Lid margin split in the surgical correction of epiblepharon

Purpose: To describe the technique of splitting the lid margin combined with the excision of redundant skin and muscle during the surgical correction of epiblepharon and to report its clinical outcome. Methods: A combined procedure that included splitting the lid margin to repair lower eyelid epiblepharon was performed on 31 eyes of 19 consecutive patients. Lid margin splitting was performed along the grey line on the medial third or half of the lower eyelid by making a 1 mm‐deep incision. Having made a transverse subciliary skin incision and a dissection between the tarsus and the orbicularis oculi muscle, the subcutaneous tissue of the superior edge of the incision was secured to the tarsus with interrupted sutures to evert the cilia. An excision of the redundant skin and orbicularis tissue was made and the skin was closed. The patients were followed for direct inspection of the wound, the split lid margin, the direction of the lashes and the status of the cornea. Results: The mean postoperative follow‐up period was 29.4 weeks. Symptoms disappeared in all patients. In 30 eyelids of 19 patients the cilia did not touch the cornea, even in the down‐gaze. In one eyelid the cilium touched the medial conjunctiva, but not the cornea. The cosmetic outcome of the lower lid was satisfactory in all cases and the wounds of the split lid margin healed without scarring. To date, there have been no complications such as wound dehiscence, ectropion or eyelid retraction. Conclusions: The lamellar splitting of the lid margin is a beneficial addition to the repair of prominent lower lid epiblepharon, especially on the medial aspect of the eyelid. This simple technique ensures easier eversion of the cilia in epiblepharon repair, without disturbing the posterior lamella or causing unfavourable results.     

Eyelid retractor surgery as an adjunct to cicatricial ectropion repair

Purpose : To evaluate the effectiveness of eyelid retractor repair in cicatricial ectropion of the lower eyelid. Methods : The study design was a prospective case series. One hundred and twenty eight eyelids were operated on in 100 consecutive patients with cicatricial ectropion. All patients underwent lower eyelid retractor repair via a conjunctival approach combined with skin replacement to the anterior lamella with or without a horizontal lid tightening procedure. When only medial ectropion was present, a medial‐based transpositional skin flap was used to repair the anterior lamella (26 eyelids). The remaining eyelids with ectropion involving all or most of the eyelid underwent upper‐to‐lower eyelid lateral‐based transpositional skin flap repair (92 eyelids), or full thickness free skin grafting (10 eyelids). Horizontal lid tightening was performed by lateral canthoplasty in 123 eyelids. Results : Relief of cicatricial ectropion symptoms was reported in 90% of patients overall. A normal punctum position was achieved in 70% of eyelids, overall, and was highest (88%) with a medial‐based transpositional skin flap. Conclusions : Eyelid retractor repair combined with skin replacement and horizontal lid shortening is an effective procedure for cicatricial ectropion.     

Correction of involutional lower eyelid medial ectropion with transconjunctival approach retractor plication and lateral tarsal strip

AIM: We describe the technique and our results in managing lower eyelid involutional medial ectropion using a combination of lateral tarsal strip to address horizontal eyelid laxity, and transconjunctival inferior retractor plication to address inferior retractor dehiscence. METHODS: Patients with symptoms of epiphora or signs of medial ectropion were offered this procedure. All had the following characteristics: medial lower eyelid eversion, punctal eversion >3 mm, medial canthal tendon laxity <4 mm, significant horizontal eyelid laxity and lacrimal systems that were patent to syringing. RESULTS: A total of 24 eyelids of 17 patients underwent this procedure over a 12-month period. The mean age of the patients was 79.7 years; 11 were male and six were female. The mean follow-up time was 18 months. Two eyes had undergone previous surgery. All patients had restoration of the eyelid margin to the globe and relief of symptoms. No complications were noted. DISCUSSION: These results suggest that excision of posterior lamellar tissue is not necessary for correction of involutional medial ectropion. Transconjunctival plication or reattachment of retractors is easy to perform and allows for the repair of more than the medial portion of the retractors if required.     

