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.     

颞区水平皮瓣修复瘢痕性下睑外翻的临床观察

目的探讨外眦角颞侧水平带蒂皮瓣在下睑瘢痕性外翻修复中的应用。方法对11例（11只眼）伴有皮肤组织缺损的下睑外翻患者实施该手术,其中3只眼为局部疖肿溃破后皮肤瘢痕挛缩,2只眼为铝水烫伤后,6只眼为皮肤挫裂伤后。年龄15～58岁。局麻下手术,根据下睑皮肤缺损范围,在颞区设计一以肌肉组织为蒂的水平向皮瓣。皮瓣穿过供、受区之间的皮下隧道后缝合于缺损区。结果术后第2天,有1只眼皮瓣的鼻侧端微紫,1周后色泽日趋正常。术后随访3～6个月,11只眼下睑皮瓣色泽良好,与周围组织差异小,无外翻发生。颞区伤口瘢痕细而淡。结论颞区水平皮瓣在伴有皮肤组织缺损的瘢痕性下睑外翻修复中疗效良好,供区水平伤口愈合佳,瘢痕小。但供皮量受颞区皮肤松弛程度的限制,且应严格控制皮瓣长度,避免因血供不足造成组织坏死,因而更适合于下睑颞侧半皮肤缺损的修复。     

风筝皮瓣修复眼睑前层及中面部皮肤缺损

目的 评价风筝皮瓣修复合并或不合并中面部皮肤缺损的眼睑前层缺损的疗效.方法 自2008年1月至2010年3月,以面部皮下组织为蒂,设计"风筝"皮瓣,联合或不联合硬腭黏膜移植,修复合并或不合并中面部皮肤缺损的眼睑缺损共10例.眼睑前层或和中面部皮肤缺损面积为(1.2～6.5)cm2、(0.7～4.0)cm2.其中下眼睑中央水平方向4/5、垂直方向完全全层缺损合并颧颊部皮肤缺损1例,下睑内侧水平方向1/2、垂直方向完全全层缺损、下泪小点下泪小管缺损合并中面部皮肤缺损1例,下睑水平及垂直方向均完全全层缺损合并下泪小点及下泪小管缺损1例,上下睑水平方向完全、垂直方向1/3全层缺损合并上下泪小点泪小管缺损1例,下睑中央水平方向4/5、垂直方向完全全层缺损合并颧颊部皮肤缺损1例,全上眼睑前层及颞部皮肤缺损1例,下睑内侧水平方向1/3、垂直方向1/5前层缺损1例,上下睑中央水平方向2/3、上睑垂直方向1/3,下睑垂直方向2/3全层缺损1例,上下睑内侧1/3前层及内呲内侧皮肤缺损合并上下泪小点缺损1例,外眦外侧前层及颞部皮肤缺损1例.结果 皮瓣均无张力修复缺损,皮瓣及硬腭黏膜均全部成活,眼睑外形、功能完全恢复.结论 风筝皮瓣是修复眼睑缺损及面部皮肤缺损的良好方法.

Abstract：

Objective To evaluate the effect of rehabilitating the anterior 1amella of eyelids and midfacial skin defects with kite flap.Methods From January 2008 to March 2010,with or without combination of a hard palate mucosal grafts,the kite flap on a subcutaneous pedicle have been used to repair defect in the anterior lamella of eyelids and midfacial skin in 10 patients.The area of the defect in the anterior lamella of eyelids and midfacial skin ranged from(1.2～6.5)×(0.8～4)cm.Among them,defects span central 4/5 in horizontal direction and complete in vertical direction in full-thickness lower eyelid and partes zygomatica skin in 2 patient,medial 1/2 in horizontal direction and complete in vertical direction and puncta and canaliculus in full-thickness lower eyelid and midface skin in 1 patient,complete lower eyelid and inferior puncta and canaliculus in 1 patient,complete in horizontal direction and 1/3 in vertical direction and puncta and canaliculus both in full-thickness upper and lower eyelids in 1 patient,complete anterior layer of upper eyelid and temples skin in 1 patient,medial 1/3 in horizontal direction and 1/5 in vertical direction in the anterior lamella of lower eyelid in 1 patient,central 2/3 in horizontal direction and 1/3 in vertical direction in full-thickness upper eyelid,and central 2/3 in horizontal direction and 2/3 in vertical direction in full-thickness lower eyelid in 1 patient,medial 1/3 of anterior lamella and puncta and canaliculus both in upper and lower eyelid and inside skin of medial canthus in 1 patient,outside skin of outer canthus and temples skin in 1 patient.Results All flaps and hard palate mucosal grafts were survived.All defects were repaired without tention.The cosmetic appearance and function of eyelids rehabilitated.Conclusions The kite flap provides a competitive method for repairing the anterior lamella of eyelids and facial skin defects.     

