as viruses and prions. The hard palate graftprocedure should be in every oculoplastic sur-geon’s armamentarium.

Hard palate grafting

The hard palate graft has been performed alone andin conjunction with other procedures. Patel andcoworkers [21] treated 29 eyelids with lower eyelidretraction by severing the cicatrix of the middlelamella and placing a hard palate graft to serve asa lower eyelid spacer. They demonstrated excellentresults in all eyelids treated in this manner.Several studies have examined the role of per-

forming a subperiosteal midface-lift in associationwith hard palate grafting for severe lower eyelid re-traction [8,22,24]. These investigators treated post-blepharoplasty lower eyelid retraction using anapproach that addressed each lamellar layer ofthe lower eyelid. A total full-thickness lower eye-lid reconstruction and subperiosteal midface-lift[Fig. 2A, B] were performed. Each lamellawas evalu-ated for the presence of deficiency or cicatrix. Incases in which the anterior lamella was deficient,

rather than the surgeon performing an autoge-nous skin graft, a subperiosteal midface-lift was per-formed to augment the anterior lamella. Formiddle lamellar cicatrix, adhesions in the subor-bicularis space and orbital septum that limited thevertical ascent of the lower eyelid were identifiedand subsequently lysed. For the posterior lamella,the placement of a hard palate graft to the inferiortarsus and inferior retractor muscles augmentedthe vertical length of this lamella and providedstability to the eyelid. In the presence of lower lidectropion, lower eyelid retraction was treated witha horizontal shortening procedure plus hard pal-ate grafting [Fig. 3A, B].

Surgical techniqueThe surgical technique for the hard palate graft isas follows. Local anesthesia with intravenous seda-tion can be performed [31]. Topical anesthetic(eg, tetracaine) is placed on the eye and conjunc-tiva, and a protective scleral contact lens is placedover the cornea. Local anesthetic consisting of2% lidocaine with 1:100,000 units of epinephrineis injected subcutaneously along the central lowereyelid, and approximately 0.5 mL of local anes-thetic is injected into each of the three fat pads.This injection is performed with a 25-gauge needlefor a depth of approximately 1 cm. Additionalanesthetic is injected at the central eyelid marginof the upper eyelid. At the central aspect of theupper and lower eyelid, a 4-0 silk suture is placedthrough the skin, orbicularis, and superficial tar-

Fig. 2. (A) Patient with preoperative lower eyelid retraction secondary to deficiency of internal and externallamellae from previous blepharoplasty. (B) Same patient after cheek-midface lift to provide external lamellae andhard palate graft to provide internal lamellae with tarsal strips. (FromMauriello JA. Techniques of cosmetic eyelidsurgery. 1st edition. Philadelphia: Lippincott, Williams, and Wilkins; 2004. p.105; with permission.)

Fig. 3. (A) Patient with preoperative lower eyelid retraction secondary to deficiency of internal lamellae. (B) Samepatient after recession of lower eyelid retractor muscles and hard palate grafting plus tarsal strips. (FromMauriello JA. Techniques of cosmetic eyelid surgery. 1st edition. Philadelphia: Lippincott, Williams, and Wilkins;2004. p. 104; with permission.)

566 Pak & Putterman

sus to serve as traction. The superiorly placed silksuture is tied upward, and the lower silk suture isused to evert the lower eyelid over a Desmarresretractor. Eversion of the lower eyelid with theretractor will expose the palpebral conjunctiva.Local anesthetic is injected in the subconjunctivalspace inferior to the inferior tarsal border and isinjected diffusely across the length of the lowereyelid. Commonly, a tarsal strip procedure is per-formed in conjunction with hard palate grafting,particularly in the presence of lower eyelid laxity.The procedure is described elsewhere [32].Using forceps, the surgeon grasps the conjunc-

tiva, Muller’s muscle, and capsulopalpebral fasciaat the lateral aspect of the lower eyelid adjacent tothe inferior tarsal border. A Westcott scissors is usedto pierce the tissue, severing it from the inferiortarsal border. Once the tissues are separated fromthe tarsus, the Westcott scissors is used to burrowand dissect in a plane between the orbicularis oculimuscle and the capsulopalpebral fascia. The scis-sors cuts the inferior retractor muscles from thetarsal border along the length of the eyelid. Toensure that the plane is correctly entered and sev-ered, the Westcott scissors is pulled superiorly whilethe traction from the skin is placed in opposingdirections. In this manner, the skin and orbicularisoculi physically separate from the underlying cap-sulopalpebral fascia, creating a wider plane forproper dissection. Separation of the two lamellaeis critical, because inadvertent severing of the orbi-cularis oculi can jeopardize the vascular supply tothe eyelid and its appendages, such as cilia. As thetwo lamellae are separated, one blade of the West-cott scissors is situated between them while theother blade is external to the conjunctiva. The tis-sues within the blades are severed with the Westcottblade, tenting the capsulopalpebral fascia in anupward direction. Alternatively, the dissection canbe accomplished using a Colorado needle or dis-posable cautery in experienced hands.A 4-0 silk suture imbricates the conjunctiva,

