Chapter 88 – Ectropion
FIONA O. ROBINSON
J. RICHARD O. COLLIN
• Ectropion is an abnormal eversion of the eyelid margin away from the eye.
• The eyelid margin and lash drive are turned away from the cornea.
• The conjunctival surface is exposed, sometimes resulting in keratinization of the epithelium.
• Corneal exposure results in foreign body sensation, corneal dryness, and occasionally ulceration.
• Conjunctival infection
• Decreased vision
• Ocular surface pain
Ectropion, or eversion of the eyelid, is a common lid malposition frequently seen in clinical practice. It has various causes and may be broadly classified as follows:
• Congenital ectropion—congenital ectropion is rare and is due to a shortage of skin in the eyelids. It most commonly is seen in Down’s syndrome, in which it may affect all four lids. It is also seen in blepharophimosis syndrome and can be idiopathic. If corneal exposure is mild, treatment with topical lubricants may be adequate. In more severe cases, skin grafting is necessary to avoid permanent corneal scarring and amblyopia. It is often a temptation to treat the corneal exposure with a simple lateral tarsorrhaphy, but this causes an inflammatory reaction, does not control the exposure, and so should not be attempted. If a shortage of skin exists, it must be replaced. However, skin grafting should be avoided in very young children, if possible, as postoperative scars are unattractive when they develop at an early age.
• Acquired ectropion—involutional, cicatricial, mechanical, paralytic; by far the most common
– Involutional ectropion, in which aging changes result in a generalized laxity of lower lid structures. Treatment depends on the anatomical defect that predominates and on the region of the lid that shows maximum laxity. The first sign of lower lid ectropion is often punctal eversion, which prevents tears from reaching the inferior canaliculus and may cause epiphora. As the ectropion progresses exposure causes secondary inflammatory changes in the conjunctiva and thickening of the tarsus, which further worsens the ectropion. Marked ectropion may result in lagophthalmos with resultant corneal exposure and, in extreme cases, corneal ulceration. Treatment of the ectropion in the early stages should avoid such late complications.
– Cicatricial ectropion is caused by a vertical shortening of the anterior lamella of the lower lid. The onset may be gradual, as seen with many skin diseases, or sudden when due to surgery, trauma, or acute allergic skin reactions. It often is associated with horizontal lid laxity. If the cicatricial changes are mild, correction of the horizontal component alone may suffice. If both elements are significant, the cicatricial changes should be corrected first. Whenever possible, the original cause (e.g., cicatricial skin diseases) should be treated medically. When the scarring is permanent and the cicatricial element is generalized, a full-thickness skin graft or pedicle transposition flap is necessary to correct the deformity. A Z-plasty corrects any localized scar.
– Mechanical ectropion results from mass lesions that displace the lid margin away from the globe. Causes include tumors, scars, conjunctival cysts, and edema. Treatment should be directed at the primary cause—it should include surgery only if residual ectropion remains following the initial treatment.
– Paralytic ectropion occurs in facial palsy. It results from loss of muscle tone and weakening of orbicularis muscle contraction. If the paresis is temporary, surgical treatment is usually not indicated. Topical lubrication of the eye is all that is needed until recovery is complete. If the palsy is permanent, surgery is usually necessary. In younger patients who have better elasticity and lid tone, loss of orbicularis function may result in only mild ectropion. Older patients who already have some lower lid laxity prior to the facial palsy may develop a marked ectropion. The ectropion is usually most severe in the region of the medial canthal tendon, which is the tendon of insertion of the orbicularis muscle. The choice of surgical procedure to correct paralytic ectropion depends not only on the extent and area of lid affected but also on the presence of other ocular sequelae, including corneal exposure, epiphora, and poor cosmesis. Procedures should be carefully individualized depending on the degree of anatomical deformity and lid dysfunction. With good lid elasticity, medial and/or lateral canthal support may be sufficient. If lid laxity is also present, a horizontal tightening procedure should be performed, but care must be taken not to overtighten the lid, which can increase lower lid retraction.
