Posterior Lamellar Graft Research Articles

Cheeklift With and Without Posterior Lamellar Spacer Grafts for Treatment of Lower Eyelid Retraction

BackgroundTo compare outcomes of lower eyelid retraction repair using a subperiosteal midface lifting technique with and without posterior lamellar grafts.MethodsCharts of patients undergoing a sub-periosteal midface lift for treatment of lower eyelid retraction using 4 techniques for posterior lamellar reconstruction were reviewed. Thirty patients were included in each of the groups: midface with hard palate graft (HPG), midface lift with acellular cadaveric graft (ADG), midface lift with retractor disinsertion (RD) and midface lift alone (NG). Measurements of distance from pupil center to lower lid margin (MRD2) and from lateral limbus to lower lid margin (MRD2limbus) were taken from pre- and postoperative photographs and compared. Secondary outcomes included rates of reoperation, major and minor complications, resolution of symptoms and keratopathy.ResultsOne hundred twenty operations were assessed (n = 30 for each surgical group). The average follow-up time was 20 weeks. The median MRD2 elevation was 0.95 mm (NG), 0.85 mm (HPG), 1.59 mm (ADG) and 1.02 mm (RD). The median MRD2limbus elevation was 1.06 mm (NG), 0.92 mm (HPG), 1.45 mm (ADG) and 1.12 mm (RD). There were no significant differences in MRD2 or MRD2limbus between the 4 groups (p = 0.06 and 0.29, respectively). Reoperation rates were highest with in the hard palate graft group (33%) compared to other techniques (p = 0.0006).ConclusionsSimilar degrees of lower eyelid elevation were achieved with all the midface lifting techniques, and complication rates did not significantly differ between techniques. However, the higher reoperation rates with the use of spacer grafts suggest that a no-graft technique may be preferable.Level of Evidence IIIThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Экспериментальное обоснование использования 1% раствора гидроксипропилметилцеллюлозы для защиты эндотелия заднего послойного трансплантата роговицы при его выкраивании низкоэнергетическим фемтосекундным лазером по инвертированной методике

Purpose. To evaluate experimentally endothelial cell loss of animal's cornea during inverted posterior lamellar corneal graft preparation technique by low-energy femtosecond laser with and without ophthalmic viscosurgical device (OVD) – 1% hydroxypropyl methylcellulose (HPMC) solution application. Material and methods. Posterior lamellar corneal grafts were created using a femtosecond laser (FSL). In the control group (n=16), a few drops of corneal storage solution were applied to the endothelium just before applanation, in the experimental group (n=16) – 1% HPMС. The quality of the applanation were monitored using an integrated in laser OCT system. The endothelial viability was determined using live/dead cells assay and the grafts were examined on a confocal laser scanning microscope. The obtained images were analyzed to count live and dead endothelial cells (EC). To assess the state of collagen fibers of the stromal side of the graft, samples from the control and experimental groups were examined using a scanning electron microscope (SEM). Results. According to the OCT, in all samples of both groups, a flat profile of the contact zone between the laser head and the endothelial monolayer was observed during applanation. The difference between the number of live and dead ECs was statistically significant between both groups. There were 2854 [2819; 2879] live cells/mm² in the control group, and 3477 [3426; 3719] live cells/mm² in the experimental group (p<0.001). Thus, the number of dead ECs in the control group was 710 [649; 728] cells/mm² . The number of dead ECs in the experimental group was 402 [366; 427] cells/mm² (p<0.001). When analyzing the images obtained on a SEM, the preservation of the architectonics of the graft collagen fibers with their single defibrations in both groups was observed. Conclusion. Application of 1% HPMC provides protection for endothelial cells from damage during posterior laser dissection using an FSL. In the study group, the number of endothelial cells was 9.92% higher than in the control group. The presence of the OVD layer in the interface between the head of the FSL and the EC did not affect the formation of an effective laser cut and did not reduce the quality of the stromal surface of the graft. The inverted technique FSL cut using a 1% solution of HPMC on the surface of the endothelium may be recommended for use in clinical practice. Key words: endothelium, keratocytes, corneal transplantation, keratoplasty, posterior lamellar keratoplasty, femtosecond laser, ophthalmic viscosurgical device, hydroxypropyl methylcellulose, confocal microscopy, scanning electron microscopy

