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Clin Ophthalmol
v.1(2); 2007 Jun
PMC2704509
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Clin Ophthalmol. 2007 Jun; 1(2): 141–147.
Department of Ophthalmology, Aichi Medical University, Nagakute-cho, Aichi-gun, Aichi-ken, Japan
Correspondence: Hirohiko Kakizaki, Department of Ophthalmology, Aichi Medical University, Nagakute-cho, Aichi-gun, Aichi-ken, 480-1195, Japan, Tel +81 561 62 3311, Fax +81 561 63 7255, Email
pj.en.noid.1d@emsoc
Copyright © 2007 Kakizaki et al, publisher and licensee Dove Medical Press Ltd.
This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.
Keywords: posterior layer of the lower eyelid retractors, lower eyelid retraction, cicatricial entropion, ear cartilage, transcutaneous approach
Bartley GB, Kay PP. Posterior lamellar eyelid reconstruction with a hard palate mucosal graft. Am J Ophthalmol. 1989; 107 :609–12. [ PubMed ] [ Google Scholar ] Baylis HI, Perman KI, Fett DR, et al. Autogenous auricular cartilage grafting for lower eyelid retraction. Ophthal Plast Reconstr Surg. 1985; 1 :23–7. [ PubMed ] [ Google Scholar ] Ben Simon GJ, Lee S, Schwarcz RM, et al. Subperiosteal midface lift with or without a hard palate mucosal graft for correction of lower eyelid retraction. Ophthalmology. 2006; 113 :1869–73. [ PubMed ] [ Google Scholar ] Cohen MS, Shorr N. Eyelid reconstruction with hard palate mucosa grafts. Ophthal Plast Reconstr Surg. 1992; 8 :183–95. [ PubMed ] [ Google Scholar ] Collin JRO, Rathbun JE. Involutional entropion. A review with evaluation of a procesure. Arch Ophthalmol. 1978; 96 :1058–64. [ PubMed ] [ Google Scholar ] Duke-Elder SS, MacFaul PA. System of Ophthalmology vol. XIII– The Ocular adnexa. London: Henry Kimpton; 1976. Abnormalities of the palpebral aperture; pp. 573–81. [ Google Scholar ] Fay AM, Pieroth L, Rubin PA. An animal model of lower eyelid spacer grafting with a cellular dermis. Ophthal Plast Reconstr Surg. 2001; 17 :270–5. [ PubMed ] [ Google Scholar ] Feldman KA, Putterman AM, Farber MD. Surgical treatment of thyroid-related lower eyelid retraction: a modified approach. Ophthal Plast Reconstr Surg. 1992; 8 :278–86. [ PubMed ] [ Google Scholar ] Gardner TA, Kennerdell JS, Buerger GF. Treatment of dysthyroid lower lid retraction with autogenous tarsus transplants. Ophthal Plast Reconstr Surg. 1992; 8 :26–31. [ PubMed ] [ Google Scholar ] Goldberg RA, Joshi AR, McCann JD, et al. Management of severe cicatricial entropion using shared mucosal grafts. Arch Ophthalmol. 1999; 117 :1255–9. [ PubMed ] [ Google Scholar ] Harvey JT, Anderson RL. The aponeurotic approach to eyelid retraction. Ophthalmology. 1981; 88 :513–24. [ PubMed ] [ Google Scholar ] Hawes MJ, Dortzbach RK. The microscopic anatomy of the lower eyelid retractors. Arch Ophthalmol. 1982; 100 :1313–8. [ PubMed ] [ Google Scholar ] Henderson JW. Relief of eyelid retraction: A surgical procedure. Arch Ophthalmol. 1965; 74 :205–16. [ PubMed ] [ Google Scholar ] Jones LT. A new concept of the orbital fascia and rectus muscle sheaths and its surgical implications. Trans Am Acad Ophthalmol. 1968; 72 :755–64. [ PubMed ] [ Google Scholar ] Kakizaki H, Zako M, Mito H, et al. Modified operation to correctly detect and fix the lower eyelid retractor in involutional entropion. Jpn J Ophthalmol. 2005; 49 :330–2. [ PubMed ] [ Google Scholar ] Kakizaki H, Zhao J, Nakano T, et al. The lower eyelid retractor consists of definite double layers. Ophthalmology. 