Patel B C, Patipa M, Anderson R L, McLeish W
Division of Ophthalmic Plastic, Reconstructive and Orbital Surgery, Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.
Plast Reconstr Surg. 1997 Apr;99(5):1251-60. doi: 10.1097/00006534-199704001-00007.
Lower eyelid malposition is the most common long-term complication following transcutaneous lower eyelid blepharoplasty. The malposition may include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, or frank ectropion. The result is cosmetically unacceptable and may be associated with tearing, irritation, and other exposure keratitis symptoms. Multiple factors, including lower eyelid laxity, shortage of skin, and scarring of the middle lamella, may be responsible for this malposition. A systematic examination of the lower eyelid, as presented, helps to assess the degree to which each of these factors is responsible for the malposition. Patients with the most severe degree of lower eyelid malposition generally have middle lamella scarring. If this abnormality is not addressed, lower eyelid procedures aimed at correcting the malposition are doomed to failure. In the presence of significant middle lamella scarring, a spacer is required to provide vertical height and stiffness to support the lower eyelid following release of the cicatrix. A systematic approach aimed at addressing the underlying abnormalities was developed. In patients with significant middle lamella scarring, hard palate mucosa grafts were used as spacers in 29 eyelids (17 patients). A lateral canthotomy and transconjunctival incision allow access to the scarring in the lower eyelid retractors and septum. After careful release of all cicatrix, a hard palate mucosa graft is inserted between the lower border of the tarsal plate and the recessed conjunctiva, lower eyelid retractors, and septum. Horizontal lower eyelid laxity, when present, is corrected by performing a lateral tarsal strip. Most patients do not have a true deficiency of the anterior lamella (skin and orbicularis oculi muscle). When a moderate amount of anterior lamella deficiency is present with significant scarring of the middle lamella, the technique we describe allows correction of the lower eyelid malposition without a skin graft. After a follow-up interval of 6 to 30 months (mean 14 months), excellent results were obtained in all eyelids. Complications included corneal abrasions in two eyes before routine use of bandage cornea contact lenses at the end of surgery and a secondary bleed from the roof of the mouth in one patient. Palate mucosa closely resembles tarsus and provides excellent vertical support to the eyelid. It is stiff enough to maintain eyelid contour without causing a cosmetically unacceptable bump. Tissue can be obtained with ease. The technique, as described, addresses the underlying causes of lower eyelid malposition and gives excellent functional and cosmetic results.
下睑位置异常是经皮肤下睑眼袋整形术后最常见的远期并发症。这种位置异常可能包括外眦角变圆、下睑退缩伴下方巩膜外露，或明显的睑外翻。其结果在美容上是不可接受的，并且可能伴有流泪、刺激感以及其他暴露性角膜炎症状。多种因素，包括下睑松弛、皮肤短缺以及中板瘢痕形成，可能导致这种位置异常。如本文所述，对下睑进行系统检查有助于评估这些因素各自导致位置异常的程度。下睑位置异常程度最严重的患者通常存在中板瘢痕形成。如果不处理这种异常情况，旨在纠正位置异常的下睑手术注定会失败。在存在明显的中板瘢痕形成时，需要一个间隔物来提供垂直高度和硬度，以便在瘢痕松解后支撑下睑。我们开发了一种旨在解决潜在异常情况的系统方法。在存在明显中板瘢痕形成的患者中，29只眼睑（17例患者）使用硬腭黏膜移植片作为间隔物。外眦切开术和经结膜切口可进入下睑缩肌和眶隔的瘢痕。在仔细松解所有瘢痕后，将一块硬腭黏膜移植片插入睑板下缘与凹陷的结膜、下睑缩肌和眶隔之间。如果存在水平方向的下睑松弛，则通过进行外侧睑板条手术来纠正。大多数患者并不存在真正的前层（皮肤和眼轮匝肌）缺损。当存在中等程度的前层缺损且伴有明显的中板瘢痕形成时，我们所描述的技术可在不进行皮肤移植的情况下纠正下睑位置异常。在6至30个月（平均14个月）的随访期后，所有眼睑均获得了良好的效果。并发症包括在手术结束时常规使用绷带角膜接触镜之前，有两只眼睛出现角膜擦伤，以及有一名患者口腔顶部出现继发性出血。腭黏膜与睑板非常相似，可为眼睑提供出色的垂直支撑。它足够坚硬以维持眼睑轮廓，而不会造成美容上不可接受的隆起。组织获取容易。如本文所述的技术解决了下睑位置异常的根本原因，并带来了出色的功能和美容效果。
