Keywords

Lower eyelid retraction describes an inferior displacement of the lower eyelid, for which anterior lamellar deficiency is a common cause. The anterior lamella of the eyelid includes both the skin and orbicularis oculi muscle, and deficiency can result from actinic damage, thermal or chemical burns, trauma, or iatrogenic causes following cosmetic lower eyelid blepharoplasty, laser resurfacing, chemical peel, or the aggressive use of retinoids [1]. In addition to lower eyelid retraction and inferior scleral show, careful examination of these patients may reveal UV-related skin changes, which can contribute to a cicatricial ectropion in which the eyelid is distracted away from the globe (Fig. 16.1). Additional contributing factors include middle lamellar contracture, posterior lamella shortening, lateral canthal tendon laxity, and weakened orbicularis tone [2]. Lower eyelid retraction may cause significant ocular comorbidities such as dry eye, tearing, conjunctival erythema and keratinization, exposure keratopathy, corneal ulceration, and globe perforation. Furthermore, lower eyelid malposition results in an unsatisfactory aesthetic appearance.

Fig. 16.1
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Pre-op photo of patient with lower eyelid retraction due to anterior lamellar deficiency

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Treatment for lower eyelid retraction due to anterior lamellar deficiency should be targeted to each patient’s condition. Patients with mild retraction due to a dermatitis-related skin condition can be initially managed conservatively with a topical steroid [3]. In these patients, it is imperative to monitor the patient’s intraocular pressure (IOP) in the event that the steroid results in elevation of the IOP. One nonsurgical option involves hyaluronic acid filler injected into the lower eyelid to serve as a tissue expander [4]. However, in patients with more severe retraction, adequate elevation of the lower eyelid into proper anatomic position requires surgical correction. Surgical repair ultimately addresses the vertical shortening of skin. The options for addressing anterior lamellar deficiency include a full-thickness skin graft, local myocutaneous flap, or a midface lift. A full-thickness skin graft can be used in this clinical scenario due to the availability of excess skin and ease of harvest; however, a full-thickness skin graft does not carry its own blood supply and has a potential higher rate for necrosis and infection. Alternatively, a local myocutaneous flap brings its own blood supply to the lower eyelid, which can be useful in an area of prior irradiation or trauma when the local blood supply may be compromised.

Two examples of commonly used local myocutaneous flaps include the Tripier flap and Fricke flap. The Tripier flap was first described by Tripier in 1890 as a bipedicle flap involving the skin and orbicularis oculi muscle isolated from the upper eyelid and transposed to the lower eyelid [5] (Fig. 16.2). Excess upper eyelid skin is required in order to execute this flap. The pedicles may be severed in a staged procedure, but can also be incorporated into the lower eyelid defect in order to avoid the need for a second procedure [6]. Variants of this flap have been described addressing the medial or lateral eyelid with a single pedicle, although the size of eyelid defect must be a consideration in surgical planning as a unipedicle flap may be limited by its blood supply. Alternatively, the Fricke flap was first described in 1829 as a temporal forehead unipedicle flap transposed to the upper eyelid or lower eyelid [7] (Fig. 16.3). Due to the unipedicle nature of this flap, it may be limited in its extension to the medial lower eyelid. In order to avoid distal necrosis and flap failure, the length to width ratio should not exceed 4:1 [8]. Both of these flaps can lead to asymmetry, as can be seen in upper eyelid position with the use of the Tripier flap or the eyebrow height when using the Fricke flap . Similar to a full-thickness skin graft, intact posterior lamella is needed with the use of both of these myocutaneous flaps.

