I need advice for the best long-term solution for my lowerlid retraction revision surgery (Photo)

Question

9 mos ago had transc SOOF lift bleph w/ canthopexy. Upper creases look thicker & unnatural. Is that because lateral canthal disposition? Skype w/ 2 oculoplast both suggested MFL, spacer (alloderm/HPG), canthoplasty. Is the result permanent? Other idea gorotex orbital implant to take the weight of cheek but there is late infection risk. Is it true? How about skin graft, is the result more permanent? Confused, just want to regain my eye function and appearance. Willing to travel, even to US.

Kenneth D. Steinsapir, MD · Answer

I pioneered the repair of these lower eyelids with the use of a three pronged approach using a vertical mid face lift over a hand carved orbital rim implant fabricated from ePTFE (the material that is used in GoreTex), hard palate graft, and lateral canthal reconstruction.  Some surgeons have used pre-made porous polyethylene implants on the orbital rim and these implants are associated with late infections in about 20% of cases.  For that reason, I abandoned the use of this material over 20 years ago and now only use ePTFE.  While it is theoretically possible for any implant to become infected at any time, that risk is only theoretically. In hundreds of these surgeries, the actual rate of late infection has been nonexistent.  That does not mean it is impossible. The ePFTE implant material is highly stable and FDA approved for precisely this type of deep facial implantation. 
I have become aware that colleagues who also do lower eyelid repairs have taken to emphasizing the possible risk of late implant infection to help convince potential patients of the wisdom of not placing a rim implant.  That is unfortunate because not placing a rim implant removes one of the most critical factors in the long term success of these surgeries.  When I have to fix their work, it is often the omission of this support that causes their surgery to fail. Generally the problem in these eyelids is damage to the motor nerve that supply the muscle along the lower eyelid that helps hold the lower eyelid against the eyelid.  It gets damaged with the lower eyelid incision made with the original eyelid surgery. The original lower eyelid surgery also removes lower eyelid skin and soft tissue and is associated with scar contraction.  Perhaps most crucially, individuals who get into trouble also have a predisposing weakness in the inferior orbital rim support for the mid face tissue.  
Surgeons who only rely on an eyelid spacer (hard palate graft, alloderm, or skin graft) and lateral canthoplasty, neglect the structural reality of why the problem developed after the original surgery in the first place.  The orbital rim implant is primarily used as a felting material to hold the weigh of the vertically lifted mid face tissue.  It is not used like say a cheek implant for adding cosmetic volume.  These are very low volume implants.  They are placed to structurally support the weight of the cheek.  This will prevent the mass of the cheek from pulling on the lower eyelid. Additionally skin and soft tissue is recruited into the lower eyelid without the necessity of an unsightly skin graft. This means that very little tension is needed in performing the lateral canthal reconstruction (canthoplasty).  In contrast, without the rim implant, additional tension is needed in performing the lateral canthoplasty.  In some cases, surgeons resort to using wire to fix the lateral canthal tendon to the bone, which I think is a big problem.  Over time that tension compromises the long term result because the weight of the cheek will continue to be a problem.
 The purpose of the hard palate graft is to control the shape of the eyelid.  I seldom use Alloderm because it does not provide long term help.  Alloderm is acellular cadaveric human dermis.  Your body treats it as the foreign collagen that it is and will remove the material in a matter of months.  If your eyelid needs the support of the grafted material, the disappearance of this material will lead to an early reconstruction failure.  Your own hard palate grafted is a permanent spacer.  It does require extra time to harvest it and, optimally, the fabrication of a custom acrylic stent by a dentist to protect the harvest site after surgery.  Some surgeons prefer to cut a corner and used Alloderm.  In my opinion, this is seldom a good idea. A skin graft can also be used as a spacer but it is unsightly and disfiguring.
In addition to your lower eyelid issues, you also have a high upper eyelid crease, a levator disinsertion of the upper eyelids, and a compensatory eyebrow elevation.  These are issues that would also benefit from help and would be discussed as part of a comprehensive consultation.  That visit with me will likely last about 2 hours to carefully measure and document the anatomic issues that are adversely affecting the appearance and function of your eyelids and to discuss the range of options that would be best for you.  Unfortunately, this information cannot be gathered and communicated as part of a Skype consultation.

Craig Harrison, MD · Answer

The best solution depends on what is the primary issue creating your present anatomy.  I believe that only by examining you, could I be certain of the best solution.  If there is skin deficiency, then the MFL has some validity.  If there is contraction in the lower lid soft tissues, then the spacer graft and canthopexy come into play.  I am less inclined to augment your cheek unless you have a morphologically prone eye( negative vector eye) which I couldn't tell without more photos or the benefit of an exam.  I would exhaust your local options because most lower lid corrections can look good for a few weeks, so longer follow up would be important.  Best wishes

I need advice for the best long-term solution for my lowerlid retraction revision surgery (Photo)

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I need advice for the best long-term solution for my lowerlid retraction revision surgery (Photo)

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