Reconstruction of a Traumatic Large Upper Eyelid Avulsion with Tarsoconjunctival Graft and Rotational Flap: A Surgeon’s Preference

Introduction: Large, full-thickness upper eyelid defects management presents a thorough and challenging approach due to the multilaminar character of the eyelid and its dynamic function. The Cutler-Beard flap method has been the mainstay management, but posterior lamellar graft usage with recent modifications may reduce complications. Case Presentation: A 43-year-old man presented to the emergency ward after a traffic accident left him with a full-thickness laceration on his left upper eyelid and an approximately 60% avulsion on the one-third medial of the eyelid. Traumatic ptosis was also found. After considering the large size of the affected area and the probability of faster wound healing, a free graft from the tarsus and conjunctival eyelid of his fellow eye was harvested to replace the posterior lamellar of the affected eye and closed the defect with a rotational skin flap from the remaining of the left upper eyelid. Conclusions: This technique could be one of the alternatives to the more common cutler-beard flap with mild complications. However, temporary visual obstruction cannot be avoided due to the traumatic ptosis complication of this patient.

Clinical outcomes in a large multi‐Centre prospective corneal transplant study

AbstractThe output from Work package 2 (WP2) of the VISICORT project included four deliverables: Establishment of secure multi‐site clinical database of human corneal transplant recipients. Report of 1‐year outcomes from multi‐site prospective biological sampling and clinical follow‐up of full thickness (FT)‐ and posterior lamellar (PL)‐CT recipients Report of 3‐year prospective outcomes of FT‐ and PL‐CT recipients Report of clinical factors associated with adverse immunological outcomes from FT‐ and PL‐CT within the overall transplant practice of a network of 5 leading EU centres. In more general terms, the main mission of WP2 was to develop a cloud‐based system to collect relevant, well‐defined clinical information and track biological samples, to recruit patients from the five clinical centers, to collect biological samples and clinical data and to follow these patients clinically over several years.The current speech focus on the clinical outcomes 928 prospectively enrolled patients followed up to 3 years.Beyond confirming known factors associated with an adverse immunological outcome after FT‐ and PL‐CT such as the influence of primary diagnosis and type of surgery as risk factors, the clinical factors study revealed factors which needs to be explored further on. Identification of a re‐bubbling procedure (repeated injection of air to keep a PL graft in place) as an important risk factor for development of a later acute rejection episode is important as re‐bubbling is necessary in a fair large number of CT‐PL procedures (15–25%). The finding that presence of loose sutures after CT‐FT is a significant risk factor for AGR is not surprising, but further confirms that patients undergoing CT‐FT needs to be followed closely.Concerning graft failure, it is worth to note that presence of diabetes 2 was identified as a significant risk factor for graft failure after CT‐FT. This may be due to a partially neurotrophic disease state in many patients with diabetes 2 and this has to be taken into account when deciding to perform CT‐FT and in the clinical follow‐up, which need to be meticulous.The current clinical variables study is unique, and it would seem compelling to continue the clinical follow‐up of the recruited patients beyond the funding period for VISICORT. This would of course require new grant applications and obtaining new ethical approvals from the ethics committees at the five clinical centres.

A Novel Murine Model of Endothelial Keratoplasty.

The purpose of this study was to establish a murine model of endothelial keratoplasty. Endothelial keratoplasty (EK) was performed using C57BL/6 donor and BALB/c recipient mice. The central endothelium and Descemet membrane were removed from the recipient cornea, and a 1.5-mm posterior lamellar donor graft was made adherent to the recipient cornea with a small amount of viscoelastic. Mice were followed through slitlamp microscopy postoperatively, and OCT was used to assess the cornea and anterior chamber and measure central corneal thickness. Histology and immunohistochemistry were performed to confirm graft adherence and endothelial cell morphology. Successfully attached EK grafts were visualized in all transplanted animals. Histology and immunostaining confirmed proper graft orientation and adherence, as well as the presence of donor endothelium on transplanted grafts. We observed maximal corneal edema in all animals at day 1 postoperatively which gradually subsided. EK graft survival was 97% at 8 weeks. In this study, we describe a novel murine model for EK which we anticipate will enable detailed investigation into the cellular and molecular mechanisms involved in EK pathobiology.

