Combined hard palate spacer graft, midface suspension, and lateral canthoplasty for lower eyelid retraction: A tripartite approach

Background: Eyelid retraction is an unfortunate consequence of cosmetic surgery, trauma, and disease states. It is frequently symptomatic and may be associated with dry eye syndrome and corneal compromise. The pathophysiology of lower eyelid retraction usually involves some degree of lateral canthal tendon laxity, middle lamella scarring, and malar descent. The authors describe for the first time a series of patients whose lid retraction was treated with a tripartite procedure that addresses all three pathophysiologic components simultaneously and rehabilitates the patients cosmetically and functionally. Methods: The authors retrospectively reviewed the records of 17 patients (24 eyelids) operated on between 1999 and 2003 by one senior surgeon. The age of the patients ranged from 26 to 77 years (mean, 50.3 years), and all presented with significant scleral show (average, 2.0 mm) and symptomatic corneal exposure from a variety of causes. Preoperatively, all patients were noted to have a combination of lower eyelid laxity, middle lamellar contracture, and malar descent. Preoperative and postoperative examinations included Shirmer's test, a measurement of scleral show, and a slit-lamp examination. Mean follow-up time was 13 months. All patients underwent a triad of hard palate spacer grafting, lateral canthal suspension, and midface elevation. Results: All 17 patients (representing 24 retracted eyelids) had complete resolution of scleral show (2.5-mm average correction) and were uniformly satisfied with their cosmetic and functional outcome at last follow-up. Preoperative dry eye symptoms resolved in all patients in the series. There were no major complications and only two minor complications (corneal irritation from graft sutures in one patient and an oronasal palatal fistula in another), both of which resolved in the early follow-up period. Conclusions: The combination of hard palate spacer grafting, lateral canthoplasty, and mid-face suspension is an effective, aesthetic, and functional treatment for moderate to severe lower eyelid retraction resulting from multiple causes. This tripartite procedure is associated with predictable results, a low morbidity rate, and high patient satisfaction.