Lower lid retractor recession Figure 710

The principle here is that the lower lid retractors are separated from the lower border of the tarsal plate and recessed. Their position is maintained with a spacer.

The technique is as follows:

• Place a stay suture through the lower tarsal plate close to the lid margin. Evert the lid over a Desmarres retractor.

• Make an incision through the conjunctiva close to the lower border of the tarsal plate. Carefully dissect the conjunctiva from the underlying, white, lower lid retractor layer, as far as the inferior fornix.

• Make an incision in the lower lid retractor layer to separate it from the lower border of the tarsal plate. Carefully dissect this layer from the underlying orbicularis muscle as far as the fornix, or until the retractors will recess inferiorly freely (Figure 7.10a). Cut an appropriate size of spacer to achieve slight overcorrection of the retraction -usually 2-3mm larger than the amount of retraction.

If hard palate is to be used as the spacer, rather than donor sclera, the conjunctiva and lower lid retractor layers can be dissected as one layer, and recessed together, because no conjunctival covering is needed. If sclera is to be used the layers must be dissected separately because a scleral spacer must be covered with conjunctiva.

• If donor sclera is to be used as the spacer suture the lower border of the sclera to the recessed lower lid retractor layer with 6/0 absorbable sutures (Figure 7.10b). Draw up the conjunctiva to cover the sclera and suture the superior border of the sclera, together with the edge of the conjunctiva,

Palpebral conjunctiva reflected up _

Lower lid retractors

Palpebral conjunctiva reflected up _

Lower lid retractors

Lower Lid Retractors
(b)

Conjunctiva-

Tarsal plate--|

Figure 7.10 Lower lid conjunctiva reflected and lower lid retractors detached from tarsal plate, (b) spacer of donor sclera sutured to the lower lid retractors, (c) spacer covered with conjunctiva. All layers sutured to the lower border of the tarsal plate.

to the inferior border of the tarsal plate with a continuous 6/0 absorbable suture (Figure 7.10c).

• If a hard palate graft is to be used as the spacer recess the lower lid retractors and the conjunctiva together as one layer. Suture the lower edge of the graft to the recessed tissues and the superior edge to the inferior border of the tarsal plate using 6/0 absorbable sutures.

• Place three double-armed 4/0 sutures from the posterior aspect of the lid, through the graft to the skin and tie over small cotton wool bolsters. These sutures hold the layers together and are removed after a week. Place a traction suture in the lower lid and tape it to the forehead until the first dressing.

Complications - mild discomfort is common in the first few lays. The lid level will drop 1-2mm during the first few weeks.

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