In 1812 Sir William Adams described a new operation for the cure of ectropion, which consisted of a V-shaped shortening at the lateral canthus, closed with one suture. In 1831 Von Ammon excised a wedge of tissue from the center of the lid to cure the defect, later moving the excision toward the lateral canthus. The classical Kuhnt (1883) and Symanowski (1870) procedure has remained popular since its conception, albeit with various alterations over the years. In the past century, many modifications and new techniques were developed for the treatment of ectropion.
More recently, the importance of aiming the surgical correction at the major underlying anatomical defect or defects has been realized. The choice of operation depends on the findings at preoperative evaluation.
PREOPERATIVE EVALUATION AND DIAGNOSTIC APPROACH
Ectropion may be caused or exacerbated by one or more anatomical defects of the eyelid structures. A thorough preoperative evaluation of these separate elements is essential because treatment needs to be directed at the predominant defect(s). Hence, more than one surgical procedure may be necessary to correct fully the malpositioned lid.
A full ocular history should be taken prior to examination of the malpositioned lid. The surgeon should ask specifically about a history of facial palsy, lid trauma, and previous lid surgery. Specific examination procedures should include tests for horizontal and vertical lid laxity, integrity of the canthal tendons, orbicularis muscle tone, and changes in the overlying lid skin.
To test for eyelid laxity the lower lid is pulled away from the globe. A distance of more than 10?mm between the lower lid and globe is abnormal and confirms horizontal laxity. Alternatively, the lid is gently pulled downward, away from the globe, and upon release of the lid the speed of return back to its original position is observed. In the normal lid, the lid snaps back snugly into position almost immediately. If laxity exists, the lid recoils slowly or only with the help of a few blinks. The position of maximum lid laxity (i.e., medial, lateral, or generalized) should be noted. Once laxity is established, the specific anatomical cause, that is, lax canthal tendon(s) or generalized tarsal redundancy, must be determined.
Medial Canthal Tendon Laxity
The lid is pulled laterally and the lateral excursion of the inferior punctum measured. Normally, the punctum should lie just lateral to the caruncle at rest and should not be displaced more than 1–2?mm with lateral lid traction. If lid laxity is severe, the punctum may move to lie below the pupil. It is unusual to find medial canthal tendon laxity without also finding horizontal lid laxity. If medial canthal tendon laxity and horizontal lid laxity exist together, the medial canthal tendon is tightened first and the horizontal element should be reassessed subsequently.
Lateral Canthal Tendon Laxity
A history of watering that occurs mainly from the lateral aspect of the lower lid suggests lateral lid laxity. The lateral canthal angle should first be evaluated with the lid at rest. It should have an acute angular contour and lie 1–2?mm medial to the lateral orbital rim (palpate with your finger). If the canthus has a rounded appearance, marked laxity is present. The lateral part of the lid is then pulled medially and the movement of the lateral canthal angle assessed. In normal lids the canthal angle should move no more than 1–2?mm.
Position of the Lacrimal Puncta
The inferior lacrimal punctum should lie just lateral to the caruncle at rest and directly below the superior punctum (see Chapter 82 ). In a normal lid, the inferior punctum is directed posteriorly against the globe and should not be visible without pulling the lid downward. In this position, the punctum dips into the lacus lacrimalis (tear lake). Direction of the punctum away from the globe is often the earliest sign of medial lid ectropion. Relative punctal stenosis or even frank occlusion may be seen with long-standing ectropion. Note that even in patients who have ectropion, a complaint of epiphora demands evaluation of the lacrimal drainage system to rule out concomitant nasolacrimal system obstruction (see Chapter 98 ).
Cicatricial Skin Changes
Vertical shortening of the skin of the lower lid may lead to eversion of the lid margin. A localized vertical contraction from scarring is usually immediately obvious. More subtle causes of skin shortening are more difficult to demonstrate. Vertical skin shortage is evaluated by gently pushing the lid back into its correct position. This is impossible to accomplish if skin deficiency is severe. In milder cases one simply sees vertical tension lines in the eyelid skin. Manual elevation of the cheek skin typically corrects the ectropion, as tension on the lid is reduced. Alternatively, ask the patient to look up and at the same time to open his or her mouth widely. If a shortage of skin exists, the lower lid immediately moves downward and everts further as the skin is pulled more tightly.