Age-related medial ectropion of the lower eyelid

Background : A simplified procedure is proposed for the repair of medial lower eyelid age-related ectropion. Methods : A posterior horizontal incision is made in the medial half of the lower eyelid at the inferior border of tarsus. The lower eyelid retractors are exposed and then plicated to the tarsus without excision of posterior lamellae or the use of everting sutures. The lid is then shortened horizontally with excision of a pentagonal section or lateral tarsal strip procedure. Results : The procedure was performed in six patients successfully without complication. Conclusions : This is an effective method for repair of lower lid medial age-related ectropion.     

对位睑板结膜瓣滑行修复眼睑缺损

目的：评价对位睑板结膜瓣滑行修复眼瞪缺损的效果。方法：对41例眼瞪全层缺损患者,其中上睑10例,下睑31例,切除肿瘤导致缺损者33例。外伤导致缺损者8例,缺损范围在1/3-2/3,年龄24-79岁,采用与缺损眼睑相对应的眼睑睑板结膜瓣滑行至缺损区来修补眼睑缺损。结果：术后随访31例,随访时间3月-5年,除缺损外,1例出现轻度上睑退缩（退缩量为1-2mm),1例出现轻度下睑外翻,余眼睑外形及功能均基本恢复,眼睑活动自如,闭合完全,无严重并发症发生,结论：对位睑板结膜瓣滑行可用于修复眼睑后层缺损,且不受有无睑板替代物的限制。不需另添手术创口,可更好地恢复眼睑的功能及外观。     

Role of the lower lid retractors in involutional ectropion repair

AIM. To outline the role of the lower lid retractors in correction of involutional ectropion. METHODS. Eight eyelids with a tarsal ectropion were included in the study. Clinical clues to help identify weakness of the lower lid retractors were documented. A transconjunctival lower lid retractor reattachment with concommitant correction of horizontal lid laxity and lamellar dissociation was performed. RESULTS. Stable eyelid position was obtained in 7 of the 8 cases. One case had a lateral ectropion due to a wound dehiscence. CONCLUSIONS. This small study helps better define the clinical presentations of retractor weakness and provides evidence of a systematic approach in correcting involutional ectropion.     

Ocular manifestations of congenital lamellar ichthyosis

PURPOSE: To describe the ophthalmic manifestations in a series of children with congenital lamellar ichthyosis. These cases presented with varying types of eyelid abnormality associated with the systemic disease. The clinical features and ophthalmic management were studied. METHODS: The case histories of three children presenting to the oculoplastic clinic were reviewed. All were diagnosed with congenital lamellar ichthyosis and under the care of the Dermatology department. Family history and pedigree analysis was performed to determine mode of genetic inheritance. Ocular examination for visual acuity, eyelid and eyelash malposition, lid function and closure were carried out. Corneal examination including tests for exposure was also done. RESULTS: All three patients had eyelid position abnormalities from the systemic disease. There was no clinical evidence of conjunctival involvement. One patient required full thickness skin grafts to treat corneal exposure secondary to lower lid ectropion. One had mild lower lid ectropion but without corneal exposure. The third case had the unusual finding of inward turning of the anterior lamella of the upper eyelid with a marked lash ptosis and only mild ectropion of the lower lid. CONCLUSIONS: Congenital lamellar ichthyosis is a heterogeneous disorder with phenotypic variability. The most common eyelid abnormality is cicatricial ectropion of the upper and mainly lower eyelids. Most cases are managed conservatively although in severe cases secondary corneal exposure may require surgical correction. In this condition, to the best of our knowledge, the tendency for the eyelids to turn inwards has not previously been described.     

【In Press】Anterior lamellar recession for management of upper eyelid cicatricial entropion and associated eyelid abnormalities

AIM: To evaluate the functional and aesthetic outcomes of upper eyelid cicatricial entropion correction using anterior lamellar recession (ALR) with addressing the associated conditions including dermatochalasis, brow ptosis, blepharoptosis, and lid retraction. METHODS: Chart review of patients with upper lid cicatricial entropion who had undergone ALR from 2013 to 2016 was reviewed. Success was defined as the lack of any lash in contact with the globe, no need for a second procedure, and acceptable cosmesis at the final follow up. RESULTS: Sixty eight patients (97 eyelids) were operated by ALR with simultaneous correction of associated lid problems in each case when necessary. The mean follow-up time was 17.8mo (range, 6.0-24.0mo).Concomitantly, levator tucking was performed in 19 eyelids (19.6%), upper lid retractor recession in 18 eyelids (18.6%), and internal browpexy in 31 eyelids (32.0%). In 95.8% of patients (CI: 0.85-0.96), satisfactory functional and cosmetic outcome was achieved with a single surgical procedure. CONCLUSION: Based on the principles of lamellar recession and concurrently addressing the associated lid problems, this approach is an effective and safe treatment of upper eyelid cicatricial entropion.     

