Lower lid hollow and rounded, would AlloDerm give good results? (photo)

I happen to be an oculofacial plastic surgeon
practicing for about 20 years. I’m also boarded with facial cosmetic surgery as
well as body, breast and extremity surgery. I do everything from head to toe
including hair restoration. So with no limitations with my scope of surgical
procedures, I can share with you the different things I’ve done to patients who
come to with same problem as yours called lower eyelid retraction.



The lower eyelid has three essentials parts
that helps its position: the lateral canthal tendon which is the attachment of
a very important connection between the lower eyelid and the bone of the
orbital rim; the internal support of the lower eyelid which are like pillars
that support underneath the eyelid referred to as the posterior middle lamella;
and the amount of skin available to physically move upward. A lot of people
have come to us who had too much skin removed from their lower eyelid resulting
in the combination of eyelid retraction, or a rotation of the eyelid away from
the eye called ectropion.



When a patient comes to me, I’ll do an
assessment to evaluate all of those factors. I assess if they have enough skin
and if they have enough support in the lower eyelid. I also assess if their eye
is projected outward and the strength and position of the lateral canthal
tendon. These are all important factors in the dynamics and physics of the way
the lower eyelid is positioned.



I have experience using posterior middle
lamellar grafts such as hard palate mucosa and Alloderm, but what I have been
doing in my practice for the past couple of years is using a material called Enduragen.
Enduragen is a material derived from pig dermis. This doesn’t mean that Alloderm
is not an acceptable choice - every surgeon has their own ideal way of combining
their procedures and materials with what works with them.



Fat transfer can also be a good option.
However, I don’t do fat transfer as part of my primary procedure which is to
restore the anatomy. I would reposition the lower eyelid into its proper
anatomical position. Lower eyelid position is very important for eye function
such proper distribution of the tear film. A bowed eyelid cannot contribute to
good ocular health. Since this is a more
advanced and complex procedure and there’s grafting involved, there is a time
frame for things to heal. After the eyelid has healed and is in proper position,
then fat transfer is a possibility.



I also do adjuvant therapies such as the use of
platelet-rich plasma and extracellular matrix for improvement of wound healing.
This is a type of procedure that requires a lot of initial care after the
surgery. At this point, it is best that you meet with several oculofacial
plastic surgeons and get some opinions as to what will be their approach. After
that, you can move forward with choosing one you are comfortable with. I hope
that was helpful, I wish you the best of luck, and thank you for your question.

An oculoplastic surgeon can definitely do both procedures, if needed. It is difficult to tell from your photo what you need since you are looking slightly up. If there is true lower lid retraction, then the option you discuss are valid.

Alloderm is not an ideal product for what you need.  It is a very convenient product which makes it very tempting for surgeons to use a s spacer graft.  The problem with this product is that it does not persist.  Within a few months, the body has broken down all of the alloderm that is used in the eyelid.  For individuals who only needed the eyelid splinted, this is OK.  However you need more than splinting.  For this reason, hard palate graft is a much more appropriate material.  Regarding fat grafting, this is a very unpredictable treatment for a thin eyelid like yours.  An alternative option is to use a very subtle orbital rim implant of ePTFE and lift the cheek fat onto this implant.  My website has extensive information regarding this type of procedure.