Cicatricial changes are often accompanied by horizontal lid laxity, and both may require correction. In such cases, the cicatricial restriction should always be freed by dissection first, then the other elements(s) corrected. The cicatricial element is then repaired as discussed in the following.
Orbicularis Muscle Weakness
This is usually due to a complete or partial facial nerve palsy. Orbicularis muscle weakness is evaluated during forced eyelid closure. Lagophthalmos and reduced force of contraction demonstrate muscle weakness. Other signs of facial nerve palsy, such as brow ptosis, loss of forehead wrinkles, and a mouth droop, should also be noted. Remember that facial palsy may be bilateral.
Mass lesions on the lid, such as tumors or cysts, may result in a mechanical ectropion, where the lid margin is physically displaced away from the globe. Such lesions are usually evident on initial inspection. The conjunctival surface and deep fornices should be examined in all cases of ectropion.
Inferior Lid Retractor Laxity
A mild degree of lower lid retractor laxity is commonly associated with horizontal lid laxity and rarely occurs alone. It can present as a tarsal or marginal ectropion. In this condition the lid is completely everted with the tarsal plate turned upside down. It often becomes manifest only when other elements have been corrected.
The inferior movement of the lower lid in downgaze is reduced and the inferior fornix is deeper than usual due to laxity or loss of retractor attachment in this area. The resting lower lid position may be raised, and a horizontal infratarsal red band may appear on the conjunctival surface that corresponds to the defect in the retractors. This condition is said to be due to the orbicularis muscle now being directly visible through the conjunctiva. The edge of the retractors may be seen directly below this band.
Treatment requires reinsertion of the lower lid retractors into the inferior edge of the tarsal plate ( Box 88-1 ).
ALTERNATIVES TO SURGERY
No completely satisfactory nonsurgical approaches exist in the management of symptomatic ectropion. When the condition is mild, the patient may experience only mild irritation from conjunctival exposure, usually associated with epiphora and perhaps a foreign body sensation from corneal drying. Artificial tears during the day and ointments at night usually ameliorate
Preoperative Evaluation of Ectropion
Full ocular history
General ocular examination
Examination of specific eyelid changes:
• Lid laxity: horizontal lid laxity
medial canthal tendon laxity
lateral canthal tendon laxity
• Position of punctum
• Cicatricial skin changes
• Orbicularis weakness
• Lid masses
• Inferior lid retractor laxity or disinsertion
the symptoms. When the lid malposition is so severe that corneal breakdown results, even aggressive medical management may not be adequate.
Local infiltrative anesthesia may be used in almost all types of ectropion correction. It is often preferable to give a general anesthetic if a postauricular skin graft is to be harvested or if the patient is a child. For transcutaneous approaches, a subcutaneous injection of local anesthetic is adequate. However, for any surgery that involves the posterior lamella, a subconjunctival injection may be needed.
Correction of lower lid ectropion is directed toward the anatomical cause. When the primary defect is horizontal laxity, lid shortening (either tarsal or canthal tendon) should be the treatment of choice. When vertical laxity is responsible, shortening or reattachment of the lower lid retractor is necessary. In many cases, some degree of each condition is present and multiple procedures are required.
In cases of cicatricial ectropion, disparity exists in the lengths of the anterior and posterior lamellae; specifically, a shortage of skin occurs. When the condition is mild, simple horizontal lid tightening may prove beneficial. But with more significant cicatricial changes, lengthening of the anterior lamella must be achieved by tissue rearrangement, local flaps, or skin grafts.