2006a; 113 :2346–50. [ PubMed ] [ Google Scholar ] Kakizaki H, Zhao J, Zako M, et al. Microscopic anatomy of asian lower eyelids. Ophthal Plast Reconstr Surg. 2006b; 22 :430–3. [ PubMed ] [ Google Scholar ] Kakizaki H, Zako M, Kinoshita S, et al. Posterior layer advancement of the lower eyelid retractor in involutional entropion repair. Ophthal Plast Reconstr Surg. 2007a In press. [ PubMed ] [ Google Scholar ] Kakizaki H, Zako M, Iwaki M. Reverse ptosis repair targeting the posterior layer of the lower lid retractor. Ophthal Plast Reconstr Surg. 2007b In press. [ PubMed ] [ Google Scholar ] Kersten RC, Kulwin DR, Levartovsky S, et al. Management of lower-lid retraction with hard-palate mucosa grafting. Arch Ophthalmol. 1990; 108 :1339–43. [ PubMed ] [ Google Scholar ] Li TG, Shorr N, Goldberg RA. Comparison of the efficacy of hard palate grafts with acellular human dermis grafts in lower eyelid surgery. Plast Reconstr Surg. 2005; 116 :873–8. [ PubMed ] [ Google Scholar ] McInnes AW, Burroughs JR, Anderson RL, et al. Temporary suture tarsorrhaphy. Am J Ophthalmol. 2006; 142 :344–6. [ PubMed ] [ Google Scholar ] Moon JW, Choung HK, Khwarg SI. Correction of lower lid retraction combined with entropion using an ear cartilage graft in the anophthalmic socket. Korean J Ophthalmol. 2005; 19 :161–7. [ PubMed ] [ Google Scholar ] Olver JM, Rose GE, Khaw PT, et al. Correction of lower eyelid retraction in thyroid eye disease: a randomised controlled trial of retractor tenotomy with adjuvant antimetabolite versus scleral graft. Br J Ophthalmol. 1998; 82 :174–80. [ PMC free article ] [ PubMed ] [ Google Scholar ] Ortiz-Monasterio F, Olmedo A, Oscoy LO. The use of cartilage grafts in primary aesthetic rhinoplasty. Plast Reconstr Surg. 1981; 67 :597–605. [ PubMed ] [ Google Scholar ] Patel MP, Shapiro MD, Spinelli HM. Combined hard palate spacer graft, midface suspension, and lateral canthoplasty for lower eyelid retraction: a tripartite approach. Plast Reconstr Surg. 2005; 115 :2105–14. [ PubMed ] [ Google Scholar ] Shorr N, Fallor MK. “Madame Butterfly” procedure: combined cheek and lateral canthal suspension procedure for post-blepharoplasty, “round eye,” and lower eyelid retraction. Ophthal Plast Reconstr Surg. 1985; 1 :229–35. [ PubMed ] [ Google Scholar ] Shorr N. “Madame Butterfly” procedure: Total lower eyelid reconstruction in three layers utilizing a hard palate graft: Management of the unhappy post-blepharoplasty patient with round eye and scleral show. Int J Aesthetic Restorative Surg. 1995; 3 :3–26. [ Google Scholar ] Sullivan SA, Dailey RA. Graft contraction: a comparison of acellular dermis versus hard palate mucosa in lower eyelid surgery. Ophthal Plast Reconstr Surg. 2003; 19 :14–24. [ PubMed ] [ Google Scholar ] Wearne MJ, Sandy C, Rose GE, et al. Autogenous hard palate mucosa: the ideal lower eyelid spacer? Br J Ophthalmol. 2001; 85 :1183–7. [ PMC free article ] [ PubMed ] [ Google Scholar ]
Articles from Clinical Ophthalmology (Auckland, N.Z.) are provided here courtesy of Dove Press
Henderson JW. Relief of eyelid retraction: A surgical procedure. Arch Ophthalmol. 1965; 74 :205–16. [ PubMed ] [ Google Scholar ] [ Ref list ]
Harvey JT, Anderson RL. The aponeurotic approach to eyelid retraction. Ophthalmology. 1981; 88 :513–24. [ PubMed ] [ Google Scholar ] [ Ref list ]
Baylis HI, Perman KI, Fett DR, et al. Autogenous auricular cartilage grafting for lower eyelid retraction. Ophthal Plast Reconstr Surg. 1985; 1 :23–7. [ PubMed ] [ Google Scholar ] [ Ref list ]