Medical ectropion repair. A new procedure

The lazy-T procedure described by Smith corrects medial ectropion of the lower lid by combining a horizontal full-thickness shortening of the lid with excision of conjunctiva and tarsus inferior to the punctum to invert the lid. However, some cases of senile medial ectropion involve an element of vertical traction on the skin as well as horizontal lid laxity. A new procedure is described that makes use of skin gained from horizontal lower lid shortening in the form of a medially based transposition flap to produce vertical skin lengthening. It is useful to treat medial ectropions that have horizontal laxity along with cicatricial components and has successfully relieved this condition in eight patients.     

Eyelid Surgery in Ocular Myopathies

Introduction: Lid defects created by removal of tumors are conventionally repaired by lid reconstruction. An alternative to surgical repair is wound healing by secondary intention. This technique, laissez-faire, as used in the periorbital region, was first described in 1957. Purpose: This report considers how effective this technique is for defects of various sizes and different locations in the periorbital region. Methods: Defects following excision of periocular tumors in 10 Caucasian patients were allowed to heal by laissez-faire. The locations of the defects were the medial canthus (n = 4), lower eyelid (n = 4), lateral canthus (n = 1), and upper lid (n = 1). The functional and cosmetic outcome of the healing process was noted. Results: A good functional and cosmetic outcome were obtained after healing by laissez-faire in 8 of the 10 patients. Of the 2 remaining patients one patient had a large medial canthal and lower lid defect which extended onto the cheek, which healed with residual scarring and medial ectropion. The second patient had a lower lid defect, which healed with a cicatricial ectropion. Of the 2 patients, only one required further surgery. Conclusions: This report shows the technique of healing by laissez-faire can be extended for relatively large defects with good results. The medial canthal region and full-thickness lower lid defects remain the favored locations for healing by secondary intention. In large defects particularly with extension onto the cheek, there is a significant risk of cicatrization, and the possibility of a second corrective operation should be discussed with the patient prior to tumor excision.     

Comprehensive, combined anterior and transcaruncular orbital approach to medial canthal ligament plication

PURPOSE: To assess the efficacy of a comprehensive technique for correction of severe punctal and medial lower eyelid ectropion and lower eyelid retraction associated with medial canthal ligament (MCL) laxity. METHODS: A comprehensive technique that plicates the anterior and posterior crura of the MCL was performed on 8 eyelids of 6 patients with punctal ectropion and MCL laxity. Preoperative and postoperative symptoms, punctal ectropion, medial lower eyelid ectropion, lower eyelid retraction, lagophthalmos, and exposure keratopathy were evaluated. RESULTS: At an average of 13 months (range, 8-17 months), preoperative symptoms of epiphora and discomfort improved or resolved in all eyes. Punctal ectropion improved in all eyes and completely resolved in 75% of eyes. Medial lower eyelid ectropion was corrected in all eyes, when present. Lower eyelid retraction, lagophthalmos, and exposure keratopathy improved in all eyes. In 1 case, edema of the caruncle and semilunar fold persisted for 6 months. CONCLUSIONS: Combined anterior and transcaruncular MCL plication is an effective and safe procedure for addressing severe punctal and medial lower eyelid ectropion that accompanies MCL laxity and is difficult to correct by other methods. This procedure provides stable, 3-dimensional support to the medial lower eyelid and punctum.     

Infracanalicular full-thickness transverse blepharotomy for medical ectropion

Procedures performed for total lid ectropion often fail to correct medial ectropion of the lower eyelid. Described herein is a technique of infracanalicular full-thickness transverse blepharotomy using rotational sutures for the treatment of medial ectropion. This procedure has been very useful for recurrent medial ectropion and also as a primary procedure. Concomitant canthal laxity should also be corrected.     

Reconstruction of the horizontal palpebral aperture after failed ectropion surgery with temporal migration of punctum

Involutional ectropion of the lower lid is the result of progressive stretching and elongation of the lid margin and medial and lateral canthal tendons. The relative laxities of the components of the lower lid-canthal tendon complex will determine the location and extent of the ectropion. Whereas inadequate canthal tightening or horizontal lid shortening will result in recurrent ectropion, overzealous lid shortening without tendon plication will result in a noticeably narrower horizontal palpebral fissure, a persistent ectropion, or temporal migration of the punctum. We used lateral cantholysis, medial canthal tendon plication, and punctal rotation to return the punctum to its normal position and temporalis muscle to support the lower lid in eight cases in which previous procedures had failed to correct the lid malposition. In all eight cases there was improvement of the lid position. In one case of severe medial ectropion, the punctal eversion was not completely corrected. This technique is not recommended as an initial procedure for ectropion repair. It is only used to manage previous surgical failures. It is a new application and combination of well-accepted techniques.     