Plication of the Anterior Limb of the Medial Canthal Tendon
This procedure is most often performed in patients who have involutional ectropion and in those with facial palsy. It is indicated for mild medial canthal tendon laxity (see tendon evaluation earlier), without displacement of the canthal angle at rest. This operation is rarely performed alone, usually being done in conjunction with a lateral horizontal lid-shortening procedure. The aim of surgery is to give support to the medial canthal tendon.
A wire probe is placed into the inferior canaliculus to mark its precise location. This should remain in place throughout the procedure. A horizontal skin incision is made below the canaliculus, starting at the medial canthus and extending to below the inferior punctum ( Fig. 88-1 ). The inferior border of the medial canthal tendon and the medial end of the tarsus are exposed beneath the orbicularis muscle. A 5-0 nonabsorbable suture is passed through the medial edge of the tarsal plate and then through the anterior limb of the medial canthal tendon.
The suture is tightened sufficiently to stabilize the canthal angle in its normal position. It should not be overtightened, as this results in anterior displacement of the lid margin as well as wrinkling
Figure 88-1 Plication of the anterior limb of the medial canthal tendon.
of the skin and underlying canaliculus. The skin incision is closed with 6-0 silk sutures, which are removed after 5 days.
Medial Canthal Resection
This is the procedure of choice when marked medial canthal tendon laxity is present that results in dystopia of the medial canthal angle at rest. This may be associated with many forms of ectropion but is seen most commonly with involutional changes.
The procedure involves resection of the medial canthal structures combined with horizontal lid shortening. The posterior limb of the medial canthal tendon is reconstructed with a permanent suture, and the cut inferior canaliculus is marsupialized into the conjunctival sac of the lower fornix. This gives good long-term results with relief of epiphora in the majority of patients.
A vertical full-thickness cut is made through the lower lid just lateral to the caruncle to include the canthal tendon and canaliculus ( Fig. 88-2 ). The canaliculus is preserved by placing a probe into it prior to the cut and moving the scissors laterally after the initial vertical incision is made. The conjunctival incision is continued onto the bulbar surface, posterior to the plica. It may be necessary to resect the lateral half of the caruncle if it is especially prominent. This plane is followed back along the medial orbital wall with blunt-ended scissors until the posterior lacrimal crest is encountered. The exposure is improved by the use of two small malleable retractors. Each half-circle needle of a double-armed 5-0 nonabsorbable suture is passed through the periosteum of the posterior lacrimal crest, one at the level of the medial canthal tendon and one 2?mm higher on the medial orbital wall. The cut lateral part of the lid is pulled toward the posterior lacrimal crest and an appropriate amount of lid is resected. The two ends of the fixation suture are passed through the cut edge of the tarsal plate. Before tying, the exposed segment of canaliculus on the medial side of the lid incision is cut longitudinally to form anterior and posterior flaps, and the anterior flap is sutured to the posterior edge of the tarsus with one or two 8-0 absorbable sutures. The fixation suture is tied to reform
Figure 88-2 Medial canthal tendon resection, with posterior fixation and canalicular repair.
the medial canthal angle. The lid margin and skin are reapproximated with 6-0 silk.
Excision of a Diamond of Tarsoconjunctiva
If punctal eversion is present but no significant horizontal lid laxity exists and the medial canthal tendon is normal, a vertical shortening of the posterior lamella corrects localized medial lid ectropion. This procedure also includes shortening of the medial lid retractors and can be used in cases of mild involutional ectropion or with mild cicatricial changes.
A canalicular probe is passed into the inferior canaliculus. A diamond-shaped segment of tarsus and conjunctiva is resected directly below the punctum ( Fig. 88-3 ). Care should be taken to place the edge of the diamond at least 2?mm below the lid margin to avoid entering the canalicular ampulla when the inverting suture is placed. One arm of a double-armed 6-0 absorbable suture is passed through the superior apex of the diamond from the conjunctival surface to emerge within the wound. The other end of the suture is passed through the conjunctiva and lower lid retractors at the inferior apex of the diamond and again emerges within the wound. As the suture is tied, the medial lid margin and punctum are rotated inward. The punctal inversion should be overdone at the time of surgery as the lid will relax outward postoperatively. If the inversion is not sufficient, an inverting suture can be placed. For this, a double-armed 4-0 catgut mattress suture is passed from the conjunctiva immediately below the closed wound, anteriorly and somewhat downward through orbicularis and skin, and tied over a bolster. This suture advances the anterior lamella upward and thus enhances the correction.
