29.1.1 Patient History Leading to the Specific Problem

A 40-year-old patient presents with a history of previous lower lid blepharoplasty 1 year ago with fat distribution and transconjunctival revisional surgery to revise the scleral show of the first operation (Fig. 29-1). He was a healthy nonsmoker with no significant medical issues.

29.1.2 Anatomic Description of the Patient’s Current Status

The patient presents with the common problem of lower lid retraction after lower lid surgery. This can be due to overresection of skin or muscle denervation at the anterior lamellar, hematoma, or infection at the midlamellar or at the level of the posterior lamella with contraction of the conjunctiva or Müller’s muscle after transpalpebral approach or Graves’ disease. The lower lid malposition is often seen in negative vector patients with no lower lid support of soft tissue or bony structures. Care should be taken to analyze the patient’s history and the anatomical situation according to the lamellas.

He provides a history of severe hematoma especially on the right side postoperatively with a long-lasting swelling, chemosis, and ectropion for several months, which was treated conservatively.

29.1.3 Recommended Solution to the Problem

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  Convert the negative vector patient to a normal vector by a subperiosteal midface lift.

  
  
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  Recruiting skin and releasing vertical restriction by the subperiosteal midface lift.

  
  
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  Treatment of the horizontal lid laxity by a canthopexy with bony fixation on the left side and a tarsal strip procedure on the right side.

  
  
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  Support and reconstruction of the midlamellar by acellular dermal matrix (ADM).

29.1.4 Technique

The revision procedure is started with the subperiosteal midface lift, as described by Hester et al, with an anterior skin incision. All attachments from the septum to the orbital rim and the periosteum down to the vestibulum oris are released to free the whole cheek. The periosteum is incised at a low level. Two 3–0 PDS sutures are used to lift the whole cheek up in order to recruit skin. Two drill holes are made at the level of the pupil and 1.5 cm laterally of the orbital rim to secure a stable fixation. Another two holes at the zygomaticotemporal suture for the canthopexy are drilled (Fig. 29-2).

The ADM, 1 mm thick (Permacol), is sutured into the gap between tarsal plate and septum with 5–0 Vicryl, taking care not to suture it to the bone to prevent rendering the lid immobile (Fig. 29-3).

The canthopexy with 4–0 Prolene is performed with the bridge-over-bone technique to slip into the orbit to prevent from lateral canthal displacement. A tarsal strip procedure is added to the right side to address the horizontal lid lengthening (Fig. 29-4).

29.1.5 Postoperative Photographs and Critical Evaluation of Results

Fig. 29-5a shows the patient after 10 days, showing exact position of the lower lid margin touching the limbus and no more scleral show. Good support of the lower lid structures is achieved with a conversion into a normal vector. Fig. 29-5b,c shows complete lid closure after 1 year.