My plastic surgeon put in a hard palate graft in my lower lid in an attempt to fix my droopy lid (which was caused by a previous surgery) about 7 months ago. He is pleased with how the graft fixed the shape of my lid but the lid is still being pulled down when I open my mouth. The next step he said was a steroid injection to break up the scar tissue and hope that helps with the pulling. What are the risks with the shot? Do the effects of the shot last forever or do I need maintenance injections?
Answer: Scar modulation with 5FU and Steroid Hard palate is the "gold standard" for fixing lower eyelid retraction, which sounds like what you suffered from after your first surgery. It does have the negative side effect of morbidity of the roof of the mouth which can take a couple of weeks to heal. A "roof guard" or dental splint is very effective in minimizing this pain, and sometimes a short course of topical oral steroid can help the pain as well. Now after any surgery, scar formation can occur, which is likely what is happening in the postop period of your hard palate graft. Scar modulation with injections of certain medicines can sometimes help minimize rebound retraction. I generally use a combination of 5 Fluorouracil, originally used as a chemotherapy drug intravenously, mixed with a lower concentration of Kenalog steroid. It is true that injection of steroids can cause tissue atrophy [some call it "melting" which sounds pretty scary]. But using a low concentration steroid with the 5FU will have a lower risk. There have not been any good randomized trials that confirm these recommendations, and most of this is based on anecdotal evidence, but we feel that there is some benefit to this attempt at scar modulation.Good luck
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Answer: Scar modulation with 5FU and Steroid Hard palate is the "gold standard" for fixing lower eyelid retraction, which sounds like what you suffered from after your first surgery. It does have the negative side effect of morbidity of the roof of the mouth which can take a couple of weeks to heal. A "roof guard" or dental splint is very effective in minimizing this pain, and sometimes a short course of topical oral steroid can help the pain as well. Now after any surgery, scar formation can occur, which is likely what is happening in the postop period of your hard palate graft. Scar modulation with injections of certain medicines can sometimes help minimize rebound retraction. I generally use a combination of 5 Fluorouracil, originally used as a chemotherapy drug intravenously, mixed with a lower concentration of Kenalog steroid. It is true that injection of steroids can cause tissue atrophy [some call it "melting" which sounds pretty scary]. But using a low concentration steroid with the 5FU will have a lower risk. There have not been any good randomized trials that confirm these recommendations, and most of this is based on anecdotal evidence, but we feel that there is some benefit to this attempt at scar modulation.Good luck
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June 24, 2014
Answer: OK, I don't agree with Dr. Pacella. First, it is very hard to tell what is going on with your eyelids from the photo you have posted. Generally these reconstructive situations are very complex. When you put your chin down and look up, you put your lower eyelid on maximal stretch. Even a normal eyelid may pull away from the eyelid from this maneuver. Rather than adapt the surgery to address this ridiculous position that you are only in when you explore every possible stress on the eyelid, we advise individuals who are able to manipulate the eyelid in this fashion to not expect the lid will sit against the globe when you do this. The important issue is having the eyelid correctly positioned against the cornea when your head is in a normal straight ahead position and when you gently look down to read. I would not advise you to have steroids to melt the eyelid. Steroids can cause harm. They are not vitamins. We use them when they are necessary.Now regarding Dr. Pacella's comment about not using hard palate graft because "hard palate grafts, in particular are not often stiff enough to correct lid malposition," I would say this is silly. Hard palate grafts have much more structure than acelluar dermal matrix, also known as Alloderm. It makes me wonder if Dr. Pacella has actually ever used hard palate graft? Hard palate graft is difficult material to harvest and generally needs a special palate stent made by the dentist. Without this the roof of the mouth can bleed after surgery and feels very uncomfortable (like the worlds worst soup burn). However, hard palate graft has many very favorable qualities that Alloderm does not. Alloderm is very convenient because it does not take time during surgery to harvest from the roof of the mouth. A custom palate stent is not needed to protect the roof of the mouth. However, Alloderm is not a reliable spacer graft material for eyelid reconstruction. It does not have the power to control the shape of the lower eyelid. The graft itself disappears over the course of several months. It is primarily used in minor eyelid malposition cases where a permanent graft is not needed to control the shape of the eyelid. However, when definitive lower eyelid shaping is needed, which is quite common in post-blepharoplasty reconstruction, then nothing replaces a hard palate graft.To summarize, I am not sure if a steroid injection is what you need. There is no substitute for an actual personal consultation.