Medial Diamond Excision Plus Horizontal Lid Shortening (“Lazy-T”)
This procedure was first described by Byron Smith and remains the treatment of choice for medial ectropion with punctal eversion associated with predominantly medial horizontal lid laxity.
Figure 88-3 Medial diamond excision. Inset shows the same procedure combined with a horizontal lid shortening procedure—the lazy-T procedure.
A full-thickness incision is made through the lid margin 4?mm lateral to the punctum. The cut is extended inferiorly to below the inferior tarsal edge. The amount of redundant lid to be resected is assessed by overlapping the cut edges, and this amount is excised as a full-thickness pentagon lateral to the first incision ( Fig. 88-3 ). In most cases, a resection of 5?mm or less is sufficient. As described previously for medial diamond excision, a diamond of tarsus and conjunctiva is excised, but the closing suture is not tied. The vertical lid defect is repaired first as described for horizontal lid shortening subsequently. Finally, the diamond is closed by tying the preplaced suture.
Lateral Tarsal Strip Procedure
The lateral canthal sling was first described by Tenzel in 1969. Various modifications have been made since then, the most well known being the lateral tarsal strip procedure. This procedure can be used to correct both lateral canthal tendon laxity and generalized horizontal lid laxity.
The lid is tightened at the lateral canthus and is shortened by the amount necessary to produce snug apposition of lid and globe. In addition to tightening, the canthal angle can be elevated, which may be necessary to aid tear drainage. This is very effective in the correction of ectropion from many causes and is cosmetically useful in the restoration of a normal canthal configuration.
The area of the lateral canthus is infiltrated with local anesthetic down to the orbital rim and along the periorbita just inside the rim. A lateral canthotomy is performed by dividing the lateral canthal tendon horizontally from the canthal angle to the lateral orbital rim. A blunt dissection is carried through the orbicularis to expose periosteum of the orbital rim. The lower lid is pulled upward and medially to place it under tension, and the
inferior crus of the canthus is divided completely. The lower lid is felt to yield as the tendon is released. It may be necessary to cut the temporal aspect of the orbital septum (along the inferior orbital rim) to mobilize the lower lid fully. The superior crus of the lateral canthal tendon should remain intact. The lower lid is pulled up and laterally over the upper lid to determine the amount of shortening necessary. The lid margin is excised to this point with Westcott scissors. The anterior lamella of lashes, skin, and orbicularis muscle is removed with scissors to expose several millimeters of tarsal plate, which is separated from the lid retractors inferiorly. Conjunctiva is scraped from the bulbar surface of the tarsal strip with a No. 15 Bard-Parker blade. A 5-0 nonabsorbable suture, such as Prolene, on a small, strong half-circle needle is passed through the superior edge of the tarsal strip and then firmly through the periosteum of the lateral orbital rim ( Fig. 88-4 ). The suture should be placed inside the orbital rim to ensure posterior placement of the lid against the globe. The position of the lateral canthus is determined by the height at which the suture passes through the periosteum—it is often desirable to elevate this a little. It is important not to overcorrect the lid laxity.  The lateral canthal angle is reformed with a 6-0 Dexon suture that passes through the gray line 2?mm medial to the cut edge of both upper and lower lids, with the knot buried in the wound. The skin incision is closed in two layers. This procedure is especially useful in patients who wear an ocular prosthesis. Not only does it tighten the lid, it also effectively deepens the fornix in anophthalmic sockets.
