Modified everting sutures combined with reattachment to the inferior tarsal plate for involutional lower eyelid entropion: A new technique

Background This study evaluated the outcomes of a new modified Wies technique for patients with involutional lower eyelid entropion without horizontal eyelid laxity.Methods This case series retrospectively analyzed consecutive patients with entropion who underwent surgery between January 2014 and March 2019 by the same experienced surgeon. Horizontal eyelid laxity, lower eyelid retractor function, and orbicularis muscle overriding were recorded before and after surgery. The recurrence rate and complications were also evaluated. This technique consisted of modified everting sutures combined with reattachment of the lower eyelid retractors to the inferior tarsal plate.Results This new technique was performed on 28 eyes in 25 patients (mean age, 71.0±8.0 years; range, 56–87 years). Nine patients (36%) were women and 16 (64%) were men. Lower lid entropion was present in the right eye in 14 patients (56%), the left eye in eight patients (32%), and both eyes in three patients (12%). The mean follow-up period was 27.3±12.4 months (range, 6–60 months). No intraoperative complications were observed. All patients’ symptoms were alleviated. One patient (3.6%) had recurrence after 2 years (success rate, 96.4%). The remaining 27 eyes maintained a satisfactory and comfortable eyelid position. No patients had problems with scarring.Conclusions The approach described herein proved to be safe and feasible in eyes with involutional lower eyelid entropion without horizontal eyelid laxity. These advantages of this procedure include the lack of a conjunctival scar, punctal eversion, and lateral canthal angle deformation. A low recurrence rate and a long interval to recurrence were also observed.

Vertical-to-Horizontal Rotational Myocutaneous Flap for Repairing Cicatricial Lower Lid Ectropion: A Novel Surgical Technique

Objective. To evaluate the efficacy and complications of a novel surgical technique for cicatricial lower lid ectropion that uses a vertical-to-horizontal (V-to-H) rotational myocutaneous flap procedure (Tsai procedure). Methods. We performed the V-to-H rotational myocutaneous flap procedure on 20 eyelids in 20 patients with mild to moderate cicatricial lower lid ectropion. A vertical myocutaneous flap was created from the anterior lamella of the vertical pedicle in the lateral third of the lower eyelid. Following a horizontal relaxing incision from the base of the flap, a vertical myocutaneous flap was created and rotated to horizontal. Two patients with combined cicatricial ectropion and paralytic lagophthalmos simultaneously underwent additional lateral tarsorrhaphy. Results. After a minimum follow-up period of 6 months, all patients showed good anatomical and functional improvement with decreased dependence on topical lubricants and a satisfactory cosmetic appearance. Two patients with combined cicatricial and paralytic ectropion had mild residual asymptomatic lagophthalmos. No patients required further revision surgery and there were no complications or recurrence. Conclusion. The V-to-H rotational myocutaneous flap technique was an effective and simple one-stage procedure for correcting cicatricial lower lid ectropion. It lengthened the anterior lamella and tightened horizontal eyelid laxity without the need for a free skin graft.

Management of Ectropion and Floppy Eyelids

Ectropion is defined as an eversion of the upper or lower eyelid away from the globe. Classes of ectropion include involutional, cicatricial, paralytic, and mechanical. Ectropic eyelids develop from horizontal eyelid laxity, medial canthal tendon laxity, vertical skin tightness, neuromuscular dysfunction, and lower eyelid retractor disinsertion. Ocular complications associated with ectropic eyelids include corneal exposure and scarring, conjunctivitis, ocular discomfort, photophobia, epiphora, and decreased vision. The entire face and eye should be carefully examined when a patient presents with ectropion. A systemic approach enables the physician to more fully understand the underlying disease process and best therapeutic approach. Ectropion can be quantified by pulling the central portion of the lid anteriorly and measuring the number of millimeters from the anterior cornea to the apex of the eyelid. Ectropion etiology can be elucidated by evaluating for horizontal eyelid laxity, orbicularis dysfunction, vertical skin tightness, and lower eyelid retractors disinsertion. Horizontal eyelid laxity is typically a result of lateral or medial canthal tendon stretching. Laxity of the canthal tendons produces a redundancy in the eyelid tissues, resulting in ectropion, often referred to as an involutional ectropion. Lateral canthal tendon status can be determined by gently pulling the eyelid nasally. The inferior crus of the tendon can then be palpated to evaluate for dehiscence. The medial canthal tendon can be evaluated by pulling laterally and noting the displacement of the inferior punctum. The severity of canthal tendon laxity should be quantified prior to any surgical intervention. 8-2-1 Lateral Canthal Tendon Laxity and the Lateral Tarsal Strip Procedure. Although a variety of methods have been advocated for treatment of lateral canthal tendon laxity, we prefer the lateral tarsal strip, introduced by Anderson. This procedure corrects the underlying anatomic abnormality, does not require reapproximation of the eyelid margin, and is relatively easy to perform. The lateral canthal region is injected with lidocaine 2% mixed with 1:100,000 epinephrine using a 27- or 30-gauge needle. After ensuring appropriate anesthesia, Stevens scissors are used to create a lateral canthotomy and exposure of the lateral orbital rim.