1. University of California Los Angeles Division of Plastic & Reconstructive Surgery Reconstruction of the Severely Scarred and Displaced Lower Eyelid Following Violation of All Three Lamellar Planes Jason Roostaeian, MD, Emil Kohan, MD, Neil Tanna, MD, Henry K. Kawamoto MD, DDS, James P. Bradley, MD Mattel Children’s Hospital UCLA Ronald Reagan Medical Center

2. University of California Los Angeles Division of Plastic & Reconstructive Surgery Disclosure of Relevant Financial Interests for All Authors “Nothing to disclose”

3. University of California Los Angeles Division of Plastic & Reconstructive Surgery Severe Lower Eyelid Scarring Trilamellar Lower Eyelid Reconstruction Post-traumatic Lower Eyelid Scar Traumatic violation of all three lamellae leads to severe scarring Post-traumatic full-thickness lower eyelid injury Post-surgical: Trans- conjunctival incision after partial thickness anterior scar

4. University of California Los Angeles Division of Plastic & Reconstructive Surgery Objective Trilamellar Lower Eyelid Reconstruction Post-surgical Lower Eyelid Scar Evaluate staged operative approach for symptomatic improvement

5. University of California Los Angeles Division of Plastic & Reconstructive Surgery Methods Trilamellar Lower Eyelid Reconstruction First Stage: Palatal Graft  Mid/Posterior lamellae FTSG  Anterior lamella Second Stage: Fat grafting  Spacer

6. University of California Los Angeles Division of Plastic & Reconstructive Surgery Methods Trilamellar Lower Eyelid Reconstruction First Stage: Palatal Graft  Mid/Posterior lamellae FTSG  Anterior lamella Second Stage: Fat grafting  Spacer

7. University of California Los Angeles Division of Plastic & Reconstructive Surgery Methods Trilamellar Lower Eyelid Reconstruction First Stage: Palatal Graft  Mid/Posterior lamellae FTSG  Anterior lamella Second Stage: Fat grafting  Spacer

8. University of California Los Angeles Division of Plastic & Reconstructive Surgery Methods Trilamellar Lower Eyelid Reconstruction First Stage: Palatal Graft  Mid/Posterior lamellae FTSG  Anterior lamella Canthopexy Second Stage: Fat grafting  Spacer

9. University of California Los Angeles Division of Plastic & Reconstructive Surgery Cadaveric Anatomic Dissection Trilamellar Lower Eyelid Reconstruction Cross-section / Reconstruction Showed consistent anatomy Tarsal plate=10-12 mm Palatal graft support but pliable orbital rim PG Cadaver specimens (n=20)

10. University of California Los Angeles Division of Plastic & Reconstructive Surgery UCLA Clinical Review Trilamellar Lower Eyelid Reconstruction Lower eyelid reconstruction (1999-2008) (n=52) 1. Ectropion (eversion): 51% 2. Entropion (inversion): 30% 3. Full-thickness Scar: 19% or n=10 Underwent described staged technique

11. University of California Los Angeles Division of Plastic & Reconstructive Surgery Results Trilamellar Lower Eyelid Reconstruction Mechanism: 75%  Full-thickness injury 25%  After transconjunctival incision with partial injury MVA = 60% Assault = 40% PreoperativePostoperative

12. University of California Los Angeles Division of Plastic & Reconstructive Surgery Results Trilamellar Lower Eyelid Reconstruction Timing: 9.1 months after injury (range=6-17 mths) Procedures: 2.6 required PreoperativePostoperative

13. University of California Los Angeles Division of Plastic & Reconstructive Surgery Results Trilamellar Lower Eyelid Reconstruction Symptoms: Preop: Epiphora (90%), tearing (100%), redness (100%), Blurring vision (80%), dryness (80%) Postop: Epiphora (0%), tearing (0%), redness (0%), Blurring vision (10%), dryness (20%) PreoperativePostoperative

14. University of California Los Angeles Division of Plastic & Reconstructive Surgery Results Trilamellar Lower Eyelid Reconstruction Complications: (40%) 1. Redundant palatal graft (office excision) 2. Partial loss FTSG (healed secondarily) 3. Cellulitis after fat graft (resolved abx) PreoperativePostoperative

15. University of California Los Angeles Division of Plastic & Reconstructive Surgery Conclusions Trilamellar Lower Eyelid Reconstruction Our staged approach for reconstruction of scarred/displaced lower eyelid provided symptomatic improvement. We suggest caution with transconjunctival approach following partial lower eyelid injury.