Cicatricial ectropion: repair with myocutaneous flaps and canthopexy

BACKGROUND: To evaluate the effectiveness of myocutaneous upper eyelid flaps combined with canthopexy to treat cicatricial lower eyelid ectropion. METHODS: A prospective non-comparative case series undertaken in a private practice setting. Consecutive patients with moderate lower eyelid cicatricial ectropion and upper eyelid dermatochalasis underwent transfer of a bipedicle or monopedicle flap from the upper eyelid combined with canthopexy. The main outcome measures included the occurrence of complications, eyelid position and cosmesis. RESULTS: Sixty-two consecutive cases of cicatricial ectropion repair using myocutaneous flaps and canthopexy. After a mean follow up of 20 months, 58 (93.5%) of the cases had the lower lid punctum facing posterosuperior into the tear lake, showed lid globe apposition and satisfactory eyelid position. There was mild recurrence of cicatricial ectropion in four patients (6.5%). There were no cases of graft failure or granuloma formation. CONCLUSION: The use of a myocutaneous flap from the upper eyelid combined with a canthopexy suspension suture for repair of cicatricial ectropion may offer good eyelid position and function. This technique has the advantage of avoiding full thickness blepharotomy and was associated with a low incidence of early recurrence.     

Lower eyelid retractor (white-line) advancement to correct tarsal ectropion

Objective

To describe a modification of trans-conjunctival, lower eyelid retractor advancement to correct tarsal ectropion.

Involutional entropion and ectropion of the Asian lower eyelid

PURPOSE: A clinical observation showed that involutional entropion of the lower eyelid in Asians may occur more commonly than ectropion. A review of surgical cases was performed to examine this hypothesis. METHODS: A retrospective review of the number of Asian lower lid involutional ectropion and entropion repairs was performed in three different clinical practice settings. These data were compared and statistically analyzed with similar data for non-Asian patients. RESULTS: The frequency of ectropion among Asians was significantly less than in non-Asians (chi-square, p < 0.001). Asian entropion repair represented 11.4% of the 604 eyelid operations performed on Asians, whereas Asian ectropion repair made up only 1.5% of cases. Non-Asian entropion and ectropion repairs were 3.7% and 6.2%, respectively, of the 1,849 eyelid procedures performed on non-Asians. CONCLUSIONS: Because of the normal anteriorly protruding position of the orbital fat within the Asian lower eyelid, Asians may be more predisposed than whites to the development of involutional entropion rather than ectropion. Removal of lower eyelid fat should be considered in entropion repair of the Asian lower eyelid.     

Medial palpebral tendon repair for medial ectropion of the lower eyelid

The primary functional support for the medial eyelid is from the deep attachments of the orbicularis muscle to the posterior lacrimal crest and lacrimal diaphragm. A dehiscence of the deep medial canthal attachments can alter the position of the lower eyelid with subsequent tearing, medial ectropion, and ocular exposure. In this study, medial palpebral tendon reconstruction was performed on seven lower eyelids with medial instability or ectropion and a dehiscence of the medial palpebral tendon. A periosteal flap left attached to the posterior lacrimal crest was used to replace the attenuated or absent medial palpebral tendon. After a mean follow-up of 7 months, 86% (6/7) of the eyelids had acceptable cosmetic and functional results. The use of a periosteal flap to replace a dehiscence of the medial palpebral tendon has several advantages. The periosteal flap is readily available, strong, and autogenous. The lower eyelid and punctum are pulled tightly against the globe. Lastly, the procedure may be repeated or combined with other ectropion procedures.     