Bartley GB, Kay PP. Posterior lamellar eyelid reconstruction with a hard palate mucosal graft. Am J Ophthalmol. 1989; 107 :609–12. [ PubMed ] [ Google Scholar ] [ Ref list ]
Kersten RC, Kulwin DR, Levartovsky S, et al. Management of lower-lid retraction with hard-palate mucosa grafting. Arch Ophthalmol. 1990; 108 :1339–43. [ PubMed ] [ Google Scholar ] [ Ref list ]
Cohen MS, Shorr N. Eyelid reconstruction with hard palate mucosa grafts. Ophthal Plast Reconstr Surg. 1992; 8 :183–95. [ PubMed ] [ Google Scholar ] [ Ref list ]
Gardner TA, Kennerdell JS, Buerger GF. Treatment of dysthyroid lower lid retraction with autogenous tarsus transplants. Ophthal Plast Reconstr Surg. 1992; 8 :26–31. [ PubMed ] [ Google Scholar ] [ Ref list ]
Olver JM, Rose GE, Khaw PT, et al. Correction of lower eyelid retraction in thyroid eye disease: a randomised controlled trial of retractor tenotomy with adjuvant antimetabolite versus scleral graft. Br J Ophthalmol. 1998; 82 :174–80. [ PMC free article ] [ PubMed ] [ Google Scholar ] [ Ref list ]
Fay AM, Pieroth L, Rubin PA. An animal model of lower eyelid spacer grafting with a cellular dermis. Ophthal Plast Reconstr Surg. 2001; 17 :270–5. [ PubMed ] [ Google Scholar ] [ Ref list ]
Wearne MJ, Sandy C, Rose GE, et al. Autogenous hard palate mucosa: the ideal lower eyelid spacer? Br J Ophthalmol. 2001; 85 :1183–7. [ PMC free article ] [ PubMed ] [ Google Scholar ] [ Ref list ]
Moon JW, Choung HK, Khwarg SI. Correction of lower lid retraction combined with entropion using an ear cartilage graft in the anophthalmic socket. Korean J Ophthalmol. 2005; 19 :161–7. [ PubMed ] [ Google Scholar ] [ Ref list ]
Patel MP, Shapiro MD, Spinelli HM. Combined hard palate spacer graft, midface suspension, and lateral canthoplasty for lower eyelid retraction: a tripartite approach. Plast Reconstr Surg. 2005; 115 :2105–14. [ PubMed ] [ Google Scholar ] [ Ref list ]
Goldberg RA, Joshi AR, McCann JD, et al. Management of severe cicatricial entropion using shared mucosal grafts. Arch Ophthalmol. 1999; 117 :1255–9. [ PubMed ] [ Google Scholar ] [ Ref list ]
Kakizaki H, Zhao J, Nakano T, et al. The lower eyelid retractor consists of definite double layers. Ophthalmology. 2006a; 113 :2346–50. [ PubMed ] [ Google Scholar ] [ Ref list ]
Hawes MJ, Dortzbach RK. The microscopic anatomy of the lower eyelid retractors. Arch Ophthalmol. 1982; 100 :1313–8. [ PubMed ] [ Google Scholar ] [ Ref list ]
Kakizaki H, Zako M, Kinoshita S, et al. Posterior layer advancement of the lower eyelid retractor in involutional entropion repair. Ophthal Plast Reconstr Surg. 2007a In press. [ PubMed ] [ Google Scholar ] [ Ref list ]
Kakizaki H, Zako M, Iwaki M. Reverse ptosis repair targeting the posterior layer of the lower lid retractor. Ophthal Plast Reconstr Surg. 2007b In press. [ PubMed ] [ Google Scholar ] [ Ref list ]
Ben Simon GJ, Lee S, Schwarcz RM, et al. Subperiosteal midface lift with or without a hard palate mucosal graft for correction of lower eyelid retraction. Ophthalmology. 2006; 113 :1869–73. [ PubMed ] [ Google Scholar ] [ Ref list ]
Sullivan SA, Dailey RA. Graft contraction: a comparison of acellular dermis versus hard palate mucosa in lower eyelid surgery. Ophthal Plast Reconstr Surg. 2003; 19 :14–24. [ PubMed ] [ Google Scholar ] [ Ref list ]
