Treatment of prominent eyes with orbital rim onlay implants: four-year experience

PURPOSE: Different approaches have been proposed to address the aesthetic or reconstructive challenge associated with relatively prominent eyes. Operations that address the soft tissues alone are prone to failure if the underlying orbital bony relationships are not addressed. Orbital rim advancement can serve as a supplement to orbital decompression in this setting or as an alternative for patients who may not maximally benefit from decompression surgery. METHODS: We report our 4-year experience with porous polyethylene orbital rim onlay grafts used to address relative proptosis in 24 patients. RESULTS: All patients had some degree of subjective and objective improvement. Proptosis decreased an average of 4.65 mm, with a range of 3 to 9 mm, based on single-observer Hertel exophthalmometry measurements (5.2 mm in those with concomitant decompression). Lagophthalmos was also improved in all patients with preoperative inadequacy in eyelid closure. Interpalpebral fissure size was reduced 1.3 mm on average, with a range of 0.5 to 6 mm (2 mm in those with concomitant decompression). Average follow-up was 41 months, with a range of 7 to 70 months. In 3 cases, we noted postoperative lower eyelid retraction with eyelid adhesion to the implant; possible risk factors for this complication included reoperative cases and simultaneous eyelid reconstruction with hard palate grafts. CONCLUSIONS: The porous polyethylene orbital rim onlay implant offers a relatively simple and effective surgical technique for the treatment of symptomatic relative proptosis. It can be used alone or in combination with other techniques including midface lift, lower eyelid retractor recession, and orbital decompression. To be effective, the implant should be placed so that it is flush with or overlapping the orbital rim; lateral displacement negates the effect of the implant in improving the eyelid/globe relationship. Postoperative eyelid retraction with tethering to the implant is a potential risk of the onlay implant, and although it may not be possible to avoid this in all cases, surgeries should be designed to minimize postoperative eyelid retraction.