Horizontal Lid Shortening by Full-Thickness Wedge Excision
If horizontal lid laxity exists without significant lateral canthal tendon or medial canthal tendon laxity, the excision of a full-thickness pentagon of lid often corrects the ectropion completely. It is a simple procedure that can be performed at any point on the lower lid, although the preferred site is usually in the lateral third. It is especially useful if the lateral canthal angle
Figure 88-4 Tightening of the lateral canthal tendon using the lateral tarsal strip procedure.
contour and position are normal because then correction of the ectropion can be achieved with no alteration of these parameters. However, if it seems that to tighten the lid in this way will distort an already lax lateral canthus and lead to rounding, surgery should be carried out at the lateral canthus itself.
The first full-thickness lid incision is made at right angles to the lid margin and extended to the lower border of the tarsal plate. The cut edges of the lid are overlapped to assess how much needs to be resected to correct the horizontal laxity. The required amount is excised from the medial part of the lid incision. It is important to make both incisions perpendicular to the lid margin to avoid marginal notching after closure. The base of the resection should be brought to an angle near the inferior fornix, which results in a defect with the shape of the pentagon. The tarsal plate edges are approximated using two or three long- acting 6-0 absorbable sutures ( Fig. 88-5 ). Perfect alignment of the lash-bearing margin is essential and is best assured by placing the marginal suture first. This uppermost tarsal suture may be used as a traction suture to ease placement of the other sutures. The cut eyelid retractors at the apex of the pentagon are closed side to side with 6-0 Vicryl. Additional 6-0 marginal sutures are passed through the gray line and lash line and tied—the ends are left long. The wound edge should be slightly everted at this stage to avoid notching later. The skin is closed with interrupted 6-0 silk sutures, with the long ends of the lid margin sutures incorporated into the uppermost knot to prevent corneal touch. The skin sutures are removed at day 5 and the lid margin and highest skin sutures at day 10.
Horizontal Lid Shortening Plus Blepharoplasty (Kuhnt-Symanowski Procedure)
This procedure is useful when there is an excess of lower lid skin in addition to generalized horizontal lid laxity. It is used primarily in cases of involutional ectropion.
A subciliary incision is cut through skin 2?mm below the lashes, from the punctum to the lateral canthal angle. At the lateral
Figure 88-5 Horizontal lid shortening with a full-thickness wedge resection combined with a blepharoplasty excision of redundant skin. (Modified Kuhnt-Symanowski procedure.)
canthus the incision is continued obliquely downward in a natural skin crease for a distance of 10?mm ( Fig. 88-5 ), and the skin flap is undermined to the level of the orbital rim. A full-thickness pentagonal wedge excision is cut from posterior lamella at the lateral portion of the lid and repaired as described previously. The redundant skin flap is pulled laterally and the excess is cut as a triangle, as for a standard lower lid blepharoplasty (see Chapter 89 ). The subciliary skin incision is closed with a continuous 6-0 nylon suture and the lateral extension with interrupted 6-0 sutures.
A Z-plasty is a flap rearrangement procedure used to correct skin shortening due to a focal linear scar. The transposition of two flaps of skin cut in a defined configuration increases the length of the scar line at the expense of shortening skin at right angles to it. The Z-plasty may have to be combined with other procedures to correct ectropion effectively.
The edges of the scar are marked, but if the lid margin is involved and notched it should be excised using a pentagonal full-thickness resection before the Z-plasty is performed. A 4-0 nylon traction suture is placed across the lid margin in the line of the scar. The planned Z-shaped incision is fashioned by drawing a line from each end of the scar line to form a 60° angle with it (see Fig. 88-6 ). Each of these lines should be equal in length to the scar line itself. If the scar is especially long, two or more Zs may be marked in tandem along its length. The skin flaps are cut and extensively undermined beneath the surrounding tissue. Any obvious scar tissue should be excised. The triangular skin flaps are transposed and closed with 6-0 sutures. Upward traction should be maintained on the lid for 48 hours using the marginal suture placed previously.
Pedicle Transposition Flap
If cicatricial changes in the lid are mild, the transposition of a pedicle of skin from the upper lid to the lower lid corrects the ectropion. This may be performed using the medial or lateral canthus
Figure 88-6 Z-plasty procedure for lengthening focal cicatricial scarring. Flaps a and b are transposed to lengthen the scar line.