Management of upper eyelid cicatricial entropion

Purpose: There is a paucity of published data on the management of upper eyelid cicatricial entropion. We report on our results using such techniques as lamella repositioning, recession or augmentation and terminal tarsal rotation. Design: Observational retrospective case series. Participants: Consecutive cases of upper eyelid cicatricial entropion of two specialist oculoplastic centres (Corneoplastic Unit, East Grinstead, UK and South Australian Institute of Ophthalmology, Adelaide, Australia) were reviewed over a 7‐year period. Methods: All patients underwent anterior lamellar repositioning or terminal tarsal rotation. Main Outcome Measures: Success was defined by two definitions: anatomical success was defined where the lid margin was restored to its normal position. Complete success was defined where there were no eyelashes touching the globe. Gain or loss (≤ or ≥2 Snellen lines) in best corrected visual acuity using a Snellen chart and resolution of any corneal epitheliopathy at final follow‐up were also recorded (as graded by experienced oculoplastic consultants). Results: Fifty‐two procedures were performed on 41 patients (11 bilateral). All patients underwent either an anterior lamellar repositioning or a terminal tarsal rotation. Trachoma, previous upper lid surgery, Stevens–Johnson syndrome and meibomian gland dysfunction were the commonest underlying diagnoses. Ninety‐eight per cent of the group had a normal anatomical lid position at follow‐up. Nine eyelids (17%) of the group had recurrence of trichiasis. Conclusion: This large case series demonstrates that upper eyelid cicatricial entropion is managed effectively utilizing procedures that involve recession and reposition. We recommend that excision of tissue is avoided, especially in pathology that has a progressive immunological cicatricial drive.     

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.     

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.     

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.     

Reconstruction of large upper eyelid defects with a free tarsal plate graft and a myocutaneous pedicle flap plus a free skin graft

Purpose: To review and present the results of a one-step method employing a free tarsal plate graft and a myocutaneous pedicle flap plus a free skin graft for reconstruction of large upper eyelid defects after tumour surgery.Methods: This was a retrospective case-series of 8 patients who underwent reconstruction of the upper eyelid after tumour removal. The horizontal defect involved 50–75% of the lid (3 pts.), more than 75% (3 pts.), and more than 75% plus the lateral canthus (2 pts.). The posterior lamella was reconstructed with contralateral upper eyelid tarsal plate. The anterior lamella was reconstructed with a laterally based myocutaneous pedicle flap in 7 patients, leaving a raw surface under the brow which was covered with a free skin graft. In 1 patient with little skin left under the brow, the anterior lamella was reconstructed with a bi-pedicle orbicularis muscle flap together with a free skin graft.Results: All patients healed without necrosis, did not suffer from lagophthalmos, achieved reasonable cosmesis, and did not need lubricants. In one patient, a contact lens was necessary for three weeks because of corneal erosion. One patient still needs a contact lens 3 months after excision to avoid eye discomfort.Conclusion: Large upper eyelid defects can be reconstructed with a free tarsal plate graft and a laterally based myocutaneous pedicle flap in combination with a free skin graft. Two-step procedures can probably be avoided in most cases.     

Lateral canthal reconstruction

After the lateral aspect of both the upper and lower eyelids were excised in six patients, a method of reconstruction was used employing a combination of periosteal flaps from the lateral orbital rim and a transpositional skin flap based in the temporal area. The periosteal flaps were crossed to form a sharp canthal angle and were joined to the tarsal edges creating the posterior lamella. The transpositional skin flap was divided at the distal end to form the anterior lamella of the upper and lower lids. The results have been satisfactory from a functional and cosmetic standpoint.     

Anterior lamellar recession for management of upper eyelid cicatricial entropion and associated eyelid abnormalities

AIM: To evaluate the functional and aesthetic outcomes of upper eyelid cicatricial entropion (UCE) correction using anterior lamellar recession (ALR) with addressing the associated conditions including dermatochalasis, brow ptosis, blepharoptosis, and lid retraction. METHODS: Chart review of patients with upper lid cicatricial entropion who had undergone ALR from 2013 to 2016 was reviewed. Success was defined as the lack of any lash in contact with the globe, no need for a second procedure, and acceptable cosmesis at the final follow up. RESULTS: Sixty eight patients (97 eyelids) were operated by ALR with simultaneous correction of associated lid problems in each case when necessary. The mean follow-up time was 17.8mo (range, 6.0-24.0mo). Concomitantly, levator tucking was performed in 19 eyelids (19.6%), upper lid retractor recession in 18 eyelids (18.6%), and internal browpexy in 31 eyelids (32.0%). In 95.8% of patients (95%CI: 0.85-0.96), satisfactory functional and cosmetic outcome was achieved with a single surgical procedure. CONCLUSION: Based on the principles of lamellar recession and concurrently addressing the associated lid problems, this approach is an effective and safe treatment of UCE.     

