Is a hard palate graft the right procedure for lower lid retraction caused by scar tissue? (photo)

Question

A surgeon said a graft from my hard palate would be the last option to have this issue fixed. I've gone through all the simple fixes. My lid pulls down when I open my mouth. This is what bothers me. It shows up in photos, my eye gets really red and I'm constantly trying to not open my mouth for fear that my eyelid will pull down. Will the graft procedure correct this? (If the operation goes well) Or is this just a procedure to fix the scleral show when my face is at rest?

Kenneth D. Steinsapir, MD · Answer

I am going to guess that you have already had a series of lateral canthal "tightening" surgeries.  Unfortunately, tighten the lower eyelid forces the lid margin below the curvature of the globe making the situation worse not better.  The answer is actually horizontally and vertically lengthening the eyelid.You ask if hard palate graft will fix your situation.  The answer is that as powerful as hard palate graft surgery is, it does not have the power to fix your situation.  The hard palate graft is placed behind the lower eyelid on the conjunctival side as a way of lengthening the lower eyelid without the necessity of using an unsightly skin graft.  Practically it is hard to use a hard palate graft to provide more than 4-5 mm of lift to the eyelid margin.  To lengthen the lower eyelid, failed methods of the past relied on atonic reconstruction such as large skin grafts and denervated muscle flaps like a Mustarde flap.  While still occasionally used dynamic adjacent musculocutaneous flaps are much more useful.  The favored approach is the vertical elevation of the cheek.  In order to accomplish this, alloplastic agumentation of the cheek is necessary to create a better relationship between the inferior orbital rim and the globe.  Some advocate the use of porous polyethylene implants for this purpose.  I personally do not believe that this material is well tolerated at the orbital rim.  For this reason, I use hand carved ePTFE which is bolted to the orbital rim.  This then supports the elevate cheek myocutaneous flap.  The hard palate graft is used to control the shape of the lid margin.  This approach had proven very reliable for these very tough situations.  Here is a reference to my article on my method published in Plastic and Reconstructive Surgery: Steinsapir, K. Aesthetic and restorative mid face lifting with hand-carved, expanded polytetrafluoroethylene orbital rim implants. Plast Reconstr Surg 2003; 111(5):1727-37.

John J. Martin, Jr., MD · Answer

You will need to see an experienced oculoplastic surgeon as this will not be an easy fix.  With this amount of scleral show, and no apparent excess skin, you will probably need both a spacer graft for the inside portion of the lid, and a skin graft on the outside. Hard palate is an excellent spacer graft for the inside.  There are some other options however, such as Alloderm.  Your surgeon can discuss the risks and benefits of each.

Amy T. Bandy, DO, FACS · Answer

The short answer is yes, the hard palate graft will provide the support to allow proper healing and prevent recurrant ectropion.  Good luck!

Matheson A. Harris, MD · Answer

When the lower eyelids pull down, you have a few options. You often need to lengthen the inner eyelid. This can be done with hard palate, ear cartilage, or spacer materials made out of purified animal cartilage like Tarsys.  The most important thing is choosing an experienced surgeon familiar with all aspects of eyelid surgery.

Chase Lay, MD · Answer

hello LauraMake sure that you are comfortable with her surgeon and you have obtained consultations with board certified facial plastic surgeons or very experienced oculoplastic surgeons.in any case in year condition a graft to the posterior or inner lining of the eyelid called the posterior lamella is a very sound and important part of a reconstruction like years.  Hard palate graft or even mucosal graft from the inner lining of the lip is a very good choice.  The hard palate component may be chosen for U because it offers a little more rigidity and support particularly early on.  He may also require a tarsal strip or lid tightening procedure and potentially even a skin graft to the skin of the anterior part of the eyelid or anterior lamella as recall.Willits fix the issue of the lid pulling down when he opened her mouth?  Possibly and I would say most likely however I don't really know how much effect your midface and your malar support has on this.  Basically how strong as her cheekbone and how supportive visit is the question.It sounds like there is a sounds plan for you in general but specifically the questions we need to answer our1.  Doesn't midface need any support2 does of lower eyelid need additional help with the anterior lamella or eyelid skin?3 DU also need a lid tightening procedure?  It appears that her young and he may not but I can't really answer these questions for you without seeing myself.  Just use this information in your research not as actual clinical recommendations.Chase Lay, MDDouble board-certified facial plastic surgeon

Is a hard palate graft the right procedure for lower lid retraction caused by scar tissue? (photo)

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