(or both) as the flap base, depending on the position of greatest skin shortage. The pedicle transposition flap provides additional skin as well as support for the lower lid. A moderate excess of skin must be present in the upper lid to allow the transposition.
The skin pedicle is marked on the upper lid and a subciliary incision of equal length is marked along the lower lid area into which the flap is to be transposed ( Fig. 88-7 ). In the upper lid the flap should straddle the skin crease if the crease is to remain in the same position postoperatively. The lower border of the flap base should join the subciliary incision just above the lateral canthal angle, and the upper border should lie above and lateral to this. If the base of the flap lies below the lateral canthal angle, it will not support the lower lid. The flap should be a little wider than the vertical deficit to be corrected. The lower lid incision is cut, the skin dissected, and scar tissue excised until the ectropion is fully corrected. The transposition flap is cut and freed from the upper lid and rotated into the lower lid defect. The flap is shortened as necessary to give adequate support to the canthal angle. All skin incisions are closed with 6-0 sutures. Owing to the length of the flap and its narrow width, the distal part should be treated as a free graft and a pressure dressing should be applied for 24 hours. All sutures are removed at day 5.
If a cicatricial ectropion is caused by diffuse skin shortage, the skin area must be increased. For the lower lid, a full-thickness skin graft is taken from the postauricular area (most commonly), upper lid, supraclavicular fossa, or inner arm.
The lower lid host site is prepared by placing two 4-0 nylon traction sutures through the lid margin. A horizontal incision is cut 2–3?mm below the lashes, along the area of skin shortage. It is best to extend the incision beyond the limits of the scarred area and above the canthi to allow for postoperative graft shrinkage (the theory is that if postoperative contraction occurs, it will tend to pull the lower lid up due to support at the canthal areas). The skin is undermined and scar tissue is resected to whatever depth is necessary to relieve the ectropion completely
Figure 88-7 Pedicle transposition flap of skin and muscle from upper lid to lower lid for cicatricial ectropion.
Figure 88-8 Full-thickness skin graft for lower lid cicatricial ectropion. Inset shows the retroauricular donor site.
and return the eyelid to its normal position. Adequate hemostasis is essential to avoid hematoma formation under the graft. The traction sutures exaggerate the defect. A template of the lower lid defect is used to mark the donor site. The donor graft should be marked slightly larger than the defect to allow for shrinkage. If the retroauricular area is used as the donor site, equal amounts of skin are removed from either side of the postauricular crease ( Fig. 88-8 ). The donor defect is repaired with a continuous 4-0 nylon suture and covered with a light dressing for 24 hours. The sutures are removed at day 10. Subcutaneous tissue is dissected from the donor skin graft. Several stab incisions are cut in the graft with a No. 11 blade to enable fluid drainage postoperatively. The graft is sutured into the host defect with multiple interrupted 6-0 absorbable sutures plus a continuous 6-0 nylon suture. A moist pressure dressing is applied for 48 hours—this is preferred to sutures tied over a bolster, which may perpetuate the ectropion. Any postoperative irregularities on the graft surface often resolve with massage applied for 3 months postoperatively.
A medial canthoplasty provides support to the medial lower lid, reduces the vertical palpebral aperture (so reducing the corneal exposure), and brings the lacrimal punctum into the tear film. It is useful in cases of mild paralytic ectropion in which lower lid punctal eversion is present. The upper and lower lid margins are sutured together, medial to the lacrimal puncta, which thus narrows the medial canthal angle.
A lacrimal probe is passed into the upper and lower canaliculi. The upper and lower lid margins are split along their edges from the medial canthal angle to 1?mm medial to the lacrimal punctum. A No. 11 blade is used, and the cuts are directed away from the punctum. The two incisions should meet at the medial canthus. This splits each lid into an anterior lamella of skin and orbicularis muscle and a posterior lamella of canaliculus, medial canthal tissues, and conjunctiva. The edges are undermined for 5?mm using sharp-pointed scissors.