Fig. 16.2
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The Tripier flap is a bipedicle myocutaneous flap transposed from the upper eyelid to the lower eyelid

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Fig. 16.3
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The Fricke flap incorporates a temporal forehead unipedicle flap transposed to the lower eyelid

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Surgical planning for a flap must involve assessment of surrounding tissue laxity and ease of tissue mobility without causing secondary retraction. In some cases the area of retraction may be localized to the medial or lateral lower eyelid due to focal cicatricial forces. There are a variety of localized rotational flap designs that may be utilized. The nasojugal flap involves a flap adjacent to the nasojugal fold rotated superiorly to the lower eyelid [9]. The rhomboid flap is rotated around a pivot point into the lower eyelid defect [10]. A vertical V-Y advancement flap has been described as a simple and effective option in burn patients [11]. When tissue cannot be mobilized from immediate surrounding tissue due to extensive eyelid pathology, a paramedian forehead flap centered around the supratrochlear artery is an option [12].

In some cases, the regional tissue is not suitable for flap rotation. Another surgical approach to addressing lower eyelid retraction is a midface or cheek lift. This technique involves releasing the deep facial ligaments, allowing upward mobilization of the overlying soft tissue with an improved elevated position of the lower eyelid. One technique that has proven successful involves lateral canthoplasty, transconjunctival orbicularis-retaining ligament release, transcutaneous superficial muscular aponeurotic system elevation, and orbicularis contouring [13]. Besides addressing the functional issues associated with lower eyelid retraction, the midface lift also targets common facial changes associated with aging leading to a rejuvenated and aesthetically desirable result. This surgical approach is more technically challenging compared to a graft or flap creation, and careful dissection must be employed to avoid branches of the facial nerve. Despite robust midface lifting, in some patients the anterior lamellar deficiency is so significant that a flap or graft is required to address the skin shortage.

Surgical planning for a lower eyelid skin graft must take into account the thickness, skin quality, and hairless nature of the lower eyelids in order to find a donor site that most closely matches. Several locations provide an excellent match for the lower eyelid that will optimize the aesthetic result. Redundant upper eyelid skin is an ideal graft as it most closely resembles the thin lower eyelid skin. The next best option includes postauricular or preauricular skin. This skin in this location is thin and may receive similar sun exposure to the lower eyelid. Other donor sites include the supraclavicular area, inner upper arm, inguinal area, or inframammary fold [14]. Lateral canthal tendon laxity should be addressed concurrently, if needed, with the use of one of a variety of techniques available to properly tighten the canthus [15, 16].

Below are the key steps in performing a full-thickness skin graft to the lower eyelid for anterior lamella deficiency:

  • Perform a lateral canthoplasty if required.

  • Place a Frost suture tarsorrhaphy to put the lower eyelid on vertical tension.

  • Make a subciliary incision across the length of the lower eyelid.

  • Release the cicatricial attachments and prepare the recipient bed for a skin graft.

  • Measure the area required for a full-thickness skin graft.

  • Harvest the full-thickness skin graft.

  • Suture the full-thickness skin graft in place.

  • Apply a pressure dressing to the wound.

Surgical Technique

Marking the Skin

Topical anesthetic drops are instilled into the eyes and the skin is cleaned with an alcohol wipe. The skin is marked approximately 2–5 mm below the eyelid margin horizontally along the length of the margin and can extend beyond the lateral canthus approximately 5 mm.

Anesthesia

The lower eyelid and donor skin sites are injected subcutaneously with local anesthetic consisting of 2% lidocaine with 1:100,000 epinephrine mixed 50:50 with 0.75% bupivacaine and hyaluronidase. The patient is then prepped and draped in the usual sterile manner for surgery.

Incision

Two Prolene or silk sutures (5-0 or 6-0) are passed through the gray line of the upper and lower eyelid and secured over bolsters to the eyebrow to place the lower eyelid on vertical stretch. Using a #15 Bard-Parker blade, a subciliary incision is made along the skin marking.

Releasing Cicatricial Forces

A #15 Bard-Parker blade or Westcott scissors are used to release the subcutaneous attachments and allow the anterior lamella to recess. This is performed until the lower eyelid elevates into an anatomically acceptable position without retraction (Fig. 16.4).

