This is Richard Allen at the University of Iowa. This video demonstrates placement of an Enduragen graft with a preperiosteal midface lift for treatment of lower eyelid retraction. A lateral canthotomy and inferior cantholysis are performed. 4-0 silk suture is then placed to provide traction during the case. A transconjunctival incision is then made with the needle tip cautery inferior to the inferior border of the tarsus extending from the punctum medially to the lateral canthotomy incision laterally. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. A 4-0 silk suture is then placed through the cut end of the lower lid retractors and conjunctiva in order to provide traction during the case. The inferior orbital rim is then exposed. A freer periosteal elevator is then used to dissect inferior to the inferior orbital rim in a preperiosteal plane. A 4-0 vicryl suture is then used to engage the soft tissue of the midface. The needle is then placed through the periosteum of the inferior orbital rim. Three sutures are placed along the length of the inferior orbital rim in order to get elevation of the midface. The silk suture is then removed from the cut end of the conjunctiva and lower lid retractors. Dissection is then carried out between the conjunctiva and lower lid retractors. It is not uncommon to get a button hole through the conjunctiva. Additional dissection can then be performed with Westcott scissors. The Enduragen graft is then sized and placed between the cut end of the lower lid retractors/orbital septum and inferior border of the tarsus. The graft is sutured into position, veering medial, with 5-0 fast absorbing sutures. The graft is thick, and a larger needle is needed. The graft is placed into position and the eyelid appears elevated. Due to the fact that the Enduragen graft is not epithelial lined, the conjunctiva needs to be draped over it. The conjunctiva is sutured to the inferior border of the tarsus with 7-0 vicryl sutures. A lateral tarsal strip is then performed by dissecting between the anterior and posterior lamella. The mucocutaneous junction is excised. The strip is scraped with a 15 blade. The strip is then shortened the appropriate amount and a 4-0 mersilene is used to engage the strip. The mersilene then engages the periosteum of the lateral orbital rim. Prior to tying the mersilene, the lateral portion of the upper eyelid mucocutaneous junction is excised. A 5-0 vicryl suture then engages the lateral tarsal strip followed by the lateral upper eyelid tarsus. The suture is tied. The mersilene is then tied. The canthotomy incision is closed with 7-0 vicryl suture. At the conclusion of the case, antibiotic ointment is placed into the eye. The silk sutured is taped to the forehead to place the eyelid on stretch for a week. The eye is then patched.