CHAPTER 18 Treatment of Lower Eyelid Retraction with Recession of Lower Lid Retractors and Placement of Hard-Palate or Allogeneic Dermal Matrix Spacer Grafts

Treatment of lower eyelid retraction is common in patients with thyroid ophthalmopathy. It may also occur as a complication of previous blepharoplasty procedures, both cosmetic and functional. Treatment consists of recessing the lower lid retractors and placing a spacer between them and the inferior tarsal border. Present options include hard-palate grafting for the spacer because (1) it provides a mucous membrane lining to the internal lower lid; (2) it is rigid and flat; and (3) it is autogenous. A useful alternative however is using an allogeneic spacer graft to avoid issues relating to harvesting and also to reduce operative time.

A lower internal blepharoplasty along with lower retraction surgery is commonly performed. This approach differs slightly from the transconjunctival approach to resection of lower eyelid herniated orbital fat (see Chapter 14), in that the retractor incision is made at the inferior tarsal border rather than 5–6 mm inferior to the inferior tarsal border.

Allen M. Putterman and Steven Fagien

The most common cause for lower eyelid retraction today relates to eyelid malposition caused by cosmetic lower blepharoplasty. Lower eyelid retraction also frequently occurs in patients with thyroid ophthalmopathy. At times, it is associated with exophthalmos. In other cases it is an entity in itself, presumably secondary to contracture of the inferior rectus muscle, which then lowers the eyelid through its attachment to the capsulopalpebral fascia and the capsulopalpebral fascia attachment to the tarsus. This not only creates a cosmetic disturbance but also leads to ocular irritation and keratopathy.

Most patients who present with dissatisfaction after lower blepharoplasty complain or have symptoms related to lower eyelid malposition combined with a more ‘round’ appearance to the eye that is secondary to an increased vertical palpebral aperture and a shortened horizontal aperture. Often, mild to even moderate degrees of lower eyelid retraction need not be addressed depending upon the patient’s concerns, desires and expectations. Frequently, lower eyelid retraction is minimal and can be ignored. If, for instance, the patient with thyroid disease undergoes an orbital decompression for treatment of exophthalmos, the eye will commonly descend, thus making the lower eyelid retraction less apparent. If the retraction is moderate to severe and a decompression is not in the picture, the lower eyelid retraction should be treated. If a patient presents with lower eyelid retraction after blepharoplasty that is mild and without symptoms, they may have options for correction that are dependent upon what they are willing to endure regarding the surgical procedure, recovery, and final result.

Other causes can include orbital morphological situations such as maxillary hypoplasia with the so-called ‘negative vector’, or globe-related changes such as buphthalmos or high axial myopia. The most common cause for lower eyelid retraction in our practices is a complication of lower blepharoplasty.

An assessment of the type and amount of lower eyelid malposition can be performed on gross inspection and digital palpation of the lower eyelid. In the situation related to thyroid ophthalmopathy or other orbital morphological contributions, there is usually not a cicatricial component to the eyelid malposition. In the postoperative (blepharoplasty) variety, one must differentiate between a posterior or middle lamellar cicatrix versus a cicatrix mostly related to skin shortage (overzealous removal of lower eyelid skin, or skin/muscle). With the latter, posterior spacer grafts will be less effective in restoring normal lid position (due to skin shortage); however it has become more popular even in this scenario as patients wish to avoid visible external scarring.

Lower eyelid retraction can be formally measured by determining the distance from the lower eyelid to the inferior limbus of the eye in the primary position of gaze. This measurement is made not only centrally but also nasally and temporally.

Another method involves measuring the distance from a light reflex that is made to shine on the cornea to the lower lid as both patient and examiner look in the primary position of gaze, that is, the margin reflex distance-2 (MRD₂) (see Chapter 3, Fig. 3-9).¹ Normally, the lower eyelid rests at the inferior limbus. Measurements of retraction greater than 2 mm may be enough to warrant retraction surgery.

