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Surgical Technique
The collagen splint surgical tech-
nique is outlined in Video, Supple-
mental Digital Content 1 (in the par-
ticular case shown, lateral canthal
drill-hole fixation was performed
first). Step-by-step photographs are
shown in Figure 1. After infiltration
of 10 cc of local anesthetic and stan-
dardized surgical preparation, a left
lateral canthotomy incision is creat-
ed with a #15 blade and continued
to the subciliary area. The anterior
and middle lamellae are divided
with Westcott scissors. A 1 mm–thick
spacer graft derived from porcine Figure 1. Step-by-step photographs of the collagen splint procedure.
acellular dermal collagen matrix (A) After a lateral canthotomy incision is performed, the anterior and middle
(ENDURAGen Stryker, Kalamazoo, lamellae are divided. (B-F) The porcine acellular dermal collagen matrix spacer
Michigan) is then cut to configu- graft is customized to fit in the middle lamella, but with enough material to
ration (dimensions 40 to 50 × 8 to extend temporally past the lateral canthus. The graft is then sutured into
12 mm). This is customized to fit in place, and the lateral extent of the graft is anchored to the lateral rim
the middle lamella but with enough periosteum or temporalis fascia. Arrow in (C) highlights extension of the
graft temporally past the lateral canthus. See text for further details.
material to extend temporally past
the lateral canthus. The graft is then
sewn into place with interrupted
5-0 polyglactin and 6-0 chromic gut
sutures placed at the perimeter of
the implant. The lateral extent of the
graft is anchored to the lateral rim
periosteum, or temporalis fascia, or
both with 5-0 polyglactin sutures.
The lateral canthal angle is then Figure 2. (A) Facial photograph of individual with left-sided anophthalmia and
reconstructed with the tarsus an- severe retraction of the left lower eyelid associated with multiple etiologies,
chored to the inner rim periosteum including involution, floppy eyelid, and stretching of the lower eyelid due to a
poorly fitting prosthesis with hypoglobus. Furthermore, the severe retraction
or a drill hole (when the periosteum itself forestalled eye-prosthesis retention. The individual shown had three
is scarred or otherwise insecure) previous unsuccessful surgeries for the left lower eyelid retraction, including
using 4-0 polyester fiber suture. The two lateral canthoplasties and a fascia lata sling. (B) Facial photograph
skin is closed using 6-0 plain gut 6 months after collagen splint procedure performed on the left lower eyelid.
sutures. The wound is then dressed
with antibiotic ointment, which the patient
is instructed to apply three times daily for the first tests. Previous unsuccessful lower eyelid retraction
postoperative week. repair interventions ranged from one to three previous
surgeries. All of these cases had adequate orbital
Results volume and appropriate underlying orbital implants.
The initial search identified 374 cases of which 6 sub- Figure 2A depicts an example of an individual with
jects met the inclusion criteria. Patient demographic left-sided anophthalmia and refractory lower eyelid
data, surgical history, and preoperative examination retraction. This case demonstrates apparent hypo-
findings are shown in Table 1. globus due to the low ocular prosthesis position and
All included patients demonstrated evidence of multi-vector eyelid malposition including mechanical
floppy eyelid as well as horizontal eyelid laxity as de- and laxity.
termined by positive snap-back and eyelid-distraction

28 | GARCIA JOURNAL OF OPHTHALMIC PROSTHETICS