Muller’s muscle, and the capsulopalpebral fasciaat the center of the eyelid and is placed superiorlyto cover the eye. A small Desmarres retractor is usedto pull the lower eyelid downward, and blunt dis-section with cotton-tipped applicators within thesuborbicularis space is performed to identify thetemporal, central, and nasal fat pads. The inferioroblique muscle separates the central and nasal fatpads. It is important to identify the inferior obliquemuscle during the dissection because damage tothis muscle can lead to diplopia, strabismus, orboth. Care should be taken when cauterizing inthis area. The fat pad capsules are delicately openedto excise herniated orbital fat. The herniated fatthat prolapses can be excised by clamping using a

straight hemostat, excising it with a No. 15 Bard-Parker blade and cauterizing the clamped fat hemo-stat with Bovie cautery. Before the fat is releasedfrom the hemostat, it is grasped with a toothedforceps to ensure there is no hemorrhaging fromthe fat pad before allowing the fat to return to theorbit. This technique is performed for all prolapsedfat in each fat pad.Once excision of the prolapsed fat has been

accomplished, the 4-0 silk suture imbricating theinferior retractor muscles is released. The lower eye-lid is placed in its natural position, and any restric-tion in the upward movement of the lower lid isevaluated. If any exists, the lower retractors, par-ticularly at the extreme nasal and temporal edges,may need to be released further. One should notrecess the nasal edge near the lower canaliculusbecause of possible damage to this structure. Thelower eyelid is everted to measure the distance be-tween the inferior tarsal border and the recessedinferior retractor muscles. This measurement servesas the guide for the creation of the hard palate graft.Obtaining the hard palate graft has been de-

scribed elsewhere [23,25,26,31]. The mouth is pre-pared using several washes of povidone-iodinesolution. The authors use a Jennings oral retractorto pry open and keep the mouth open during theprocedure. A tongue blade places downward pres-sure on the tongue to improve exposure of thehard palate. A methylene blue pen is used to drawan area on the hard palate with the dimensionsneeded for the lower lid graft. The borders of thegraft are as follows: posterior border, junctionbetween the hard and soft palate; central border,several millimeters temporal from the center of thehard palate; and temporal border, several milli-meters from the temporal aspect of the hard pal-ate. Local anesthetic is injected in the submucosalspace surrounding the areas marked for the graft.A No. 15 Bard-Parker blade is used to incise alongthe demarcated area of the hard palate graft, butthe incision is not extended deep into the mucoperi-osteum. A No. 66 Beaver blade is used to dissect thetissue from the hard palate. Care should be taken toreduce buttonholing the graft during the dissection.Once the graft is successfully removed, hemosta-

sis at the donor site is maintained by placing anabsorbable gelatin sponge on the wound andapplying pressure using a hard palate prosthesis.The hard palate prosthesis can be molded andcreated before surgery by a dentist. The conformershould extend to the posterior border of the pro-posed donor site of the hard palate graft. Discuss-ing the dimensions with the dentist can reduce thediscomfort and improve the healing of the hardpalate postoperatively. The hard palate graft shouldbe measured, and any excess submucosal tissue

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should be excised to create a graft that consists ofmucous membrane and the underlying tissue.Afterward, the graft can be submerged in a solutionof antibiotic such as gentamicin sulfate.After the graft has been prepared properly and the

inferior retractor muscles recessed, the graft is readyto be sutured to the lower eyelid retractors. Withthe graft’s mucosal surface facing the eye, a 5-0chromic gut suture is placed to attach the inferiorretractors to the inferior edge of the hard palategraft. Care must be taken to ensure that the nasaland temporal edges of the graft and lower eyelidcoincide. After the lower aspect of the graft issutured to the inferior retractors, the scleral contactlens is removed, and the lower eyelid is placed at itsnatural position. This technique will determinewhether any excess tissue of hard palate graft existsand, if so, whether any graft needs to be excisedbefore suturing the superior end to the tarsus of thelower eyelid. Excision of excess graft can be per-formed with a Westcott scissors. The superior edgeof the hard palate graft is sutured to the inferioredge of the tarsus with 5-0 chromic gut run in anasal to temporal direction. Because this suturemay rub against the cornea, it is important tobury the suture knots.To prevent cicatricial retraction and improper

lower eyelid scarring, a nasal and temporal suturetarsorrhaphy is placed using 4-0 silk sutures. Thesutures are placed through the skin and orbicularisof the lower eyelid and exit from the eyelid marginat the gray line. They are placed through the skinand orbicularis above the eyebrow. Before tyingthe sutures permanently over cotton pledgets, thescleral contact lens is removed, and a 24- or48-hour collagen contact lens is placed over thecornea. The sutures are placed tautly to ensurethat the lower eyelids are on upward stretch. Thesuture tarsorrhaphies are removed after 7 days.

References

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569Revisional Eyelid Surgery