We prefer to treat cases of lower eyelid retraction (that do not exhibit a primary component of skin shortage) secondary to the variety of causes mentioned above that include thyroid disease and blepharoplasty complications by recessing the lower lid retractors and placing a hard-palate or allogeneic dermal graft between the recessed retractors and the inferior tarsal border. The purpose and utility of a posterior eyelid lamellar spacer graft in the aforementioned situations is to promote a normal lower eyelid position when the lower eyelid retractors or cicatrix is released/removed so that these options (autogenous or allogeneic) provide a stent to prevent or reduce recurrences. Presently we also use two different commercially available dermal matrix grafts, Alloderm TM (LifeCell, Woodlands, TX) and Dermaplant TM (Collagen Matrix Technologies, Boca Raton, FL).

The hard-palate graft presents a surface that is not only flat and rigid but also lined by oral mucous membrane, which simulates the conjunctiva. The allogeneic dermal graft requires in-vivo epithelialization to produce a soft interface between the lower eyelid and the globe. The treatment of lower eyelid retraction by recession of the lower lid retractors and placement of spacer grafts can be performed in conjunction with excision or transposition of herniated orbital fat through an internal lower eyelid approach.

The procedure for recession of lower eyelid retractors and placement of a hard-palate graft with excision of herniated orbital fat, or placement of an allogeneic dermal spacer graft is described under ‘Surgical technique’.

Preparation before surgery (with the implementation of a hard palate graft)

At some time before surgery, it is our preference when a hard palate graft is the chosen spacer graft, to work with a dentist who constructs a custom-fitted plastic plate that will fit onto the roof of the patient’s mouth.^2,³ This plate is attached to several teeth with extensions that come off the plastic plate. After retrieval of the hard-palate grafts and the placement of an absorbable gelatin sponge (Gelfoam) to the donor site, the plastic plate is inserted onto the roof of the mouth. The plate provides comfort and maintains hemostasis.

Surgical technique

Hard palate harvesting and grafting

Local anesthesia with intravenous sedation is usually used. Topical tetracaine is applied over the eye. A corneo-scleral contact lens is placed over the eye and under the upper and lower eyelids to protect the eye and minimize the patient’s discomfort from the operating lights. The patient is prepared and draped in the usual fashion, similar to that used for upper or lower blepharoplasty (see Chapters 7, 14 and 16). The mouth is prepared with povidone-iodine (Betadine) sponges rubbed over the teeth, hard palate, and tongue surface.

Two percent lidocaine (Xylocaine) with epinephrine is injected subcutaneously and diffusely throughout the lower eyelid. Injections of 2 percent lidocaine with epinephrine (∼0.5 ml) also are given into each fat pad. This is done via a 25-gauge needle inserted over the temporal, central, and nasal inferior orbital rim, for a distance of 1 cm, and aimed downward during each insertion. Additional 2 percent lidocaine with 1 : 100,000 epinephrine is injected into the central aspect of the upper eyelid just above the eyelashes.

A 4-0 black silk suture is placed through skin, orbicularis oculi muscle, and superficial tarsus at the center of the upper eyelid. The suture is used to pull the upper eyelid upward. Another 4-0 black silk suture is placed through skin, orbicularis muscle, and superficial tarsus at the center of the lower eyelid to evert the eyelid over a Desmarres retractor. Two percent lidocaine with epinephrine is injected subconjunctivally inferior to the inferior tarsal border and diffusely across the eyelid.

Recessing the lower eyelid retractors

Whether a hard palate graft or allogeneic spacer is used, the technique for recessing the lower eyelid retractors is basically the same. The goal is to release the lower eyelid retractors and/or cicatrix to optimize the lower eyelid position followed by placement of an inter-positional graft to maintain this correction.

A toothed forceps grasps the conjunctiva, Müller’s muscle, and the capsulopalpebral fascia at the temporal aspect of the eyelid, just beneath the inferior tarsal border (Fig. 18-1A). With a Westcott scissors, the surgeon penetrates this tissue and severs it from the inferior tarsal border. The Westcott scissors enters this opening and passes between capsulopalpebral fascia and orbicularis muscle across the eyelid (Fig. 18-1B). The surgeon facilitates this maneuver by separating the Westcott scissors blades during the passage and by pulling the scissors upward toward the conjunctival surface. At the same time, the surgeon’s assistant is releasing the Desmarres retractor slightly or pulling the skin surface outward. Because skin (and scar tissue in previously operated lower eyelids) is firmly attached to the orbicularis muscle and the conjunctiva is firmly attached to Müller’s muscle and capsulopalpebral fascia, the two lamellae separate in opposite directions during this maneuver.