Li TG, Shorr N, Goldberg RA. Comparison of the efficacy of hard palate grafts with acellular human dermis grafts in lower eyelid surgery. Plast Reconstr Surg. 2005; 116 :873–8. [ PubMed ] [ Google Scholar ] [ Ref list ]
Duke-Elder SS, MacFaul PA. System of Ophthalmology vol. XIII– The Ocular adnexa. London: Henry Kimpton; 1976. Abnormalities of the palpebral aperture; pp. 573–81. [ Google Scholar ] [ Ref list ]
Kakizaki H, Zako M, Mito H, et al. Modified operation to correctly detect and fix the lower eyelid retractor in involutional entropion. Jpn J Ophthalmol. 2005; 49 :330–2. [ PubMed ] [ Google Scholar ] [ Ref list ]
Feldman KA, Putterman AM, Farber MD. Surgical treatment of thyroid-related lower eyelid retraction: a modified approach. Ophthal Plast Reconstr Surg. 1992; 8 :278–86. [ PubMed ] [ Google Scholar ] [ Ref list ]
McInnes AW, Burroughs JR, Anderson RL, et al. Temporary suture tarsorrhaphy. Am J Ophthalmol. 2006; 142 :344–6. [ PubMed ] [ Google Scholar ] [ Ref list ]
Jones LT. A new concept of the orbital fascia and rectus muscle sheaths and its surgical implications. Trans Am Acad Ophthalmol. 1968; 72 :755–64. [ PubMed ] [ Google Scholar ] [ Ref list ]
Ortiz-Monasterio F, Olmedo A, Oscoy LO. The use of cartilage grafts in primary aesthetic rhinoplasty. Plast Reconstr Surg. 1981; 67 :597–605. [ PubMed ] [ Google Scholar ] [ Ref list ]
Collin JRO, Rathbun JE. Involutional entropion. A review with evaluation of a procesure. Arch Ophthalmol. 1978; 96 :1058–64. [ PubMed ] [ Google Scholar ] [ Ref list ]
Kakizaki H, Zhao J, Zako M, et al. Microscopic anatomy of asian lower eyelids. Ophthal Plast Reconstr Surg. 2006b; 22 :430–3. [ PubMed ] [ Google Scholar ] [ Ref list ]
Shorr N, Fallor MK. “Madame Butterfly” procedure: combined cheek and lateral canthal suspension procedure for post-blepharoplasty, “round eye,” and lower eyelid retraction. Ophthal Plast Reconstr Surg. 1985; 1 :229–35. [ PubMed ] [ Google Scholar ] [ Ref list ]
Shorr N. “Madame Butterfly” procedure: Total lower eyelid reconstruction in three layers utilizing a hard palate graft: Management of the unhappy post-blepharoplasty patient with round eye and scleral show. Int J Aesthetic Restorative Surg. 1995; 3 :3–26. [ Google Scholar ] [ Ref list ]
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The lower eyelid retractors consist of double layers, the posterior layer of which is the main tractional component. Therefore, shortening of the posterior layer of the lower eyelid retractors causes lower eyelid retraction or cicatricial entropion. Based on this concept, we report a modified lower eyelid lengthening surgery involving complete recession of the posterior layer of the lower eyelid retractors by way of a transcutaneous approach that leaves the palpebral conjunctiva intact and inserts ear cartilage as a rigid spacer between the lower edge of the tarsal plate and the recessed anterior layer of the lower eyelid retractors. This procedure completely extirpated the preoperative maladjusted states of lower eyelid retraction and cicatricial entropion. Our procedure also prevented postoperative discomfort of the ocular surface due to the intact palpebral conjunctiva. As well, lower eyelid mobility and contour were good and within their respective permissible ranges. The lower eyelid lengthening surgery focusing on the posterior layer of the lower eyelid retractors using auricular cartilage via a transcutaneous approach is a useful procedure for lower eyelid retraction or cicatricial entropion.