Posterior layer advancement of the lower eyelid retractor in involutional entropion repair

PURPOSE: To examine effectiveness of posterior layer advancement of the lower eyelid retractor in involutional entropion repair. METHODS: Fifty lower eyelids (30 right and 20 left, average patient age 75.5 years) of 43 patients with involutional entropion underwent surgery. All cases were observed for at least 1 year postoperatively. During surgery, after detaching the anterior and posterior surfaces of the lower eyelid retractor, we positively advanced and fixed the posterior layer of the lower eyelid retractor to the tarsus. The anterior layer was used as reinforcement for the posterior layer. When lower eyelid retraction was intraoperatively observed, the suture was changed to fix to a more undercorrected position. RESULTS: Of the 50 patients, only 1, who was the second case operated on, showed recurrent entropion 5 months postoperatively, but following a repeat operation using the same procedure no recurrence was seen in the next 2 years. Three eyelids showed a low degree of ectropion in the early postoperative period, but all improved within 1 month. No postoperative lower eyelid retraction was observed in any patient. CONCLUSIONS: Posterior layer advancement of the lower eyelid retractor is useful for entropion repair.     

Transconjunctival lower eyelid blepharoplasty. Technique and complications

The transconjunctival lower eyelid blepharoplasty is extremely effective at reducing lower lid fullness due to prominent orbital fat. The authors performed 122 consecutive transconjunctival blepharoplasties over a 24-month period. Four patients had skin excision via the pinch technique in conjunction with the transconjunctival fat excision. The main complication was under excision of fat which occurred in nine patients (7.4%). Moderate postoperative wound hemorrhage without hematoma formation occurred in one patient (0.8%). There were no cases of lid retraction, ectropion, entropion, inferior oblique palsy, or over excision of fat. The main advantage of this technique is that it avoids the most common complication of transcutaneous lower eyelid blepharoplasty, namely lower eyelid retraction.     

Rotational Flap Repair of Full Thickness Eyelid Defects without a Posterior Lamellar Graft or Flap

Background: To determine the safety and effectiveness of full thickness eyelid reconstructions using a semicircular rotational flap without reconstructing the posterior lamella.

Methods: The charts of all patients undergoing semicircular flap closure of full thickness eyelid defects by one surgeon (JDP) at the Cole Eye Institute between March 2000 and October 2012 were reviewed. Charts were reviewed for patient demographic information, as well as for the size of the defect, the type of flap used, length of follow-up and complications.

Results: Fifty eyelids of 50 patients underwent a semicircular flap repair without posterior lamellar reconstruction during the study period, and 41 charts were available for review. Average patient age was 74 years (range, 40–92 years). Average follow-up was 9.8 months (range, 1–84 months). Average defect size was 19.1?mm (range, 14–30?mm, SD 4.6). Complications included pyogenic granuloma (10 patients, 24.4%), exposure keratopathy (7 patients, 17.1%) lagophthalmos (5 patients, 12.2%), ectropion (6 patients, 14.6%), lateral canthal dystopia (2 cases, 4.9%), eyelid notch (2 cases, 4.9%) and trichiasis (4 cases, 9.8%). Two patients underwent subsequent tarsorrhaphy and one patient underwent ectropion repair. There were no cases of wound dehiscence, diplopia or fornix inadequacy, and the recruited aspect of the eyelid healed well in each case. No case required reconstruction of the eyelid margin or fornix.

Conclusions: Semicircular flap repair of full thickness eyelid defects without flap or graft repair of the posterior lamella results in an adequate fornix and a low rate of secondary surgery.     

Modification of Bick's procedure for treatment of eyelid laxity

A modification of Bick's procedure is presented that offers a simple, effective treatment of ectropion and entropion secondary to eyelid laxity. A full-thickness lid-shortening procedure performed at the lateral canthus avoids lid notching, with good cosmetic results. The success of the procedure is determined by suture of the tarsus directly to the orbital periosteum. The modification of Bick's procedure improves the outcome of the operation and simplifies its performance.     

The Use of AlloDerm in the Reconstruction of Full-Thickness Eyelid Defects

Purpose: To demonstrate the potential for the use of AlloDerm as a posterior lamellar graft in the reconstruction of full-thickness lid defects. Method: In our case series, we evaluated the surgical outcome of three consecutive patients, two with an upper eyelid defect and one with a lower eyelid defect who underwent lid reconstruction using AlloDerm grafts. Results: AlloDerm was readily taken up into the wound defect, with complete coverage of its bulbar surface by conjunctiva. In all the cases, the cornea was not affected by its contact to the AlloDerm. A mucocutaneous junction formed over the margin of the AlloDerm graft with good cosmesis. Conclusion: AlloDerm has the potential to act as an effective posterior lamellar substitute in situations where there is an adequate amount of skin muscle cover available to drape over it. It is rigid enough to replace tarsus and its structure behaves as a scaffold allowing conjunctiva to readily grow over it.     

