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The treatment of lower eyelid retraction often Methods
involves the implantation of spacer materials to
lengthen the vertical dimension of the eyelid, provide Study design
stability, or both. Acellular dermal collagen matrix This article is a surgical-technique description and
is an option that obviates a second surgical site with retrospective case series of cases of the collagen splint
autografts such as cartilage or hard palate. These procedure performed by a single surgeon at an aca-
bioengineered grafts may be additionally advanta- demic oculoplastic surgery specialty referral practice.
geous because they are durable and flexible; they offer Institutional Review Board approval was obtained
a uniform, predictable structure and thickness; and for this study. This investigation was conducted in
they demonstrate tissue tolerability and longevity accordance with the Declaration of Helsinki and
after implantation. 6, 7,8 The graft material demonstrates was compliant with the Health Insurance Portability
good tensile strength and thus is used for a variety of and Accountability Act. 16,17 Informed consent for use
load-bearing applications such as repair of abdominal of publication of photographs was obtained from
wall defects. 8,9,10,11 Because these grafts are acellular, subject(s) with photograph(s) relevant for illustrative
they are purported to be less antigenic and carry fewer purposes.
transmission risks than other biologic grafts. Several Cases were identified through a billing database
12
reports suggest they are effective and safe for implan- search for lower eyelid retraction diagnoses codes
tation in the lower eyelid. 6,7,13,14,15 Barmettler and Heo, (ICD-9 or ICD-10) coupled with Current Procedural
14
in a prospective, randomized trial, report that porcine Terminology code 67911 for lower eyelid retraction
acellular dermal matrix had similar outcomes com- repair and 15275 for application of a skin substitute to
pared with autologous cartilage or a bovine acellular the eyelid or 17999 for unlisted eyelid procedure.
matrix xenograft. Inclusion criteria were patients with (a) an anoph-
Acellular dermal matrix spacer grafts are usually thalmic socket who had undergone the collagen splint
implanted into the middle or posterior lamella by way procedure, (b) refractory lower eyelid retraction on the
of a transcutaneous or transconjunctival approach. operated side, defined as at least one previous unsuc-
Typically, these devices are tailored to fit within the cessful surgical intervention for lower eyelid retraction
confines of the medial and lateral canthus. This repair, and (c) horizontal eyelid laxity on the operated
configuration may offer support and vertical eyelid side as determined by positive snap-back and eye-
lengthening in uncomplicated cases of retraction. In lid-distraction tests. A positive snap-back test was
severe cases of lower eyelid retraction with significant defined as failure of the lower eyelid to return to its
laxity, this approach may be insufficient or prone to initial position without blinking. A positive eyelid-
allow recurrence. Central placement may be inade- distraction test defined as horizontal distraction of
6,7
quate to support an eye prosthesis. the lower eyelid >7 mm away from the globe. 16,17 Cases
Herein, we describe a surgical technique for lower were excluded based on the following criteria: (a)
eyelid retraction repair, in which a porcine acellular subject age <18 years and (b) follow-up interval <6
dermal collagen implant is implanted to the mid- postoperative months.
dle eyelid lamella in the traditional manner but also Data on demographic information, surgical history,
extended past the lateral canthus and anchored to the preoperative and postoperative oculofacial examina-
lateral rim periosteum or temporalis fascia (hereafter tion, including margin reflex distance-2 (MRD-2),
also referred to as a “collagen splint”). We hypothesize anesthesia specifics, follow-up interval, complica-
that this approach may provide more robust sup- tions, and subsequent lower eyelid surgeries were
port in cases of refractory lower eyelid retraction and extracted from the charts. A single clinician performed
enable adequate prosthesis retention in patients with all preoperative and postoperative assessments. All
anophthalmic sockets. analyses in this investigation were post hoc, and the
surgical and clinical protocol did not deviate from
standard of care.

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