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Solution for lower lid retraction after blepharoplasty

Article-Solution for lower lid retraction after blepharoplasty

San Diego — Lower lid retraction is probably the most common complication following skin muscle blepharoplasty or lower eyelid surgery, and sometimes it occurs even if the surgeon removes no skin. Yet, ophthalmic cosmetic surgeon Allan E. Wulc, M.D., says none of the methods of correcting the deformity were completely acceptable — until now.

Dr. Wulc discussed how autogenous dermis provides a solution that solves most of the problems created by other surgical solutions at the American Academy of Cosmetic Surgery annual meeting here.

The most common reason the lower lid retracts is the removal of excess skin, scarring in the middle portion of the eyelid, and, sometimes, because the predisposition to have a retraction is not recognized.

Doctors use a variety of approaches to dealing with the problem, and Dr. Wulc, associate clinical professor, University of Pennsylvania, lists the potential problems with each.

  • Skin graft: "This is probably the most commonly touted solution in the literature," Dr. Wulc says.

"The problem is that grafted skin looks horrible; it has a wrinkly appearance. It defeats the purpose of surgery and actually makes the person look worse. The eyes can be dry, irritated, uncomfortable and look really sad."

  • Interpositional graft in the posterior lamella of the eyelid. A variety of materials are used; the most commonly accepted comes from the hard palate of the mouth.

"This is extremely painful for the patient after the harvesting of the palate. It takes two to three weeks to heal, during which time the mouth is incredibly sore, and you can't eat much of anything or drink coffee," Dr. Wulc says.

Other materials used in this manner are ear cartilage and septocartilage.

  • AlloDerm: cadaver-derived, freeze-dried dermis.

"I used this and presented results from 23 cases. It looks great. Unfortunately, in time, it resorbs."

That's when Dr. Wulc turned to autogenous dermis.

Dermis alternative "By harvesting dermis from the flank, or any non-hair-bearing area, and putting it between the tarsus and the conjunctiva, not only does the eye look good in the beginning, it is accepted by the patient because it is autogenous."

Dr. Wulc says the dermis is hardy and has a long history of use around the eye. Dermis fat placed in the eye socket of a child will grow with the child.

In many cases, patients who have blepharoplasty have had a lot of fat removed — so in addition to lower lid retraction, they experience skeletonization.

Dr. Wulc says with this method, the surgeon can actually take fat along with the dermis — harvest them together and insert it in the eyelid — basically performing a composite graft.

"If you pull the eye down, you sew the dermis to the conjunctiva on the eyelid. It's interposed — going between the tarsus and the conjunctiva.

"The fat faces toward the skin if you add fat for people who have been skeletonized. Not only does it provide vertical height, it can also provide projection."

The procedure is done using local anesthesia and Frost sutures, and usually accompanied with a lateral lid lifting procedure. In about two weeks, mucosa will grow over the graft, completing the repair.

During that time, vision may be a bit blurred, but Dr. Wulc says blurriness disappears when the healing is complete.

Safe, reliable option Dr. Wulc presented the results of surgery on 33 patients with a follow-up of more than two years. He told the surgeons results show the method to be a reliable, safe and less painful way of correcting lower lid retraction.

"The advantage of taking the dermis from a non-hair-bearing body surface versus using the palate is that it is less painful and heals quickly. The disadvantage is that there is a scar — but generally the scar can be camouflaged."

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