Optimization of polycaprolactone - based nanofiber matrices for the cultivation of corneal endothelial cells

Posterior lamellar transplantation of the eye’ s cornea (DSAEK, DMEK) currently is the gold standard for treating patients with corneal endothelial cell and back surface pathologies resulting in functional impairment. An artificial biomimetic graft carrying human corneal endothelium could minimize the dependency on human donor corneas giving access to this vision-restoring surgery to large numbers of patients, thus reducing current long waiting lists. In this study, four groups of electrospun nanofibrous scaffolds were compared: polycaprolactone (PCL), PCL/collagen, PCL/gelatin and PCL/chitosan. Each of the scaffolds were tissue-engineered with human corneal endothelial cells (HCEC-B4G12) and analyzed with regard to their potential application as artificial posterior lamellar grafts. Staining with ZO-1 and Na+/K+-ATPase antibodies revealed intact cell functionalities. It could be shown, that blending leads to decreasing contact angle, whereby a heterogeneous blend morphology could be revealed. Scaffold cytocompatibility could be confirmed for all groups via live/dead staining, whereby a significant higher cell viability could be observed for the collagen and gelatine blended matrices with 97 ± 3% and 98 ± 2% living cells respectively. TEM images show the superficial anchoring of the HCECs onto the scaffolds. This work emphasizes the benefit of blended PCL nanofibrous scaffolds for corneal endothelial keratoplasty.

Переживаемость кератоцитов и эндотелиальных клеток заднего послойного трансплантата роговицы, культивированных в модифицированной консервационной среде

Purpose. To study the survival of keratocytes and endothelial cells of a human donor cornea storage in the standard and the new media which was specifically designed for optimized cornea hydration. Material and methods. 2D cell cultures of keratocytes and endothelial cells obtained from the Eye tissue bank were used for culture in improved storage media over a period of 14 and 7 days subsequently. To confirm phenotype characteristics, the cells were stained by the following markers: for keratocytes – Lumikan, Keratocan, and α-smooth muscle actin; for endothelial cells – ZO-1 and Na/K-ATPase. The onset of apoptosis in cell culture of keratocytes were detected with Cytochrome C, BAX, and Caspase 3 and 8. Viability of cell cultures after the cultivation was carried out using a commercial set of "Live and Dead". Morphology of the endothelial cells was assessed using an electron scanning microscope. Results. It was shown that the 2D keratocyte culture cultured in the improved storage media expressed specific markers: Lumican, Keratocan, and did not express α-smooth muscle actin. There were no markers of apoptosis in the cell culture of keratocytes after 14 days of cultivation. Corneal endothelium cultured in the improved storage media expresses ZO-1, Na/K-ATPase and presented hexagonal cell shape morphology according to electron microscopy. Conclusion. The improved storage media allow to preserve the unique phenotype of keratocytes, with a slight decrease in proliferative cells activity during 14 days. The media maintain a viable and functional corneal endothelium for at least seven days of cultivation. Key words: cell culture; corneal endothelium; keratocyte; posterior lamellar graft, corneal storage media.

Technology for obtaining an ultrathin posterior lamellar corneal graft at the Eye Tissue Bank

Objective: to develop technologies for preoperative preparation of the posterior lamellar corneal graft based on our own formulation of the preservation medium for optimal dehydration of the donor cornea and a technique for cutting out an ultrathin flap using an optimized method at the Eye Tissue Bank. Materials methods. In a series of experimental studies, we obtained data on the hydration level of cadaveric donor corneas that were preserved in various solutions at different observation periods. Using 16 corneas, analytical weighing and pachymetry were performed via optical coherence tomography in the experimental (n = 8) and control (n = 8) groups. Morphological and functional characteristics of the corneal endothelium were then assessed. At the next stage of work, ultrathin grafts were formed from 16 corneas after hypothermic preservation in the experimental (n = 8) and control (n = 8) solutions by single-pass microkeratome, followed by microscopy of the samples using a scanning electron microscope. Results. After the first days of preservation in the proposed solution, there was dehydration of 9% cornea in the experimental group in comparison with the samples of the control group. After 4 days of preservation, there was no reliable difference found between the groups (p > 0.05) in the study of the endothelial cell viability of ultra-thin corneal grafts by immunofluorescent microscopy using the «Live and dead» marker. Scanning electron microscopy revealed that corneal stromal collagen fibers, preserved in the proposed medium, retained their integrity. Conclusion. The proposed technology can be recommended for use at eye banks for formation of an ultra-thin corneal graft at the preoperative stage.

