stepladder approach for persistent lower eyelid retraction after blepharoplasty

Lower eyelid retraction following blepharoplasty is a multifactorial problem. Precise diagnosis is the critical first step in forming a treatment plan. Anterior lamellar shortage, mid lamellar cicatrix, orbicularis paralysis, volume collapse, and relatively prominent globe should be independently assessed. A stepladder approach to treatment is based on the degree of participation of each of these factors. Hyaluronic acid gel fillers may be useful for mild to moderate cases [and may be the best option for some severe multi-operated cases as well]. En glove lysis with fat grafting may be needed for moderate cases of volume collapse and middle lamellar cicatrix. Severe loss of volume and anterior lamella is treated with midface lift, which may require extensive release of circumfrencial midface cicatrix. Patients who fail to respond to initial midface lift and lower eyelid reconstruction present a particularly difficult to manage subgroup of patients. To address these particularly complex patients we perform a combined transconjunctival, sublabial, and temporal subperiosteal approach revision midface lift. A total of eight patients were identified who underwent revisional midface lift surgery [15 ipsilateral surgeries]. In all 15 cases, a three-dimensional cicatricial matrix was identified involving the lower eyelid and midface that limited visual exposure of the subperiosteal space and mobility of the midface despite complete subperiosteal release to the sublabial incision. Manual anterior distraction of the midface via the sublabial incision provided a mechanism for lysis of the cicatricial matrix. The improved midface mobility allowed successful vertical fixation with maximal anterior lamella recruitment and lower eyelid support. No complications were encountered. All patients reported improvement in cosmesis and ocular comfort. Average improvements in: lower margin to reflex distance [MRD2] was 0.9mm, scleral show was 0.8mm, palpebral fissure height at the medial and lateral limbus was 1.2mm. Lower eyelid retraction following blepharoplasty is a multifactorial problem requiring proper evaluation and a stepwise management paradigm. The most complex and difficult to manage subgroup of these patients, those having failed previous attempted lower eyelid reconstruction and midface lift surgery, require aggressive reconstruction efforts. We have found that a combined transconjunctival, sublabial, and temporal subperiosteal approach with manual scar matrix release for midface elevation and lower eyelid support is a safe and effective management paradigm

Orbital fat prolapse and dermolipoma: two distinct entities

A subconjunctival orbital fat prolapse is frequently confused with a dermolipoma clinically. These two entities have similar clinical appearances, but are clearly distinct. The clinical features, differential diagnosis, and treatment modalities of subconjunctival orbital fat prolapse and dermolipoma are discussed.

Orbital fat prolapse and dermolipoma: two distinct entities

A subconjunctival orbital fat prolapse is frequently confused with a dermolipoma clinically. These two entities have similar clinical appearances, but are clearly distinct. The clinical features, differential diagnosis, and treatment modalities of subconjunctival orbital fat prolapse and dermolipoma are discussed.