Helpful 2 people found this helpful
June 24, 2014
Answer: OK, I don't agree with Dr. Pacella. First, it is very hard to tell what is going on with your eyelids from the photo you have posted. Generally these reconstructive situations are very complex. When you put your chin down and look up, you put your lower eyelid on maximal stretch. Even a normal eyelid may pull away from the eyelid from this maneuver. Rather than adapt the surgery to address this ridiculous position that you are only in when you explore every possible stress on the eyelid, we advise individuals who are able to manipulate the eyelid in this fashion to not expect the lid will sit against the globe when you do this. The important issue is having the eyelid correctly positioned against the cornea when your head is in a normal straight ahead position and when you gently look down to read. I would not advise you to have steroids to melt the eyelid. Steroids can cause harm. They are not vitamins. We use them when they are necessary.Now regarding Dr. Pacella's comment about not using hard palate graft because "hard palate grafts, in particular are not often stiff enough to correct lid malposition," I would say this is silly. Hard palate grafts have much more structure than acelluar dermal matrix, also known as Alloderm. It makes me wonder if Dr. Pacella has actually ever used hard palate graft? Hard palate graft is difficult material to harvest and generally needs a special palate stent made by the dentist. Without this the roof of the mouth can bleed after surgery and feels very uncomfortable (like the worlds worst soup burn). However, hard palate graft has many very favorable qualities that Alloderm does not. Alloderm is very convenient because it does not take time during surgery to harvest from the roof of the mouth. A custom palate stent is not needed to protect the roof of the mouth. However, Alloderm is not a reliable spacer graft material for eyelid reconstruction. It does not have the power to control the shape of the lower eyelid. The graft itself disappears over the course of several months. It is primarily used in minor eyelid malposition cases where a permanent graft is not needed to control the shape of the eyelid. However, when definitive lower eyelid shaping is needed, which is quite common in post-blepharoplasty reconstruction, then nothing replaces a hard palate graft.To summarize, I am not sure if a steroid injection is what you need. There is no substitute for an actual personal consultation.
Helpful 2 people found this helpful
June 23, 2014
Answer: Steroid Injection and Grafts In general, steroid injections do very little to correct scar contraction after ectropion surgery or lid malposition surgery. In fact, I would proceed with caution as steroid injection can cause the natural ligamentous attachments of the eyelid to loosen further. Hard palate grafts, in particular are not often stiff enough to correct lid malposition. In my plastic surgery practice specializing in eyelids, I utilize a graft material known as an "acellular dermal matrix". This is very stiff, supports the lid and avoids the pain at the donor site of the mouth. In your case, it appears that the corners of the eye (i.e. the lateral canthus) are also not very tight. You may benefit from a revision with a lid-tightening procedure (i.e. a canthoplasty).
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June 23, 2014
Answer: Steroid Injection and Grafts In general, steroid injections do very little to correct scar contraction after ectropion surgery or lid malposition surgery. In fact, I would proceed with caution as steroid injection can cause the natural ligamentous attachments of the eyelid to loosen further. Hard palate grafts, in particular are not often stiff enough to correct lid malposition. In my plastic surgery practice specializing in eyelids, I utilize a graft material known as an "acellular dermal matrix". This is very stiff, supports the lid and avoids the pain at the donor site of the mouth. In your case, it appears that the corners of the eye (i.e. the lateral canthus) are also not very tight. You may benefit from a revision with a lid-tightening procedure (i.e. a canthoplasty).
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