Ectropion Lower Eyelid Reconstruction


Article Author:
Reece Bergstrom


Article Editor:
Craig Czyz


Editors In Chief:
Brian Downs
Ziad Katrib


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
5/4/2019 12:12:53 PM

Introduction

Ectropion is an eversion or outward turning of the eyelid margin. Ectropion may be classified as congenital, involutional, paralytic, cicatricial, or mechanical. Involutional ectropion is caused by horizontal eyelid laxity of the medial and/or lateral canthal tendons. Cicatricial ectropion can be caused by shortening of the anterior and/or middle lamella. Paralytic ectropion can be caused by CN VII paralysis or palsy resulting in loss of orbicularis muscle tone. Lastly, mechanical ectropion can be caused by gravity, mass effect of a tumor, fluid accumulation, herniated orbital fat, or poorly fitted spectacles. The patient may experience symptoms due to ocular exposure, inadequate lubrication, and corneal disease. An individual is at increased risk with age, eyelid rubbing, excessing eyelid pulling or manipulation, skin conditions involving the lid, injury, or previous surgery.

Anatomy

The eyelid is composed of seven tissue layers unique to this facial region. Superficial to deep the layers include skin, subcutaneous tissue, muscles of protraction/orbicularis, orbital septum, orbital fat, muscles of retraction, tarsus, and conjunctiva. The skin along the eyelid, in relation to the other skin, is much thinner.

Multiple nerves supply the eyelid. The superior lid nerves are the infratrochlear, supratrochlear, supraorbital, and lacrimal nerves of V1. The nerves of the lower eyelid are the infratrochlear and infraorbital nerve of V2.

The arterial supply of the eyelids is composed of the internal carotid artery by way of the ophthalmic artery and its supraorbital and lacrimal branches and the external carotid artery via the angular and temporal branches of the facial artery. The blood supply to the lower and upper lids is created by anastomoses of the lateral and medial palpebral arteries. These arteries branch off the lacrimal artery and ophthalmic artery.

Indications

Symptoms include foreign body sensation, hyperemia, epiphora, exposure keratitis, and corneal ulceration. Anterior lamellar shortening often is the primary cause of cicatricial ectropion, and associated disorders should be addressed and treated before surgery. Patients with congenital, paralytic, mechanical, or involutional often require different treatments. It is once again important to identify the etiology before surgical intervention. Medial tendon laxity and punctual ectropion will require additional procedures to correct.

Contraindications

Patients who cannot tolerate the procedure should not undergo a correction. Medical management of the underlying etiology should be controlled first, and then surgical correction can be considered. If inflammation or infection are not controlled, the prognosis is worse, higher risk of complications, and can often progress.

Equipment

The following equipment is needed: No. 15 Bard-Parker blade, Westcott scissors, 0.5 forceps, and cautery (monopolar or bipolar), 4-0 silk suture, 6-0 vicryl suture, 5-0 vicryl suture, corneal shield, and antibiotics ointment.

Personnel

An ophthalmologist or surgeon trained in oculofacial plastic surgery is required.

Preparation

The patient should have been properly examined before surgical intervention and deemed appropriate for surgery by an ophthalmologist or surgeon trained in oculofacial plastic surgical procedures. The patient needs to be educated about the associated risks and benefits of the intervention, including alternative therapies available. All possible complications should be discussed. Lastly, any questions from the patient need to be answered.

Technique

There are multiple procedures done depending on the etiology of the ectropion. The essential steps for the following will be listed: cicatricial, involutional, medial, and lateral tarsal strop with a medial spindle for ectropion repair with punctal eversion.[1]

Cicatricial[2]

  1. Administration of topical anesthetic and local anesthetic
  2. Corneal shield placement
  3. Traction sutures placed in gray or lash line of eyelid 
  4. Subciliary incision
  5. Dissection to release scarring until the posterior lamella returns to anatomical position
  6. Perform tarsal strip for horizontal lid tightening 
  7. Measure or draw a template of the area requiring graft
  8. Mark/transfer template to donor site
  9. Closure of donor site skin incision 
  10. Debride the dermis aspect of the graft of any extraneous subcutaneous tissue
  11. Suture graft into the wound bed
  12. Close the lateral canthal skin (if horizontal lid tightening was performed)
  13. Removal of corneal shield
  14. Frost suture (if required)

Involutional [3]