Fate of endothelial cells after intrastromal implantation of Descemet's membrane-endothelial cell tissue.

In non-Descemet Stripping Automated Endothelial Keratoplasty (nDSAEK), the host DM and endothelium are not removed surgically before the introduction of the posterior lamellar graft; the result is that the patient has both the healthy donor endothelium and the diseased or residual host endothelium. Conversely, DSAEK tissues, that are inserted with inverted polarity (upside down), do not survive and the graft fails. While the mechanism of endothelial cell transplantation is clear, the fate of the endothelial cells retained between two stromal interfaces and their physiological role, if any, is not well understood. The aim of our study was therefore to evaluate the viability of a healthy endothelial-Descemet's membrane (EDM) graft after the insertion into a stromal pocket of a recipient donor cornea. Research corneas (n = 52) were divided into three groups: Group A, where an EDM (obtained from another cornea) with good endothelium was inserted in a stromal pocket endothelium side down; Group B, consisting of control corneas with a stromal pocket but without EDM insertion; and Group C, pre-stripped membranes resting on their stroma (not in a stromal pocket). The tissues were preserved in tissue culture medium for 21 days at 31 °C. Parameters including viability of endothelial cells, expression of tight junctions (ZO-1) and thickness were evaluated. After 21 days, all the membranes inserted within the stromal pocket of Group A survived, although an average endothelial cell loss of 30.1% (± 18.10) and a mortality of 10.2% (± 22.86) were recorded. Qualitative analysis using triple staining with Hoechst, ethidium homodimer and calcein AM confirmed the mortality. ZO-1 was expressed where the cells were present, showing good integrity of tight junctions. Group C showed an average endothelial cell loss of 1.9% (± 3.38), a mortality of 0.02% (± 0.07) and a higher expression of ZO-1. An EDM graft with endothelium facing downwards can survive in a stromal pocket for at least 3 weeks, with an overall cell mortality of 30%. Further studies are needed to evaluate the possible outcomes of the insertion of a healthy intrastromal EDMs with reverse polarity and in edematous corneas.

Long-term observation of graft thickness and shape in Descemet stripping and automated endothelial keratoplasty.

To evaluate the thickness and shape of the posterior lamellar graft in Descemet stripping and automated endothelial keratoplasty after long-term observation. All patients who underwent Descemet stripping and automated endothelial keratoplasty including simple and triple Descemet stripping and automated endothelial keratoplasty between August 2009 and May 2014 were enrolled in this retrospective study. To assess postoperative thickness and shape of the Descemet stripping and automated endothelial keratoplasty graft, images of the graft taken at the center (C), mid-periphery at 4 mm optical zone (P1), and periphery at 6 mm optical zone (P2) at 1, 2, and 3 years postoperatively were obtained using anterior segment optical coherence tomography. C:P1 was 0.96, 0.96, and 0.95 at 1, 2, and 3 years postoperatively, respectively. C:P2 was 0.85, 0.84, and 0.83 at 1, 2, and 3 years postoperatively, respectively. There was a greater thinning of the central graft thickness compared with the peripheral graft thickness. The shapes of the posterior lamellar graft were variable, such as concave, asymmetrical, planar, irregular, and convex meniscus shapes. The most common shape was asymmetrical shape at 1 year postoperatively and concave at 2 and 3 years postoperatively. The most common shape of the posterior lamellar grafts was asymmetrical shape (38.18%) at 1 year postoperatively, followed by concave (34.54%), planar (20.00%), irregular (5.45%), and convex (1.81%) shapes. The most common shape was concave shape (44.44% and 57.14% for 2 and 3 years postoperatively, respectively), followed by asymmetrical (27.77% and 17.85%, respectively), planar (16.66% and 17.85%, respectively), and irregular (11.11% and 7.14%, respectively) shapes. In our study, concave meniscus was not the only observed shape of the graft. The shape and thickness of the graft did not stabilize even 3 years postoperatively in some patients. These findings should be taken into consideration in a combination of Descemet stripping and automated endothelial keratoplasty and cataract surgery.

