An animal model of lower eyelid spacer grafting with acellular dermis

Surgical Correction of Cicatricial Lower Eyelid Retraction: A Systematic Review

BACKGROUND

Cicatricial lower eyelid retraction is a challenging condition. It involves scarring of the lower eyelid, which causes it to retract and expose the sclera. This can lead to complications such as dry eye syndrome and corneal melting. It can be caused by trauma, burns, or previous eyelid surgery. Detailed assessment and understanding of eyelid anatomy and retraction are critical for successful surgical planning. Dynamic and static examinations of the eyelid including measurements of the lower eyelid margin reflex distance (MRD2) and scleral show are also essential to determine the appropriate treatment approach.

METHODS

A systematic review was conducted using Medline, Scopus, and Cochrane databases with keywords related to cicatricial lower eyelid retraction. The publication language was limited to English after 2000. A total of 29 articles were included for data extraction and analysis.

RESULTS

The main surgical techniques include tarsoconjunctival grafts, spacers, midface lift, and lateral canthal tendon suspension, although no single procedure has been universally recognized as the gold standard. New innovations such as synthetic grafts and xenografts are being explored for their potential in eyelid reconstruction. Severe cases, defined as those with inferior scleral show greater than 2 mm, may require a combination of reconstruction methods.

CONCLUSIONS

Correcting cicatricial lower eyelid retraction is a major challenge in oculoplastic reconstruction. The surgical approach should be individualized, considering the pathologies and etiologies of lid retraction. In-depth knowledge and careful surgical planning are essential for best outcomes. There is no gold standard technique, and postoperative outcomes, complications, and management vary depending on the surgical approach used.

Efficacy of allogenous fascia lata grafts in the management of lower eyelid retraction

PURPOSE

To report on the use of allogenous fascia lata (FL) grafts in patients with lower eyelid retraction (LER).

METHODS

In this retrospective study, a consecutive series of 27 patients (39 eyes) with LER who underwent lower eyelid elevation with FL was included. Examinations including measurement of the palpebral fissure vertical height (PFVH), the inferior scleral show distance, the margin reflex distance 2 (MRD 2), and the evaluation of conjunctival hyperemia were conducted at baseline and after a mean postoperative time of 25.9 ± 25.5 (5.0-81.0, median 13.0, last follow-up) months in all patients.

RESULTS

At the last follow-up, a significant reduction of the PFVH (11.3 ± 1.7 versus 12.8 ± 2.1 at baseline, p < 0.001), the inferior scleral show distance (0.7 ± 1.0 mm versus 2.1 ± 1.1 at baseline, p < 0.001), and the MRD 2 (6.4 ± 0.9 versus 7.8 ± 1.3 at baseline, p < 0.001) occurred. The conjunctival hyperemia grading score (McMonnies) was significantly reduced (1.8 ± 0.7) at the last follow-up compared to baseline (2.6 ± 0.6, p < 0.001). No case of ectropion or entropion was observed at the last follow-up visit.

CONCLUSION

In this case series, lower eyelid elevation with FL grafts as a spacer led to a significant reduction of the PFVH, MRD 2, inferior scleral show distance, and conjunctival hyperemia. No severe surgery-related complications occurred.

Efficacy of "thick" acellular human dermis (AlloDerm) for lower eyelid reconstruction: comparison with hard palate and thin AlloDerm grafts

OBJECTIVES

To evaluate the efficacy of thick acellular human dermis (thick AlloDerm [LifeCell Corporation, The Woodlands, Tex]) grafts for posterior and middle lamellae reconstruction to correct lower eyelid retraction and to compare the long-term efficacy of thick AlloDerm with thin AlloDerm and hard palate grafts.

METHODS

Retrospective analysis of patients undergoing lower eyelid reconstruction, which encompassed subperiosteal midface lifting, middle lamellae scar lysis, and placement of lower eyelid thick AlloDerm graft. Analysis included 21 surgical procedures in 11 patients. All patients had undergone at least 1 previous lower eyelid surgery with resultant lower eyelid retraction and scleral show. Preoperative and postoperative photographs were used for analysis. Measurements of the corneal diameter and distance from pupil center to lower eyelid margin were obtained, standardized, and compared.

RESULTS

Of 21 procedures, 16 (8 of 11 patients) demonstrated improvement of lower eyelid position. The mean improvement of the median marginal reflex distance was 1.6 mm (range, 0.4-2.2 mm). The average follow-up after surgery was 215 days (range, 3-12 months). Of 21 procedures (3 patients), 5 failed to demonstrate improvement of lower eyelid position, with the mean final eyelid position lower postoperatively by 0.8 mm (range, 0.4-1.4 mm).

CONCLUSIONS

We demonstrated long-lasting improvement of lower eyelid position with placement of thick AlloDerm grafts during lower eyelid reconstruction. The patients in our study had undergone previous lower eyelid blepharoplasty with resultant middle lamellae tethering. Surgical correction included subperiosteal midface-lift and middle lamellae scar lysis, in addition to thick AlloDerm graft placement to the lower eyelid. The results are comparable to hard palate grafts but perhaps superior to thin AlloDerm grafts.

Fibrovascular ingrowth into hydroxyapatite and porous polyethylene orbital implants wrapped with acellular dermis

PURPOSE

Acellular dermis is a frequently used wrapping material for hydroxyapatite (HA) and porous polyethylene (PP) orbital implants. In an animal model, we determined by histology the extent of fibrovascular ingrowth within orbital implants wrapped in acellular dermis at 6 and 12 weeks after surgery.

METHODS

Four Yucatan minipigs were used for the study. Two minipigs had HA implants and two had PP implants. Implants were harvested at 6 or 12 weeks after surgery and were examined histologically for fibrovascular ingrowth.

RESULTS

There was complete fibrovascularization of HA implants harvested at both 6 and 12 weeks after surgery. The PP implant harvested at 6 weeks had incomplete fibrovascularization, whereas the PP implant harvested at 12 weeks had complete fibrovascular ingrowth. There was no histologic evidence of inflammation seen in any of the orbital implants. On gross and histologic examination, the wraps were found to persist on the surface of all orbital implants, with little histologic evidence of inflammation localized to the acellular dermis.

CONCLUSIONS

Acellular dermis wraps support fibrovascularization of both HA and PP orbital implants. Additionally, acellular dermis does not incite significant inflammation in association with HA and PP orbital implants and can persist in situ for at least 12 weeks after surgery.