Ectropion Lower Eyelid Reconstruction
- Article Author:
- Reece Bergstrom
- Article Editor:
- Craig Czyz
- Updated:
- 3/25/2020 2:29:43 PM
- For CME on this topic:
- Ectropion Lower Eyelid Reconstruction CME
- PubMed Link:
- Ectropion Lower Eyelid Reconstruction
Introduction
Ectropion is an eversion or outward turning of the eyelid margin leading to loss of the normal apposition of the eyelid to the globe. 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 the shortening of the anterior and/or middle lamella. Paralytic ectropion can be caused by CN VII paralysis or palsy resulting in loss of orbicularis oculi 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 of corneal exposure, irritation, or epiphora due to ocular exposure, inadequate lubrication, and corneal disease. An individual is at increased risk with age, eyelid rubbing, excessing eyelid pulling or manipulation, contact lens use, skin conditions involving the lid, injury, or previous surgery.
Anatomy and Physiology
The eyelid is composed of seven tissue layers unique to this facial region. Superficial to deep the layers are skin, subcutaneous tissue, muscles of protraction/orbicularis oculi, orbital septum, orbital fat, muscles of retraction, tarsus, and conjunctiva. The skin along the eyelid, in relation to the other skin in the body, is much thinner.
Multiple nerves supply the eyelid. The superior lid is innervated by the infratrochlear, supratrochlear, supraorbital, and lacrimal nerves of V1. The innervation of the lower eyelid is via 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 ectropion often require different treatments. It is once again important to identify the etiology before surgical intervention. Medial tendon laxity and ectropion of the punctum 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 is not controlled, the prognosis is worse, as there is a higher risk of complications, and the problem can often progress.
Equipment
The following equipment is needed: No. 15 Bard-Parker blade, Westcott scissors, 0.5mm forceps, and cautery (monopolar or bipolar), 4-0 silk suture, 6-0 Vicryl suture, 5-0 Vicryl suture, corneal shield, and antibiotic ophthalmic ointment.
Personnel
An ophthalmologist, oculoplastic, facial plastic, or plastic surgeon is required.
Preparation
The patient should have been properly examined before surgical intervention and deemed appropriate for surgery by an appropriately qualified surgeon. 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 possible depending on the etiology of the ectropion, and the repair is tailored to each specific patient based on preoperative examination. The essential steps for the following will be listed: cicatricial, involutional, medial, and lateral tarsal strip with a medial spindle for ectropion repair with punctal eversion.[1]
Cicatricial[2]
- Administration of topical anesthetic and local anesthetic
- Corneal shield placement
- Traction sutures placed in gray or lash line of the eyelid
- Subciliary incision
- Dissection to release scarring until the posterior lamella returns to anatomical position
- Perform tarsal strip for horizontal lid tightening
- Measure or draw a template of the area requiring graft
- Mark/transfer template to the donor site
- Closure of donor site skin incision
- Debride the dermis aspect of the graft of any extraneous subcutaneous tissue
- Suture graft into the wound bed
- Close the lateral canthal skin (if horizontal lid tightening was performed)
- Removal of corneal shield
- Frost suture (if required)
Involutional [3]
- Administration of topical anesthetic and local anesthetic
- Corneal shield placement
- Lateral canthal incision with canthotomy and inferior cantholysis
- Split the anterior and posterior lamella of the lateral lower lid
- Remove the skin, muscle, and conjunctiva to form a tarsal strip
- Distract lid laterally to the rim to estimate the amount of tarsus required and excise the redundancy
- Anchor the strip to the periosteum of the lateral rim
- Excise any redundant anterior lamella
- Closure of skin incision
- Removal of corneal shield
Medial Ectropion Repair [4]
- Administration of topical anesthetic and local anesthetic
- Corneal shield placement
- Evert the lid margin with traction suture and/or Bowman probe
- Excise an ellipse of the conjunctiva and lower lid retractors
- Excise a portion of the lateral caruncle (if performing caruncular recruitment)
- 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.
- 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)
- Perform lateral tarsal strip (if required)
- Tie the sutures to invert the punctum appropriately
- Remove corneal shield
Lateral Tarsal Strip with Medial Spindle[2]
- Infiltrate local anesthetic at the lateral canthus, lateral lower eyelid, internal aspect of the lateral orbital rim, and conjunctiva of the inferior medial fornix
- Lateral Canthotomy
- Lateral Inferior crus cantholysis
- Excise a diamond-shaped area of conjunctiva and lower eyelid retractors below the punctum
- Close the conjunctiva and lower lid retractors
- Determine the length of the strip
- Denude the epithelium
- Split the anterior and posterior lamellae
- Disinsert the lower eyelid retractors and conjunctiva from the strip
- Excise the anterior lamella from the strip to remove lash follicles.
- Attach the strip to the periosteum of the inner aspect of the lateral orbital rim
- Reform the sharp angle of the lateral canthus
- 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
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.