Correction of Recalcitrant Cicatricial Lower Lid Retraction and Entropion With Transverse Tarsotomy and Tarsoconjunctival Flap.

To describe a novel technique to correct cicatricial lower lid entropion and retraction using a transverse lower lid tarsotomy with an interposed tarsoconjunctival flap posterior lamellar spacer. Technique description and retrospective interventional case series. Four patients underwent the procedure-two with complications following treatment of sinonasal carcinoma and two with complications following orbital fracture repair. All patients had failed prior posterior lamellar spacer grafts, including donor sclera, dermis-fat graft, and hard palate mucosa. Average time to flap takedown was 20 (11-28) days, with an average follow-up interval of 8.4 (6.2-11.5) months. All patients had resolution of lower lid entropion and significant improvement of lower lid retraction with an average of 2.8 mm (2.0-4.3) of elevation. There were no serious complications, and all patients reported significant improvement in ocular surface symptoms. Transverse tarsotomy combined with a tarsoconjunctival flap is effective for the correction of cicatricial lower lid retraction and entropion in eyelids that have failed surgery with traditional posterior lamellar spacer grafts.

Relationship between Preoperative Corneal Thickness and Postoperative Visual Outcomes after Posterior Lamellar Corneal Transplant

Purpose: To evaluate the impact of preoperative corneal thickness on visual outcomes following Descemet’s stripping endothelial keratoplasty (DSAEK) or Descemet membrane endothelial keratoplasty (DMEK). Methods: This retrospective, observational study included patients aged > 18 years that underwent a posterior lamellar graft surgery (DSAEK or DMEK) for Fuchs dystrophy, pseudophakic endothelial decompensation or other endothelial dysfunction from October 2013 to November 2016. Exclusion criteria were the technical inability of preoperative CCT measurement, a history of penetrating keratoplasty in the study eye, the need for a penetrating keratoplasty following endothelial graft failure, preexisting stromal scarring before surgery (clinically assessed by the slit-lamp exam) and severe postoperative complications resulting in unquantifiable visual acuity. Visual acuity, central corneal thickness (CCT) and graft thickness were measured preoperatively and at postoperative day 7 and months 1, 3 and 6. Results: Forty-seven eyes (40 patients) were included in the final analysis. No significant association was observed between preoperative CCT and visual acuity at any postoperative time up to month 6 (r = 0.01; p = 0.94 at month 6). Preoperative CCT showed no association with visual acuity gain at any time up to month 6 (r = -0.02; p = 0.91 at month 6). Conclusion: Preoperative CCT does not predict the visual results achievable at 6 months after DSAEK or DMEK.

Long-Term Outcomes of Acellular Dermal Allograft as a Tarsal Substitute in the Reconstruction of Extensive Eyelid Defects.

To report the long-term outcomes of using acellular dermal allograft (ADA) as a tarsal substitute for reconstruction of large full-thickness eyelid defects where ipsilateral or contralateral eyelid donor tissue was either not available or tarsoconjunctival transfer was insufficient to cover the full extent of the defect. A retrospective review of a consecutive series of 10 patients between May 2003 and April 2012. Main outcome measures were anatomical and functional outcomes and complications. The study cohort included 4 males and 6 females with a mean age of 48.1 years (range 31-64 years). Indications for reconstruction were extensive full-thickness eyelid defects (upper or lower or both) resulting from tumor excision (n = 6), traumatic eyelid defect (n = 2), electrical burn (n = 1), and eyelid necrosis (n = 1). The mean postoperative follow-up was 84.3 months (range 33-164 months). The reconstructive procedure included a variety of techniques using ADA as the posterior lamellar graft. Overall, 7 patients achieved excellent anatomical, cosmetic, and functional results. Reoperation was required in 3 patients (for postoperative upper lid retraction, upper lid entropion, and lower fornix reconstruction) despite acceptable initial results. There were no intraoperative complications, postoperative allergic or immunologic rejection associated with the use of allograft, nor any long-term sequelae. The extensive upper and lower eyelid defects with large vertical component can be successfully repaired using ADA as a tarsal substitute. The results of our study with long-term follow-up indicate excellent functional and cosmetic outcomes with minimal morbidity.