Shortening of the posterior lamella of the lower eyelid causes lower eyelid retraction ( Henderson 1965 ; Harvey and Anderson 1981 ; Baylis et al 1985 ; Bartley and Kay 1989 ; Kerstern et al 1990 ; Cohen and Shorr 1992 ; Gardner et al 1992 ; Olver et al 1998 ; Fay et al 2001 ; Wearne et al 2001 ; Moon et al 2005 ; Patel et al 2005 ) or entropion ( Bartley and Kay 1989 ; Cohen and Shorr 1992 ; Goldberg et al 1999 ), for which the shortened posterior lamella needs to be lengthened for treatment ( Henderson 1965 ; Harvey and Anderson 1981 ; Baylis et al 1985 ; Bartley and Kay 1989 ; Kerstern et al 1990 ; Cohen and Shorr 1992 ; Gardner et al 1992 ; Olver et al 1998 ; Goldberg et al 1999 ; Fay et al 2001 ; Wearne et al 2001 ; Moon et al 2005 ; Patel et al 2005 ). The posterior layer of the lower eyelid retractors has to be targeted then because it represents the site of the pathology of such diseases ( Kakizaki et al 2006a ). Although the lower eyelid retractors were originally thought to consist of a complicated single layer ( Hawes and Dortzbach 1982 ), they have now been revealed to be composed of a definite double layer ( Kakizaki et al 2006a ), consisting of anterior and posterior layers. The posterior layer, which is comprised of dense fibers of the capsulopalpebral fascia with scattered smooth muscle fibers and continues to the tarsus, is the main tractional component of the lower eyelid retractors ( Kakizaki et al 2006a ). Surgical operations targeting the posterior layer of the lower eyelid retractors for involutional lower eyelid entropion ( Kakizaki et al 2007a ) or reverse ptosis ( Kakizaki et al 2007b ), the pathologies of which are in the lower eyelid retractors, have been reported with good results.
The transconjunctival approach has been always taken in lower eyelid lengthening surgeries ( Henderson 1965 ; Harvey and Anderson 1981 ; Baylis et al 1985 ; Bartley and Kay 1989 ; Kerstern et al 1990 ; Cohen and Shorr 1992 ; Gardner et al 1992 ; Olver et al 1998 ; Goldberg et al 1999 ; Fay et al 2001 ; Wearne et al 2001 ; Moon et al 2005 ; Patel et al 2005 ; Ben Simon et al 2006 ). The shortened posterior lamellae of the lower eyelid retractors can be lengthened by spacer techniques ( Baylis et al 1985 ; Bartley and Kay 1989 ; Kerstern et al 1990 ; Cohen and Shorr 1992 ; Gardner et al 1992 ; Goldberg et al 1999 ; Fay et al 2001 ; Wearne et al 2001 ; Moon et al 2005 ; Patel et al 2005 ; Ben Simon et al 2006 ) or nonspacer techniques, such as recession, tenotomy or extirpation of the lower eyelid retractors ( Henderson 1965 ; Harvey and Anderson 1981 ; Olver et al 1998 ). Since the latter techniques have limited indications ( Olver et al 1998 ; Wearne et al 2001 ) because of their lack of rigidity or postoperative fibrous contracture, spacer techniques are usually selected ( Cohen and Shorr 1992 ; Olver et al 1998 ; Wearne et al 2001 ). The hard palate mucosa and nasal turbinate mucosa are often used as autologous spacers ( Bartley and Kay 1989 ; Kersten et al 1990 ; Cohen and Shorr 1992 ; Wearne et al 2001 ; Patel et al 2005 ; Ben Simon et al 2006 ), since they have a mucosal surface of appropriate rigidity ( Cohen and Shorr 1992 ; Wearne et al 2001 ). Although keratinization can oc
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