Lower Eyelid Retraction Repair with Resorbable Polydioxanone Implants.

PURPOSE: To report a unique technique to repair lower eyelid retraction using resorbable polydioxanone implants. PATIENTS AND METHODS: This was a retrospective, consecutive, nonrandomized interventional case series. Patients with lower eyelid retraction after trauma repaired facial fracture, thyroid eye disease, lower eyelid blepharoplasty, and long-standing facial palsy were treated with middle lamellar spacer using absorbable polydioxanone implant. All patients were recruited from the King Abdulaziz University Hospital, Riyadh, Saudi Arabia. Only patients with minimum follow-up of 12 months were included in the study.
RESULTS: Eight patients (4 males and 4 females) underwent lower eyelid retraction repair using absorbable polydioxanone implant. The mean age was 43 years (range, 23-63 years). All patients noted improved ocular surface symptoms. The improvement in eyelid retraction ranged from 1.5 to 4 mm with an average of 2.7 mm postoperatively. The implant was well tolerated with no major complications.
CONCLUSIONS: Several options for spacer materials are available. Absorbable polydioxanone implants seem to be an effective middle lamellar spacer that is a good alternative for repairing middle lamella related lower eyelid retraction and lower eyelid support.

Introduction

Lower eyelid retraction is defined as inferior malposition of the lower eyelid margin that is not associated with entropion or ectropion.[1] Different techniques have been used to treat lower eyelid retraction with differing pathophysiology. For example, the lateral tarsal strip technique addresses lateral canthal tendon laxity and the suborbicularis oculi fat lift technique addresses midface descent.[1] Despite a clear understanding of the mechanism of posttraumatic or iatrogenic eyelid retraction, there is a considerable variation in the surgical repair of eyelid retraction. The main principle of surgical treatment of eyelid retraction is recession of the eyelid retractor with or without spacer.[2] Different materials have been used as a spacer to lengthen the involved lamella as a treatment of eyelid retraction or cicatricial entropion.[3] These materials can be classified as alloplasts, allografts, autografts, and xenografts.[4] Of all the considerations in eyelid retraction repair, there are significantly differing opinions on spacer selection.

In this study, we report for the first time, the use and efficacy of resorbable implant as a middle lamellar spacer implant for the repair of lower eyelid retraction.

Patients and Methods

This retrospective interventional case series study was approved by the Institutional Review Board and adhered to the tenets of the Declaration of Helsinki. The medical records were reviewed of all consecutive patients with lower eyelid retraction who underwent repair with resorbable polydioxanone implant (Ethicon, Inc., Piscataway, NJ, USA) between, January 2012 and January 2014. The cause of the lower eyelid retraction, complete ophthalmic clinical examination, and previous ophthalmic procedures were noted. The degree of eyelid retraction was based on a consistent measurement of the marginal reflex distance between the corneal light reflex and the lower eyelid margin in the primary position (MRD2), which was accurately documented in millimeters in the patient's record. Only patients with at least 12 months follow-up were included in the study. Over the postoperative period, none of the patients had any additional orbital or eyelid surgery.

Surgical procedure and techniques

A cutaneous subciliary incision was fashioned throughout the whole length of the lower eyelid from just lateral to the punctum up to the lateral canthus [Figure 1]. The lower eyelid retractors were disinserted from the tarsus and dissected from the conjunctiva. We used 3–4 mm implant vertical height for each 1 mm eyelid retraction, aiming for overcorrection in the early postoperative period. The implant was anchored and secured to the lower edge of the tarsus and eyelid retractors with interrupted 5–0 polydioxanone sutures (Ethicon, Inc., Piscataway, NJ, USA), sandwiched between the conjunctiva and orbicularis oculi muscle [Figure 1]. The skin incision was closed using a continuous 6–0 prolene suture (Ethicon, Inc., Piscataway, NJ, USA) that was removed 1 week postoperatively. The lower eyelid was placed on stretch with a Frost suture on foam bolsters, and the eye was patched for 1 week. Postoperatively, combination antibiotic-steroid eye ointment was prescribed twice daily for 1 week following patch removal.