Novel concepts for treatment of the corneal endothelium with nanoparticles

The number of corneal transplantations has increased in Germany in recent years. One reason is an earlier time point of surgery due to less invasive posterior lamellar grafting techniques. To date, penetrating and lamellar corneal transplantations are the only established therapeutic options to treat corneal diseases resulting from endothelial cell pathologies. This review article provides an insight into nanoparticle-related translational strategies to improve or to avoid corneal transplantation. Nanoparticle-based strategies for optimization of the corneal endothelium have different fields of application: 1.during donor cornea cultivation in culture medium, 2.for single cell injection therapies and 3.to treat the patients' own endothelium in an effort to avoid transplantation. Several translational concepts exist to improve or to avoid grafting of adonor cornea. The coming decade will provide established alternatives to conventional corneal transplantation.

Long-Term Functional and Anatomical Outcome after Descemet Stripping Automated Endothelial Keratoplasty: A Prospective Single-Center Study.

Purpose To investigate the long-term anatomical and functional outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK). Methods Prospective follow-up of 114 eyes (95 subjects) after DSAEK for endothelial dysfunction. Measurements included best spectacle-corrected visual acuity (BSCVA), straylight, endothelial cell density (ECD), and graft thickness. Results The mean follow-up time was 5.1 ± 1.5 years. Four grafts ultimately failed (after 5 to 7 years). From baseline up to 1 year after DSAEK, mean BSCVA improved by 0.30 logMAR. This beneficial effect remained until the last follow-up (LFU). After DSAEK, straylight was reduced. ECD sharply dropped by 900 cells/mm2 (33%) immediately after surgery and, thereafter, steadily decreased at a rate of 11 cells/mm2 per month. No significant correlation was observed between graft thickness at 3 years and BSCVA. Conclusions We observed a low graft failure rate and a normalization of graft thickness. Postoperative straylight remained elevated relative to the normal population. The sharp initial and the subsequent more gradual ECD decline are consistent with other studies. A significant and prolonged functional gain can be achieved by posterior lamellar grafting for endothelial dysfunction.

Évaluation pratique de la prise en charge par DSAEK des décompensations endothéliales après kératoplasties transfixiantes

To report our anatomical and functional results as well as possible complications of the first six Descemet's stripping endothelial keratoplasties (DSAEK) performed in our department for endothelial decompensation after penetrating keratoplasty (PK) METHODS: This was a retrospective and observational monocentric study of six patients with DSAEK after prior PK between January 2015and July 2016. The data collected were: demographic characteristics (age, sex), ophthalmological comorbidities, initial indication for PK, delay between PK and DSAEK. Best corrected visual acuity (BCVA) preoperatively and at 1, 3and 6months postoperatively were collected in Monoyer's and Parinaud scale and converted to log MAR for statistical analysis. The central cornea and graft thickness measured on OCT as well as postoperative complications were also collected. Mean follow-up duration was 7.2months [3-10]. The average time after PK was 7.7years. The mean age of the patients was 67.5years [32-87]. The initial indication for PK was Fuchs dystrophy (3/6), pseudophakic bullous keratopathy (1/6), corneal laceration (1/6) and other corneal dystrophy (1/6). The authors report one case a combined phaco-DSAEK surgery. The complications observed were: an early graft detachment treated by an additional air bubble injection (1/6) and cystoid macular edema in one other case. The average central corneal thickness decreased from 780μm at day7postoperatively to 656μm at 6months. The average thickness of the graft decreased from 154μm at day7to 122μm at 6months. The mean preoperative BCVA was 1.52log MAR [1.0-1.7], compared to the mean postoperative BCVA which was 1.5log MAR [1.1-2.3] at 1month, 1.15log MAR [0.5-1.7] at 3months and 1.1log MAR [0.7-1.7] at 6months (data available for 4patients at 6months). The recovery of visual acuity was limited in 2cases, despite corneal clarity restored in all our patients. Our results can be compared to those described in literature. As more penetrating keratoplasty grafts reach the end of their lives, this will allow for more powerful studies. DSAEK on eyes previously treated with PK is a good alternative to a new PK in the case of endothelial decompensation of the graft. The possibility of a posterior lamellar graft allows for faster visual recovery, with preservation of the anterior corneal power and a lower rate of complications.

Avoiding the Hughes flap in lower eyelid reconstruction.

