30 Trauma-Related Lower Eyelid Retraction
Summary
Lower eyelid retraction is a well-known complication of orbital floor fracture repair, caused by violation of the eyelid’s layered anatomy. Releasing the cicatrix and resuspending the canthus usually reveal a dead space that must be spanned and supported in order to maintain an elevated eyelid position. This chapter describes free fat transfer from the contralateral lower eyelid into this dead space in order to repair the lower eyelid retraction while simultaneously achieving a more symmetric result with improved aesthetics of both lower eyelids.
30.1 Patient History Leading to the Specific Problem
This is a 46-year-old woman who sustained a right orbital blowout fracture that was repaired via transconjunctival approach (Fig. 30-1). She presented to our care some years later with ocular surface irritation, redness, and tearing. Cosmetically, she complained of more prominent lower eyelid bags under her uninjured eye. She was an otherwise healthy woman without other medical issues.
30.2 Anatomic Description of the Patient’s Current Status
The patient demonstrates a retracted right lower eyelid with slightly irregular contour, presumably due to cicatrization of her wounds after surgical repair of her blowout fracture. The retraction is inducing approximately 2 mm of inferior scleral show as well as focal entropion with a few trichiatic lashes pressed against her inferior conjunctiva and limbus. The orbital fat is nonapparent in the right lower eyelid, thereby indirectly enhancing the prominence of the orbital fat pads in the contralateral uninjured lower eyelid. Her slit-lamp examination revealed moderate inferior superficial punctate keratopathy on the right side and a clear cornea on the left. These findings are the natural sequelae of combined inferior exposure due to her retracted eyelid with trichiatic lashes against the ocular surface.
30.2.1 Analysis of the Problem
The layered anatomy of the eyelid is complex and violation of its natural structure as in the case of penetrating or surgical trauma can lead to its dysfunction. Lower eyelid malposition including lower eyelid retraction is unfortunately a well-acknowledged complication following orbital floor fracture repair, and can occur following either transconjunctival or subciliary approach. Surgically correcting the eyelid malposition will undoubtedly require releasing the cicatrix, which can be accomplished by reopening the transconjunctival incision and releasing symblepharon (if apparent) as well as middle lamellar scar bands. Canthopexy, described elsewhere in this chapter, will also help elevate the eyelid to a more functional position with regard to the inferior limbus. However, one must anticipate that releasing the cicatrix and resuspending the canthus will reveal a dead space that will need to be spanned and supported in order to maintain the elevated eyelid position. While there are many ways to do so (spacer graft discussed elsewhere in the chapters, dermis fat graft, etc.), one possibility is to look to the contralateral inferior fat pads, which the patient herself noted to be relatively more prominent after her contralateral fracture. By harvesting a fat graft from the contralateral side, one can simultaneously fill and support the elevated right lower eyelid while reducing the prominence of the left inferior orbital fat pads. Thus, one borrows fat from the left side to place into the right, allowing for a more durable retraction repair on the right and a more symmetric result with improved overall aesthetic.
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