Figure 1

(a) A 63-year-old male with the left lower eyelid retraction secondary to facial trauma and facial bone fracture repair 15 years before presentation. (b) Intraoperative picture shows the placement of polydioxanone implant between the lower edge of the tarsus and eyelid retractors and securing it with interrupted 5–0 polydioxanone sutures. (c) The same patient 15 months after lower eyelid retraction repair

Results

This study evaluated 8 patients (4 males and 4 females) who underwent lower eyelid retraction repair using an absorbable polydioxanone implant. Table 1 summarizes the etiology of the lower eyelid retraction, patient demographics, and lower eyelid position preoperatively and at last postoperative visit. One patient underwent surgery in both lower eyelids. The mean age was 43 years (range, 23–63 years). Postoperatively, 2 patients had very mild anterior lamella shorting secondary to previous transcutaneous lower eyelid blepharoplasty with skin excision. There were no other cases of significant shortening of the lower eyelid skin or conjunctiva. The average improvement in eyelid retraction was 2.7 mm (range, 1.5–4 mm) at least one-year or at least a one-year postoperatively. None of the patients had major intraoperative or postoperative complications. One patient developed a foreign body sensation at 6 weeks postoperatively. In this patient, superior nasal corner of the implant was exposed from the conjunctival side [Figure 2]. The exposed aspect of the implant was trimmed, and the patient had an uneventful postoperative course [Figure 2].

Table 1

Patient demographics, lower eyelid position, before placement of polydioxanone implant, and at the last postoperative visit

Figure 2

(a) A 38-year-old male with left lower eyelid retraction secondary to traumatic facial palsy at the age of 3 years. (b) Exposure of the superior nasal corner of the implant from the conjunctival side at 6 weeks postoperatively (black arrow). The exposed part of the implant was trimmed. (c) The same patient 13 months following lower eyelid retraction repair with no complaints

Discussion

The ideal implant materials can be naturally occurring or synthetic substances should have physical properties that most closely replicate the tissue they replace. It should be readily available, easily handled, bioinert, and biocompatible.[4] To date, no single biomaterial has been universally accepted that meet every criterion.[123] However, the clinician is responsible for selecting the most appropriate biomaterial to match the tissue needed in different clinical settings. In 1977, preserved sclera (autologous graft material) was the first spacer graft used for eyelid reconstruction and has remained the most popular material.[56] Additional materials such as mucosal hard palate and acellular human dermis have been introduced. However, donor site morbidity, difficulty with placement, transmissible diseases, and tissue availability limit the use of all these materials.[56] Hence, alloplastic materials serve as a good alternative for space grafts.[56] Different alloplastic materials such as high-density porous polyethylene, polypropylene mesh, and polytetrafluoroethylene have been recently used as a spacer for eyelid reconstruction.[1] Tan et al. have reported the use of high-density porous polyethylene in 35 eyelids with good or satisfactory outcomes.[7] However, major or minor complications were reported in 17 eyelids ranging from implant exposure to transient loss of eyelashes which limited the use of this material.[7] Polypropylene mesh with or without titanium has been used to treat lid retraction due to facial palsy and facelift.[89] However, dislocation, exposure of the mesh, foreign body-induced inflammation, and fistula are major concerns.[89] Karesh et al. reported the use of polytetrafluoroethylene as a spacer graft for correction of lower lid retraction.[10] They reported encouraging outcomes and well-tolerated material in 8 eyelids; however, removal was performed of a portion of the material in two eyelids due to infected meibomian glands and thickened eyelids.[10] Over the last two decades, there is an increasing interest in the use of alloplastic resorbable materials because of lack of late-occurring complications.[4] Polydioxanone, which is a resorbable aliphatic polyester polymer, degrades through hydrolysis in 10–12 weeks yet, persistence over 12 months has been reported.[11] During this period, the surrounding tissue can form a stable fibrotic scar sheet supporting the lower eyelid.[11] It is readily available in a preformed rectangular-shaped plate that is easily cut to fit. As polydioxanone can be easily stabilized to adjacent host tissues with screws, wires, or suture, it has been used for orbital defects or fracture repair.[11]

To the best of our knowledge, this is the first report on the effective use of resorbable polydioxanone plate implant to lengthen the middle lamella as a treatment option for eyelid retraction. The outcomes suggest that this is a well-tolerated alloplastic material with no clinically apparent inflammatory reactions. An anterior approach has been used for wider exposure and to keep the conjunctival surface untouched aiming at decreasing incidence of exposure. Despite these efforts, implant exposure occurred in one patient which was managed effectively without further sequelae. Our study showed an average of 2.7 mm improvement in lower eyelid retraction which is better than the outcomes reported by Tan et al. (1 mm) and Wearne et al. study (2.1 mm) and slightly lower than Leonard and Cohen's report (3.3 mm).[171213] Notably, resorbable materials are not free from complications as inflammatory reactions, scar formation or migration have been reported to some of these products.[1415] Despite the reported effectiveness of resorbable polydioxanone implant as a middle lamellar spacer in our case series, a large study with longer follow-up is needed to confirm our findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.