下睑缩肌后徙与切断手术治疗轻度下睑退缩

目的探讨下睑缩肌后徙或切断手术治疗轻度下睑退缩的临床效果。方法手术多在局麻下进行，采用经典的下睑袋皮肤切口。打开下眶隔，将眶脂肪向下推，暴露下睑缩肌的前表面，沿下睑板下缘处分离下睑缩肌，将下睑缩肌完全分离至下穹隆。于穹隆水平处切断或将其后徙缝合于下穹隆处结膜面。患者取坐位观察下睑位置，以下睑位于下方角膜缘上0．5mm为宜。术后1周、1月及6月测量下睑位置，观察其变化情况。结果11例（14眼），随访6—20月，平均7．3月，获良好效果。12眼在双眼平视时下睑位于角膜下缘，2眼仍残存下睑退缩约0．5mm。全部病例下睑退缩较术前有极大的改善，手术效果良好。结论下睑缩肌后徙或切断手术治疗轻度下睑退缩可获得较好的功能和美容效果。对于轻度下睑退缩的治疗是一种较理想的方法。     

Floppy eyelid syndrome and mental retardation

OBJECTIVE: To report four subjects with a combination of floppy eyelid syndrome, mental retardation, and increased mechanical stimulus to the affected side. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: The authors retrospectively reviewed the charts of four mentally retarded subjects with floppy eyelid syndrome. INTERVENTION: Surgical tightening of three upper lids and one lower lid was performed in three subjects. MAIN OUTCOME MEASURE: Relief of symptoms. RESULTS: The affected eyelids were treated surgically; in case 1 by anterior lamellar repositioning and lateral and medial canthal tightening, in case 2 by horizontal upper lid shortening, and in case 3 by horizontal lid shortening of both upper and lower lids. There was marked relief from symptoms in all three cases. In case 4, surgery was deferred at parental request. CONCLUSIONS: These cases support the role of mechanical factors in the pathogenesis of floppy eyelid syndrome. Subjects with mental retardation may cooperate poorly with examination, and we believe that there should be a careful search for floppy eyelid syndrome in the presence of chronic conjunctivitis or unexplained epitheliopathy.     

Surgical treatment of cicatricial ectropion in lamellar ichthyosis

BACKGROUND. Lamellar ichthyosis is a skin disorder that is frequently associated with cicatricial ectropion and lagophthalmos. The authors present the surgical management of cicatricial ectropion in a case with lamellar ichthyosis. PATIENT AND METHODS. A 2-year-old male presented with bilateral cicatricial ectropion of the upper and lower eyelids. He had lagophthalmos and corneal punctuate staining. His skin was totally involved with the disease process except his prepuce. The patient was circumcised, and after the correction of horizontal eyelid laxity, the penile skin graft was sutured into the defects in all four eyelids. RESULTS. 18 months following surgery the patient had no lagophthalmos or corneal exposure, but had slight ectropion at the temporal side of the left lower eyelid. He had no complications from the circumcision. CONCLUSION. Prepuce is an alternative donor tissue in male patients with no other available donor site. To our knowledge, this is the second report of cicatricial ectropion corrected with a penile skin graft.     

Surgical treatment of cicatricial ectropion in lamellar ichthyosis

BACKGROUND . Lamellar ichthyosis is a skin disorder that is frequently associated with cicatricial ectropion and lagophthalmos. The authors present the surgical management of cicatricial ectropion in a case with lamellar ichthyosis. PATIENT AND METHODS . A 2-year-old male presented with bilateral cicatricial ectropion of the upper and lower eyelids. He had lagophthalmos and corneal punctuate staining. His skin was totally involved with the disease process except his prepuce. The patient was circumcised, and after the correction of horizontal eyelid laxity, the penile skin graft was sutured into the defects in all four eyelids. RESULTS . 18 months following surgery the patient had no lagophthalmos or corneal exposure, but had slight ectropion at the temporal side of the left lower eyelid. He had no complications from the circumcision. CONCLUSION . Prepuce is an alternative donor tissue in male patients with no other available donor site. To our knowledge, this is the second report of cicatricial ectropion corrected with a penile skin graft.     

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.