Sliding tarsal flap for reconstruction of large, shallow lower eyelid tarsal defects

PURPOSE: To describe a novel technique for reconstructing shallow, full-thickness defects of the lower eyelid. METHODS: Twelve patients with shallow, full-thickness lower eyelid defects after Mohs excision of eyelid malignancies were treated with this technique. The posterior lamella was reconstructed by obliquely incising the residual tarsus to create medial and lateral tarsal flaps. These flaps were obliquely overlapped to tighten the eyelid and reconstruct a tarsus approximating normal height. The anterior lamella defect was then reconstructed by using local flaps or free grafts in a conventional manner. RESULTS: Eyelid defects ranged from 25 to 40 mm horizontally and 20 to 35 mm vertically, with tarsal defects ranging from 18 to 27 mm horizontally and 2 to 3.5 mm vertically. A stable eyelid margin with good aesthetic appearance was achieved in all patients. Two patients had mild eyelid retraction not requiring intervention, and one had lower eyelid entropion 9 months after surgery. CONCLUSIONS: Sliding tarsal flaps are an effective technique for reconstruction of this type of defect. The advantages of this approach are its simplicity, utilization of preserved tissue, and avoidance of the morbidity associated with more complex procedures.     

Eyelid reconstruction with tarsomarginal grafts

Summary In the past 3 years, 85 basal cell carcinomas were treated in our clinic using eyelid reconstruction. During the same period, 54 lids were reconstructed after other diseases, mostly after chemical burns. In one of the 54 patients, the upper lid was reconstructed using a tarso-marginal graft after congenital coloboma. Method: In 31 of the 85 patients with basal-well carcinoma (36 %), so much tarsus was lost that a transplantation of tarsus was necessary. Fifteen of the 31 patients were treated with a Hughes-plasty and 16 using a tarsomarginal graft, two in the upper lid. Results: In eight of the remaining 16 cases, the defect was less than one half of length, so that the graft was taken from the second lower lid. In the remaining eight patients, the defect was two thirds of length or longer. In six cases, a 7 mm-graft was taken from the upper lid. As the tarsus from the upper lid measures 10 mm and is thus twice as big as the lower lid tarsus, it was divided into two grafts, resulting in two grafts measuring 7 × 5 mm. They were placed in the lower lid (“double tarsomarginal graft”). The former lower part with lashes was placed in the middle of the lower lid, the former upper part peripherally. In two patients, the defect was healed with three tarsomarginal grafts. A pedicle skin flap was transposed to cover the posterior grafts. Remaining defects were closed with free skin transplants. Conclusion: The tarsomarginal graft permits a short operation time and early rehabilitation of the patients. The disadvantage of the double tarsomarginal graft is that the more valuable upper lid tarsus is used to reconstruct the less valuable lower lid tarsus.      

The maximal Hughes procedure

PURPOSE: To describe the use of oblique medial and lateral periosteal flaps with the Hughes tarsoconjunctival flap for the repair of maximal defects of the lower eyelid. METHODS: A small prospective case series of eight patients requiring lower eyelid reconstruction following with maximal defect of the lower eyelid. The patients underwent a Hughes tarsoconjunctival advancement combined with oblique medial and lateral periosteal flaps, and were assessed for aesthetic outcome and surgical complications. RESULTS: All patients had uncomplicated surgery. Outcomes assessed included corneal protection, eye closure, lower eyelid retraction, complications, and patient satisfaction. Eyelid contour and protection was excellent in all patients. Postoperatively, one patient had mild lower eyelid retraction, and in a second patient, medial ectropion with mild lower eyelid retraction developed that required subsequent revision. CONCLUSIONS: The maximal Hughes procedure is a safe and effective procedure that may be performed with patients under local anesthesia and may avoid the need for more extensive techniques for surgical repair of maximal defects of the lower eyelid.