To review current surgical practices of lower eyelid reconstruction with a focus on recent studies. Combination techniques and new flap techniques offer efficacy comparable with existing reconstructive approaches, with the advantage of less local trauma. Inappropriate handling of posterior lamellar grafts, such as kerfing, may predispose to graft failures. Modified Hughes procedure is a favorable choice for large lower eyelid reconstruction; however, it requires temporary eye closure. Other surgical options have been developed to achieve a 1-stage procedure without the need of eye closure. These include the Smith-modified Kuhnt-Szymanowski procedure and the use of flaps. For posterior lamellar grafts, both nasal septal and ear cartilage donor tissue produce esthetically and functionally satisfactory outcomes and comparable efficacy. However, the ear cartilage carries a lower risk of donor site complications. Lower eyelid reconstruction remains a challenge, especially for large or near total defects. Recent studies have explored modifications and alternatives to the conventional Hughes flap. New surgical procedures give surgeons more options. Taking into account the growing spectrum of reconstructive techniques, an individualized approach may facilitate better functional and esthetic outcomes.

Reconstructive subperiosteal midface lift: A three nonvisible incision approach

ABSTRACTThis article describes our surgical technique for subperiosteal midface elevation in patients with paralytic lower eyelid malposition or cicatricial inferior eyelid retraction. Nineteen patients with paralytic lower eyelid malposition and 15 patients with cicatricial inferior eyelid retraction underwent a subperiosteal midface lift (n = 34). The procedure was performed under local anesthesia through three nonvisible incisions. A transconjunctival incision allows preseptal dissection to the orbital rim, followed by a subperiosteal dissection of the midface. An oral incision is useful to achieve complete subperiosteal dissection and to perform the distal periostomy, which allows complete release of the midface soft tissues. A temporal incision provides access to the temporal fascia for fixation of the elevated tissues and gives the surgeon the possibility of removing redundant skin from the scalp instead of the lower eyelid. Additional posterior lamellar grafting was performed in 24 patients. There was a statistically significant reduction in the distance from the pupil centre to the lower eyelid (margin reflex distance, MRD2) 1 month after surgery (preoperative MRD2 9.62 ± 4.52 mm, postoperative MRD2 5.28 ± 2.62 mm). The ectropion and lower eyelid retraction was resolved in all patients, except for one recurrence. Midfacial elevation is a safe and effective surgical technique in the treatment of static lower eyelid malposition after chronic facial nerve palsy or posttraumatic or iatrogenic lower eyelid retraction.

Autologous Fat Grafting for Treating Blepharoplasty-induced Lower Eyelid Retraction.

Summary:Autologous fat grafting for blepharoplasty-induced lower eyelid retraction offers potential for a long-term solution while avoiding the morbidity associated with posterior lamellar spacer grafts. By combining traditional methods of lifting the retracted lower eyelid with autologous fat grafting, both functional and aesthetic concerns can be successfully addressed in these patients.

Commentary on: Lower Eyelid Retraction Surgery Without Internal Spacer Graft

I want to thank the editor for asking me to address the topic of the surgical management of lower eyelid retraction. I will focus my discussion only on post-blepharoplasty lower eyelid retraction (PBLER), as this is a topic of great interest to me, and because the other causes described in Dr Taban's report are less of a focus to aesthetic eyelid surgeons, although the same principals of treatment certainly apply. I will divide my discussion into four parts: (1) a respectful appreciation of Dr Taban's insight; (2) what the literature currently suggests; (3) what the readership wants to know; and (4) a few words on future efforts. First and foremost, thank you Dr Taban for sharing your work with the Aesthetic Surgery Journal .1 I believe those that see this problem often understand what a difficult and humbling eyelid malposition this is to understand and manage. Clearly Dr Taban has a good feel for it, and any simplification shared will certainly make the process more palatable for others. Let me summarize what I feel Dr Taban is suggesting. PBLER has been surgically addressed with midface lifting to recruit skin, open canthal suspension to suspend and support the lower eyelid, and a posterior lamellar spacer graft to vertically lengthen the lower eyelid and recess the lower lid retractors.2 This combined procedure has been the standard for over 30 years. Its component parts make sense, and each may play a vital role in surgical success. However, is each step needed in every case? Can an algorithm be developed which omits unnecessary procedures which, in and of themselves, carry various degrees of potential morbidity? These questions demand a critical reevaluation of this …