Introduction: Severe scarring and malposition of the lower eyelid following violation of all three lamellae pose a significant reconstructive challenge (1). Although there are described treatments for ectropion and entropion, for severe lower eyelid scarring and retraction, the treatment is not as well defined. We describe a staged approach for this challenging problem using: transconjunctival scar release/midface elevation/vertical spacer/subciliary scar release with full-thickness skin graft and subsequent autologous fat transfer to the lower eyelid (2,3).

Methods: We retrospectively reviewed post-traumatic and post-surgical lower eyelid deformities requiring reoperation from 1997 to 2008 (n=71) and identified 14 patients (19%) with a severely scarred and malpositioned lower eyelid who underwent our described staged technique of 1) transconjunctival scar release with subperiosteal midface elevation followed by palatal graft below the tarsal plate, and subciliary scar release followed by full-thickness skin graft from contralateral upper lid to the anterior tarsal plate; 2) subsequent autologous fat grafting to the lower eyelid. Outcome assessment was based on symptomatic improvement, perioperative complications, reoperations and long-term follow-up (greater than 1 year).

Results: Eleven of these cases resulted from full thickness traumatic laceration of the lower eyelid or malar region and 3 cases occurred after transconjunctival incisions made for zygomatic maxillary repositioning following partial lower eyelid laceration. Ten of these cases were from motor vehicle accidents and 4 from assault injuries. The lower eyelid reconstruction was performed at a mean of 9.1 months following the initial injury (range=6 to 17 months). There was an average of 2.6 procedures performed per patient. Preoperatively, symptoms of: epiphora, tearing, redness, blurry vision and dryness improved in all 14 patients and complete resolution was seen in 11 of the 14 patients (Fgiure 1). Three 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 emphasizes release of lower lid and malar scar tissue, elevation of the midface, lengthening of the contracted septum and posterior lamellae with a palatal graft and a replacement of anterior lamella with full thickness skin graft. This reconstruction allong with minor revisions with fat transfer provided symptomatic improvement in a small series. In addition, we suggest caution against transconjunctival approach following partial lower eyelid cutaneous injury.

References:

1. Ridgway EB, Chen C, Colakoglu S, Gautam S, Lee BT. 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(5):1578-86. 2. Zide, BM, Jelks, GW, Surgical Anatomy of the Orbit. Raven Press, 1985, pg. 21-29. 3. Kaufman M.R., Miller, T.A., Huang, C., Jarrahy, R., Roostaien, J., Wasson K.L., Ashley, R.K., Bradley, J.P. Autologous Fat Transfer for Facial Recontouring: Is there Science Behind the Art? Plast Reconstr Surg., 119: 2287, 2007.