Subperiosteal Midface Lift with or without
a Hard Palate Mucosal Graft for Correction
of Lower Eyelid Retraction
Guy J. Ben Simon, MD, Seongmu Lee, BS, Robert M. Schwarcz, MD,
John D. McCann, MD, PhD, Robert A. Goldberg, MD
placement of a hard palate mucosal graft (HPMG) in patients with lower eyelid retraction.
Retrospective, comparative, interventional case series.
Thirty-four patients with lower eyelid retractions who underwent surgery at the Jules Stein Eye
Institute in a 5-year period.
Medical record review of all patients who underwent surgery for lower eyelid retraction by a
subperiosteal midface lift with or without an HPMG. Preoperative and postoperative digital photographs were
taken in all patients.
Main Outcome Measures:
Change in margin reflex distance 2 (MRD2), measured from the pupillary margin
to the upper margin of the lower eyelid; patient discomfort; and surgical complications.
Thirty-four patients (20 female; mean age, 64 years) participated in the study; 11 underwent
bilateral surgery, with overall 43 surgeries performed. Eighteen patients (42%) had lower eyelid retraction
secondary to previous transcutaneous lower eyelid blepharoplasty. Postoperatively, patients attained a
better lower eyelid position, with improvement of lower eyelid height of 1.4 mm (P?0.001, 1-sample t test).
Patients operated using an HPMG (12 surgeries) achieved a greater reduction in MRD2postoperatively as
compared with patients operated by subperiosteal midface lift alone (31 surgeries; 2.2 mm vs. 1.1 mm,
respectively; P ? 0.02, Wilcoxon Mann–Whitney). One patient needed reoperation secondary to symptom-
atic lower eyelid retraction postoperatively.
The subperiosteal midface lift is effective in correction of lower eyelid retraction of various
causes. The use of an HPMG spacer may enhance surgical outcomes and results in a better lower eyelid position.
Ophthalmology 2006;113:1869–1873 © 2006 by the American Academy of Ophthalmology.
To compare functional and surgical outcomes of a subperiosteal midface lift with and without the
Lower eyelid retraction is a relatively uncommon condition
that may occur in association with various orbital or sys-
temic diseases and eyelid surgery.1Thyroid-related or-
bitopathy can manifest as upper and lower eyelid retrac-
tions, which give the typical stare appearance along with
widening of the vertical palpebral fissure. It is believed that
overactivity of the sympathetically innervated Müller’s
muscle equivalent may be the actual mechanism for lower
eyelid retraction. Postoperative transcutaneous lower eyelid
blepharoplasty with excess removal of skin and orbicularis
could result in a vertical shortage of anterior lamella or
middle and posterior lamella tethering.2,3It also may com-
plicate chronic facial nerve palsy or occur with no under-
lying pathology.4,5Clinically, ocular discomfort, lagoph-
thalmos, and exposure may ensue.
Surgeons differ in their approach to the surgical repair of
lower eyelid retraction with or without midface descent. Many
surgical techniques have been described. They can involve
relatively simple maneuvers, such as a full-thickness skin graft
or myocutaneous switch flaps, or more complicated surgeries,
such as middle and posterior lamella lengthening or midface
lifting, all with or without spacer material.6–13For the latter,
different autogenous graft materials have been used, including
tarsoconjunctiva,14,15hard palate,16–18buccal membrane,6,16
ear or conchal cartilage,19,20autogenous dermis skin,21or
biosynthetic materials such as acellular human dermis (Al-
loDerm, LifeCell Corp., The Woodlands, TX), polytetra-
fluoroethylene,22and porous polyethylene.23,24To date,
controversy exists about the optimal surgical correction and
long-term outcomes of each procedure.
In our institution, the subperiosteal midface lift generally
is performed with securing of the subperiosteally dissected
midfacial tissue to the inferior orbital arcus marginalis with
or without a hard palate mucosal graft (HPMG). The pur-
pose of the current study is to compare in a retrospective
fashion efficacies of this procedure performed alone versus
with an HPMG.
Originally received: October 11, 2005.
Accepted: May 12, 2006.
From the Jules Stein Eye Institute and Department of Ophthalmology,
David Geffen School of Medicine at UCLA, Los Angeles, California.
Correspondence to Guy J. Ben Simon, MD, Goldschleger Eye Institute,
Manuscript no. 2005-976.
© 2006 by the American Academy of Ophthalmology
Published by Elsevier Inc.
ISSN 0161-6420/06/$–see front matter