Fig. 16.4
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Lower lid defect to be covered with skin graft

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Harvesting of Skin Graft

The size and shape of the defect in the lower eyelid must be measured with a ruler or calipers. One technique involves using either clear surgical drape or Telfa pad to trace the defect. The pad is pressed against the defect and the blood will mark the borders and size of the area. This template is cut and then traced on the donor skin site using a marking pen. The marked-out outline of the graft should be slightly larger than the defect to allow for adjustment to the recipient bed and to account for skin graft contracture, as a full-thickness skin graft will shrink by an average of 12% [17]. Using a #15 Bard-Parker blade, the donor skin is cut along the measured marking (Fig. 16.5). The skin edge is elevated with forceps, and the dissection proceeds between the dermis and the subcutaneous fat using Westcott scissors. Closure of the donor site is based on the location. The upper eyelid donor site can be closed with 6-0 Prolene or plain gut suture, whereas a pre- or postauricular donor site is typically closed using deep, buried 4-0 Vicryl, Monocryl, or PDS suture. The skin is closed with 5-0 Prolene or plain gut suture in a running or subcuticular fashion.

Fig. 16.5
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Outline of donor skin graft from postauricular skin

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The skin graft should be carefully examined prior to placement in the recipient bed. Any subcutaneous fat should be gently dissected off the posterior surface of the graft using Westcott scissors. The skin graft can be stretched over the surgeon’s finger to provide tension while properly thinning the graft (Fig. 16.6).

Fig. 16.6
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Preparation of donor skin graft

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Placement of Skin Graft

The skin graft is placed within the lower eyelid defect and the graft edges are cut as needed to achieve a proper fit. As mentioned, the graft should be slightly oversized to allow for contracture. Equally spaced-out cardinal sutures are first placed with 6-0 silk in order to anchor the graft to the recipient bed (Fig. 16.7). The graft is further secured in place using 6-0 fast absorbing gut suture in an interrupted or running fashion depending on the size of the graft. Antibiotic ointment is applied over the graft.

Fig. 16.7
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Donor skin graft sutured in place

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Pressure Dressing Over the Skin Graft

Antibiotic ophthalmic ointment is placed over the skin graft and into the eye. Cotton balls soaked in mineral oil and telfa are then placed over the skin graft for compression. The eye is then patched in order to maximize contact between the graft and recipient bed. Skin adhesive, such as Mastisol® Liquid Adhesive (Eloquest Healthcare, Michigan), can be used on the skin to improve pressure patch integrity.

Postoperative Care

The bolster and patch are left in place for 7 days. Nonabsorbable sutures are removed at 1 week. Applying ointment to the graft is recommended for the first 2 weeks in order to keep it lubricated. The graft may appear darker than normal initially after surgery, but will usually return to normal color about 3–4 months after surgery. Massage of the lower eyelid may be initiated 2 weeks after surgery in order to prevent the graft from shrinking and to break mechanical contracture (Fig. 16.8).

Fig. 16.8
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Post-op photo of patient with full thickness skin graft

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As with all surgical procedures, there are potential complications with placing a skin graft in the lower eyelid, which include graft contracture, hypertrophy, infection, ischemia, necrosis, and lastly graft failure [18]. Hematoma and seroma formation are possible in the immediate postoperative period. These complications must be addressed immediately as a physical separation of the graft from its recipient bed compromises blood flow to the graft and may eventually lead to graft failure. Typical signs of graft infection include pain, tenderness, erythema, edema, and discharge, which warrant antibiotic treatment initiation and close observation. A dark or dusky appearing graft suggests early ischemia, which also must be closely monitored. Examples of treatments targeted at promoting oxygenation to an ischemic graft include hyperbaric oxygen therapy and nitroglycerin paste or ointment, which acts as a vasodilator to increase blood flow to the graft. Graft scarring or hypertrophy can be managed conservatively with observation, massage, topical steroids, or topical silicone. Injections with 5-fluorouracil (5-FU) or a combination of 5-FU with low-dose steroid can be used during the wound healing process to mitigate scar formation [19]. Dermabrasion, microneedling, or CO2 laser resurfacing can be useful for optimizing aesthetic outcome. Pigment abnormalities can be addressed with topical hydroquinone and noninvasive pulsed light or laser therapy.