  1. Administration of topical anesthetic and local anesthetic
  2. Corneal shield placement 
  3. Lateral canthal incision with canthotomy and inferior cantholysis 
  4. Split the anterior and posterior lamella of the lateral lower lid
  5. Remove the skin, muscle, and conjunctiva to form tarsal strip
  6. Distract lid laterally to the rim to estimate the amount of tarsus required and excise the redundancy
  7. Anchor the strip to the periosteum of the lateral rim
  8. Excise any redundant anterior lamella 
  9. Closure of skin incision
  10. Removal of corneal shield

Medial Ectropion Repair [4]

  1. Administration of topical anesthetic and local anesthetic
  2. Corneal shield placement
  3. Evert the lid margin with traction suture and/or Bowman probe
  4. Excise an ellipse of conjunctiva and lower lid retractors
  5. Excise a portion of the lateral caruncle (if performing caruncular recruitment)
  6. Pass a double-armed suture through the lower lid retractors, the apex near the punctum, and then the apex inferiorly, and out full thickness through the lid.
  7. Pass a double-armed suture through the lower lid retractors and then through the medial tendon beneath the caruncle. The second arm is then passed through the apex near the punctum incorporating the tendon and caruncle. Both arms are then passed full thickness through the lid (if performing caruncular recruitment)
  8. Perform lateral tarsal strip (if required)
  9. Tie the sutures to invert the punctum appropriately
  10. Remove corneal shield

Lateral Tarsal Strip with Medial Spindle[2]

  1. Infiltrate local anesthetic at the lateral canthus, lateral lower eyelid, internal aspect of the lateral orbital rim, and conjunctiva of the inferior medial fornix
  2. Lateral Canthotomy
  3. Lateral Inferior crus cantholysis
  4. Excise a diamond-shaped area of conjunctiva and lower eyelid retractors below the punctum
  5. Close the conjunctiva and lower lid retractors
  6. Determine the length of the strip
  7. Denude the epithelium
  8. Split the anterior and posterior lamellae
  9. Disinsert the lower eyelid retractors and conjunctiva from the strip
  10. Excise the anterior lamella from the strip to remove lash follicles.
  11. Attach the strip to the periosteum of the inner aspect of the lateral orbital rim
  12. Reform the sharp angle of the lateral canthus
  13. Close the skin

Complications

Infection, bleeding, pain, poor cosmesis, corneal abrasion, suture dehiscence or erosion, retrobulbar hematoma, lower eyelid retraction, and canthal dystopia are all possible complications.[5]

Clinical Significance

The goal is to return the eyelid margin and punctum to their proper anatomic positions. This treatment protects the eye from injury and reduces the exposure/dry eye symptoms in the patient. Surgical management is the only definitive treatment.[6][5][6]

Enhancing Healthcare Team Outcomes

Care should be coordinated between physicians, nurses, pharmacists and other healthcare professionals. Medical management can typically be done by an ophthalmologist, optometrist, or general clinicians experienced in handling ocular conditions. Surgical care can be performed by an ophthalmologist or surgeon who specialized in facial and ocular plastics. Patient safety and the best possible outcome should always be considered and no patient should undergo any treatment that may harm or worsen their outcome. An in depth discussion about risks and benefits should be performed with the patient prior to iniating any treatment.


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Ectropion Lower Eyelid Reconstruction - Questions

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What is the ideal treatment for punctal ectropion?



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What condition should be controlled before proceeding with eyelid reconstruction?



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Ectropion Lower Eyelid Reconstruction - References

References

Caruncular fixation in medial canthal tendon repair: the minimally invasive purse string suture for tendinous laxity and medial ectropion., Czyz CN,Wulc AE,Ryu CL,Foster JA,Edmonson BC,, Ophthalmic plastic and reconstructive surgery, 2015 Jan-Feb     [PubMed]
Age-matched, case-controlled comparison of clinical indicators for development of entropion and ectropion., Michels KS,Czyz CN,Cahill KV,Foster JA,Burns JA,Everman KR,, Journal of ophthalmology, 2014     [PubMed]
Goddard L,Chesnut C, Simultaneous Lateral Tarsal Strip and Medial Spindle Procedures for Cicatricial Ectropion. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2019 Jan 4;     [PubMed]
Srinath N,Balaji R,Basha MS, Ptosis correction: a challenge following complex orbital injuries. Journal of maxillofacial and oral surgery. 2012 Jun;     [PubMed]
Poon JS,Vahdani K,Thaller VT, Comparison of four Combined Procedures for Correction of Involutional Lower Eyelid Entropion. The Journal of craniofacial surgery. 2019 Mar 12;     [PubMed]
McKelvie J,Papchenko T,Carroll S,Ng SG, Cicatricial ectropion surgery: a prospective study of long-term symptom control, patient satisfaction and anatomical success. Clinical     [PubMed]

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