The orbicularis muscles just anterior to the inferior canaliculus and just above the superior canaliculus are approximated
Figure 88-9 Medial canthoplasty shortens the palpebral fissure.
with two 6-0 long-acting absorbable sutures ( Fig. 88-9 ). On tying the sutures, the two canaliculi are brought together and rotated inward so that the puncta become inverted. The skin edges are closed after any excess of skin has been excised. Sutures are removed at day 5.
Lateral tarsorrhaphy is a procedure used to shorten the palpebral fissure horizontally by fusing the lid margins over a variable distance. It is useful for any situation in which lagophthalmos from facial paralysis or mild ectropion from any cause results in corneal exposure. The procedure may be temporary or permanent. Many methods have been described, but the authors prefer the pillar tarsorrhaphy because it is a quick and simple operation that is readily undone and does not involve excision of the lid margin tissue, which can lead to trichiasis if opened at a later stage.
In this procedure, the length of tarsorrhaphy required is marked on the upper and lower lids. An incision to approximately 3?mm depth is cut through the gray line of both eyelids using a No. 11 blade. At each end of the incision a small cut at right angles to the lid margin is made, but not through to its extremities (which can lead to notch formation) ( Fig. 88-10 ). The resultant wound is H shaped. The marginal epithelium is left in place. The two anterior raw surfaces of tarsus are sewn together with 6-0 long-acting absorbable sutures ( Fig. 88-11 ). A mattress suture is then passed from the upper lid skin to the lower lid skin through the center of the wound and tied over bolsters. The skin edges are then sewn together to complete the three-layer closure. The mattress suture should be removed after 2–3 weeks. Although this tarsorrhaphy can be left in place for some period, it tends to stretch and become less effective over time.
Complications of ectropion procedures include undercorrection or recurrence, overcorrection, lateral canthal angle dystopia, trichiasis, canalicular injury, corneal abrasion, and eyelid notching.
Undercorrection results from shrinkage of graft materials, lack of support for the canthal angles, inadequate horizontal
Figure 88-10 Temporary tarsorrhaphy procedure. Inset shows the lid margin incision.
shortening of the lid, or loss of suture fixation. It can be avoided by careful preoperative planning, selection of the appropriate procedure for the pathology, and meticulous technique. Allowance must be made for the expected shrinkage of skin grafts and for the effects of gravity when the patient is supine. In most cases, reoperation is needed for undercorrection.
Overcorrection is related to aggressive tightening of inverting sutures when the posterior lamella is shortened or to excessive lid shortening so that retraction of the lid margin results. This usually stretches over time, which can be hastened with massage. In some cases surgical intervention may be necessary; occasionally a periosteal or fascial graft is required to lengthen the canthal tendons.
Poor alignment of the lid margin following full-thickness excisions may result in a lid notch, irregular marginal surface, and trichiasis with resultant corneal complications. The trichitic lashes can be removed with cryosurgery or electrohyphrecation. In most cases it is preferable to repair the lid margin with excision and repair of the notched area.
Injury to the canaliculi is a potential complication of any surgery carried out in the area of the medial canthus. The location of the canaliculi must be delimited with an indwelling probe whenever the surgical site is nearby, and the dissection must be meticulous. If any question of potential injury arises during the procedure, it is best to place a silicone stent in the canaliculus for several weeks or months.
The surgical treatment of ectropion aims to restore the lower lid margin and punctum to their normal positions with respect to the globe. When the ectropion is mild and primarily of cosmetic
Figure 88-11 Permanent tarsorrhaphy procedure. Inset shows appearance of end result.
concern, simple procedures usually correct the problem completely. In more advanced cases associated with involutional changes, tightening of redundant tissues restores both functional and esthetic deficits. When ectropion is severe, especially when it results from facial paralysis, cicatricial changes, or significant scarring, the results are less predictable and full correction may require multiple procedures over a period of time.
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