Lower lid hollow and rounded, would AlloDerm give good results?
I am in my late 60's and have hollows in my lower eyelids and some rounding due to a previous
surgery that was done many years ago (the doctor has since retired).
I am interested to know: Would AlloDerm (or similar) and fat transfer give a good result?
Would an Oculoplastic surgeon do both Alloderm and Fat Transfer, or would I need to go a
different doctor for each procedure?
Thank you for your question!
You've submitted a question with photos showing rounding of your lower eyelids and clearly
you've done research.
You're asking about the benefit of alloderm and fat transfer and would an oculoplastic
surgeon be able to do both or you need several surgeons.
Well, I'll you help you understand the basis of your situation and give you my idea of
my approach.
I happen to be an oculofacial plastic surgeon practicing for about 20 years.
I'm also boarded with facial cosmetic surgery as well as body, breast and extremity surgery.
So I do everything head to toe including hair restoration.
So with no limitations with my scope of surgical procedures, I can share with you the different
things I've done to patients who come to us like what you have which is called lower eyelid
retraction.
To understand the lower eyelid, you basically need to get an idea of what it takes to support
the lower eyelid before you start asking questions about materials.
So, there are three essentials to lower eyelid position.
On is the lateral canthal tendon.
The lateral canthal tendon is the attachment of a very important connection between the
lower eyelid and the bone of the orbital rim.
The second part is the internal support of the lower eyelid which is like pillars.
These vertical pillars or support underneath the eyelid behind the eyelid is referred to
as the posterior middle lamella and that's where the alloderm question comes up.
Then the next part of this is the amount of skin that is available to physically move
upward.
A lot of people have come to us who had too much skin removed from their lower eyelid
resulting in the combination of eyelid retraction or a rotation of the eyelid away from the
eye called ectropion.
So when someone comes to me, I'll do an assessment to evaluate all of those factors.
Do they have enough skin, do they have support in the lower eyelid, how far is their eye
projected because these are the important factors in the dynamics and physics of the
way the lower eyelid is positioned and of course, the strength and position of the lateral
canthal tendon.
In my practice, what we have been typically doing and I've had experienced with the posterior
middle lamellar grafts such as hard palate mucosa, alloderm and what we have been doing
mostly in our practice for the past couple of years is using a material called enduragen.
Enduragen is a material derived from pig dermis.
This doesn't mean that alloderm is not an acceptable choice.
Every surgeon has their own ideal way of combing their procedures and materials in their hands
with what works with them.
So I think what you are describing is really the scope of an oculofacial plastic surgeon.
This is an area of anyone who does blepharoplasty, when they have complications, they will ultimately
need an oculofacial plastic surgeon.
What is important is a proper physical examination to make that determination.
To discuss your other option about fat transfer, there is a role of fat transfer but in my
experience and in my approach, I don't do fat transfer as part of my primary procedure
which is to restore the anatomy.
That is a critical factor is that lower eyelid position is very important for proper eye
function and when you have this bowed eyelid and you have this stretching of the lateral
canthal tendon, you're tear film will not be properly distributed and you're not going
to have good ocular health.
So, first I would reposition the lower eyelid into its proper anatomical position.
Now because this is a more advanced and complex procedure and there's grafting involved, there
is a time frame where you watch how things heal over several month.
So typically I would do this as a stage procedure.
Now if fat transfer was indicated, then I would do the fat transfer and with all these
procedures, we have also added adjuvant therapies such as the use of platelet-rich plasma, extracellular
matrix for improvement of wound healing.
This is a type of procedure that requires a lot of initial care after the surgery.
At this point, it is best that you meet with several oculofacial plastic surgeons and get
some opinions as to what will be there approach and move forward with choosing one you are
comfortable with.
In summary, we are talking about several factors such as the lateral canthal tendon, posterior
middle lamella or middle lamellar support and skin.
A proper physical examination is necessary before you make a decision about what materials
to choose to help you the best results as possible.
So I hope that was helpful, I wish you the best of luck and thank you for your question!