Hard palate graft for lower eyelid retraction
This is Richard Allen at the University of Iowa. This video demonstrates placement of a hard palate graft for the treatment of lower eyelid retraction. A lateral canthotomy and inferior cantholysis are performed. 4-0 silk suture is then placed through the lower eyelid at the level of the meibomian gland orifices in order to provide traction during the case. A transconjunctival incision is then made with the needle tip cautery extending from the punctum medially to the lateral canthotomy incision laterally. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. This patient had previous surgery and significant scar is encountered. Additional dissection is performed with the freer periosteal elevator. The hard palate had been harvested earlier and sized in order to treat the retraction. The palate is placed between the inferior border of the tarsus and the lower lid retractors/conjunctiva/orbital septum. I believe it is important to place the graft more medial than you think. The mistake I often see is not treating the medial portion of the retraction by placing the graft too laterally. The graft is sutured into position with 7-0 vicryl suture. This can be placed with either interrupted or running sutures. The lid position is inspected and the lateral cantholysis will then be repaired by performing a lateral tarsal strip. The strip is sutured to the periosteum of the lateral orbital rim with 4-0 mersilene suture. The lateral canthotomy incision is closed with the 7-0 vicryl suture. The silk sutures are used as Frost sutures and taped to the forehead to keep the eyelid on stretch. An eye pad is then placed and kept in position for one week.