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There are certain cases of lower lid retraction that fail multiple attempts at repair. In those situations, I believe that a hard palate graft is the best space...r to use. I also like the eyelid to heal "on stretch", which is usually done with a Frost suture for one week post-operatively. Sometimes I will want the eyelid on stretch for longer than a week, however it is difficult to do that with Frost sutures. A pillar tarsorrhahy can act as a long term Frost suture. They can be easily released any time after surgery. In some situations I will leave the pillar tarsorrhaphy in permanently, and it is surprisingly well tolerated. A written transcript of this video is as follows: This is Richard Allen at University of Iowa. This video demonstrates placement of a hard palate graft with a medial pillar tarsorrhaphy in a patient with a history of lower eyelid retraction, status post multiple previous failed attempts at lower eyelid elevation. The tarsorrhaphy is being placed in order to assist in elevation of the lid postoperatively. The lower eyelid is inspected and a lateral canthotomy and inferior cantholysis are performed. 4-0 silk sutures are placed through the lower eyelid at the level of the tarsus. A trans-conjunctival incision is then made inferior to the inferior border of the tarsus extending from the punctum medially to the lateral canthotomy incision laterally. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. Scarring is encountered in this patient due to the previous surgeries. The eyelid appears to be released of the cicatricial bands. The hard palate is harvested and placed in the space between the cut in of the lower eyelid retractors/orbital septum/conjunctiva and the inferior border the tarsus. This is sutured into position with a combination of running and interrupted 70 Vicryl sutures. A lateral tarsal strip is then fashioned by dissecting between the anterior and posterior lamella. The posterior surface of posterior lamella scraped with a 15 blade. Attention is then directed to the upper eyelid which is everted over a shoehorn speculum. A medial pillar is then developed with the 15 blade and Westcott scissors. The conjunctiva of the lower eyelid is excised in the area where the pillar will be sutured. The pillar is then engaged with a double-armed 50 Vicryl suture. Each arm is then placed full-thickness through the eyelid. Attention is then redirected to the lateral tarsal strip where the strip is engaged with a double-armed 4-0 Mersilene suture. The suture then engages the periosteum at the level of Whitnall's tubercle. The sutures are then tied. The eyelid appears be in good position. Elevation of the eyelid is demonstrated with tightening of the medial pillar. The Vicryl sutures are then sutured over a cotton bolster. The pillar will be released approximately 2 months post-operatively. Over 300 oculoplastic surgery videos are available, free of charge, at http://www.oculosurg.com YouTube link to this video: https://youtu.be/7v55HT85vhM

https://www.facebook.com/oculoplasticsurgeryvideos/videos/941150243028279/?vh=e&extid=XQ9gDTOLOZOOiTsg

The challenge: how many surgeries can be done with as few external incisions as possible? In this video, an upper blepharoplasty, MMCR, browpexy, and canthoplas...ty are performed. I am doing more and more browpexies and canthoplasties through the blepharoplasty incision to stabilize both the brow and lower lid. Other procedures also to consider through the blepharoplasty incision would be transection of the corrugators and mid-face elevation. For a written transcript of this video, please see below: This is Richard Allen at the University of Iowa. This video demonstrates a blepharoplasty with a trans-blepharoplasty browpexy, canthopexy, and Muller muscle-conjunctival resection (MMCR). The blepharoplasty is marked and a needle tip cautery is used to make an incision along the blepharoplasty marking. A flap of skin and orbicularis muscle is removed. The medial fat pad is exposed and mobilized. The fat pad usually needs to be anesthetized due to the pain during its excision. The same is then performed on the other side. The fat pad is mobilized and anesthetized and each side is then conservatively excised. I don't feel the need clamp fat in these areas. I think careful excision of the fat can be performed without clamping it. Dissection is then carried out superiorly along the surface of the orbital septum to the superior rim. Dissection is then carried out superior to the superior orbital rim in a pre-periosteal fashion with the Freer periosteal elevator. The area is measured above the superior orbital rim which is usually about 12 millimeters. The spot is then engaged with a 40 Vicryl suture. The same measurement is then made from the superior skin edge to the brow fat pad. This area is then engaged with the 40 Vicryl suture. The suture is then tied which results in placement of the upper blepharoplasty incision edge at the superior orbital rim. A trans-blepharoplasty canthopexy will then be performed. This is performed with a 40 Prolene suture which is placed through the blepharoplasty incision laterally to exit out the lateral canthus at the level of the tarsus of the lower lid. The suture is then replaced and directed posteriorly where it engages the periosteum of the superior lateral orbital rim. The suture is then retrieved. Tightening the suture will result in tightening of both the upper and lower lid. The sutures are left untied at this point. The browpexy is then performed on the opposite side. The brows appear to be in good position. The trans-blepharoplasty canthopexy is then performed on the opposite side. Again the suture enters at the blepharoplasty incision and exits out the lateral canthus at the level of the tarsus of the lower lid. The suture then reenters adjacent to the exit point. The suture is directed posteriorly to engage the lateral canthal tendon which then engages the periosteum of the superior lateral orbital rim. The suture is then retrieved. Again the suture will be left untied to facilitate performance of the MMCR. Attention is then redirected to the upper lids where the MMCR will be performed. 4-0 silk sutures are placed through the upper lids at the level of the tarsus. The amount of conjunctival resection is marked with the needle point cautery. Forceps fixate the markings followed by placement of the Putterman clamp. A 6-0 chromic suture is then placed in a mattress fashion along the edge of the Putterman clamp. I don't place these sutures trans-blepharoplasty just due to the fact that I had some problems with bleeding when I placed the suture through the blepharoplasty incision. Therefore, I will place this with the knot at the conjunctiva. Often I place a contact lens postoperatively to prevent any irritation. Realistically, with the knot laterally, usually it does not cause much irritation. The same is performed on the other side with the MMCR. Attention is then directed to the canthopexy sutures which are tied. This is performed on each side. The blepharoplasty incisions will then be closed with interrupted and running 60 Prolene suture. At the conclusion of the case, the patient will use erythromycin ophthalmic ointment 3 times a day for a week. The patient will follow-up in approximately 1 week for suture removal and reevaluation. Over 300 oculoplastic surgery videos are available, free of charge, at http://www.oculosurg.com YouTube link to this video: https://youtu.be/Fef3rlp-ztc

To all my patients, friends and family: