eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Lower Eyelid Reconstruction, Ectropion: Multimedia

Author: Mounir Bashour, MD, CM, FRCS(C), PhD, FACS, Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD
Contributor Information and Disclosures

Updated: Jul 14, 2009

Multimedia

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Media file 1: Sagittal section through orbit.

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Sagittal section through orbit.

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Media file 2: Horizontal section through orbit.

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Horizontal section through orbit.

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Media file 3: Eyelid shortening by lateral tarsal strip fixation. (A) Pull the eyelid medially to prevent buckling of the lateral canthal tendon, and, with scissors, cut a lateral canthotomy to the orbital rim. Transect the inferior crus of the lateral canthal tendon. Grasp the lateral lid with forceps and pull it medially to confirm complete interruption of all attachments. (B) With fine pointed scissors, split the eyelid along the grey line for a distance of 5-10 mm, depending on the amount of lid shortening required. Continue the dissection to separate the anterior skin-muscle lamella from the posterior tarsoconjunctival lamella. (C) Cut the retractors and conjunctiva from along the inferior border of the tarsus beneath the split section. Cauterize the palpebral vessels, which are usually injured at this stage. (D) With fine scissors, remove a strip of marginal epithelium from the free portion of tarsus.

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Eyelid shortening by lateral tarsal strip fixation. (A) Pull the eyelid medially to prevent buckling of the lateral canthal tendon, and, with scissors, cut a lateral canthotomy to the orbital rim. Transect the inferior crus of the lateral canthal tendon. Grasp the lateral lid with forceps and pull it medially to confirm complete interruption of all attachments. (B) With fine pointed scissors, split the eyelid along the grey line for a distance of 5-10 mm, depending on the amount of lid shortening required. Continue the dissection to separate the anterior skin-muscle lamella from the posterior tarsoconjunctival lamella. (C) Cut the retractors and conjunctiva from along the inferior border of the tarsus beneath the split section. Cauterize the palpebral vessels, which are usually injured at this stage. (D) With fine scissors, remove a strip of marginal epithelium from the free portion of tarsus.

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Media file 4: Eyelid shortening by lateral tarsal strip fixation. (E) Lay the anterior surface of the flap over the flat face of a forceps handle for support, and scrape the conjunctival epithelium from the posterior surface of the tarsus with a scalpel blade. Cut off the remnant of the lateral canthal tendon from the bare tarsus to form a strip 3-4 mm wide and 4 mm long. (F) Pass two 4-0 Mersilene or Vicryl sutures on a small, stout, half-circle needle through the tarsal strip from outside to inside and then through the periosteum just inside the lateral orbital rim. To be certain a firm periosteal bite is achieved, pull up on the suture and observe the patient's head move slightly. Tie the sutures firmly. (G) With forceps, pull the skin-muscle flap laterally and excise the excess triangle with its marginal cilia. (H) Reform the canthal angle with an interrupted suture of 6-0 nylon. Close the orbicularis muscle with one or two 6-0 chromic sutures, and the skin with interrupted stitches of 6-0 nylon or silk.

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Eyelid shortening by lateral tarsal strip fixation. (E) Lay the anterior surface of the flap over the flat face of a forceps handle for support, and scrape the conjunctival epithelium from the posterior surface of the tarsus with a scalpel blade. Cut off the remnant of the lateral canthal tendon from the bare tarsus to form a strip 3-4 mm wide and 4 mm long. (F) Pass two 4-0 Mersilene or Vicryl sutures on a small, stout, half-circle needle through the tarsal strip from outside to inside and then through the periosteum just inside the lateral orbital rim. To be certain a firm periosteal bite is achieved, pull up on the suture and observe the patient's head move slightly. Tie the sutures firmly. (G) With forceps, pull the skin-muscle flap laterally and excise the excess triangle with its marginal cilia. (H) Reform the canthal angle with an interrupted suture of 6-0 nylon. Close the orbicularis muscle with one or two 6-0 chromic sutures, and the skin with interrupted stitches of 6-0 nylon or silk.

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Media file 5: Medial spindle tarsoconjunctival resection. (A) Place a number 00 or 0 Bowman probe in the inferior canaliculus to mark its position, and evert the lower eyelid with forceps. (B) With a scalpel blade, cut a spindle-shaped segment 8-10 mm long and 4-6 mm high from the conjunctiva and tarsus. Locate the excision 4 mm below the inferior punctum, positioned so two thirds of the spindle lie lateral to the papilla. (C) Remove the bowman probe. Pass a double-armed 4-0 chromic suture through the inferior wound edge from inside the wound to the conjunctival surface. (D) Continue passing the same sutures through the superior wound edge from the conjunctival surface to the subtarsal space to form a double vertical mattress stitch.

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Medial spindle tarsoconjunctival resection. (A) Place a number 00 or 0 Bowman probe in the inferior canaliculus to mark its position, and evert the lower eyelid with forceps. (B) With a scalpel blade, cut a spindle-shaped segment 8-10 mm long and 4-6 mm high from the conjunctiva and tarsus. Locate the excision 4 mm below the inferior punctum, positioned so two thirds of the spindle lie lateral to the papilla. (C) Remove the bowman probe. Pass a double-armed 4-0 chromic suture through the inferior wound edge from inside the wound to the conjunctival surface. (D) Continue passing the same sutures through the superior wound edge from the conjunctival surface to the subtarsal space to form a double vertical mattress stitch.

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Media file 6: Medial spindle tarsoconjunctival resection. (E) Pass both needles anteriorly through the center of the spindle-shaped defect to emerge on the skin surface. (F) Tie the suture on the skin surface with enough tension to pull the wound edges together and to invert the lid margin and punctum.

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Medial spindle tarsoconjunctival resection. (E) Pass both needles anteriorly through the center of the spindle-shaped defect to emerge on the skin surface. (F) Tie the suture on the skin surface with enough tension to pull the wound edges together and to invert the lid margin and punctum.

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Media file 7: The modified "lazy-T" procedure. (A) Hold the lid margin with 2 forceps, and, with scissors, make a full-thickness vertical cut through the lid 4 mm lateral to the inferior punctum. Cauterize the marginal artery. (B) With forceps, grasp the 2 free tarsal edges and overlap them with moderate tension. On the lateral side of the wound, mark the amount of excess lid to be resected. (C) Cut along the mark with scissors to excise a V-shaped segment of full-thickness eyelid. (D) Evert the medial portion of the eyelid with forceps. Place a number 00 or 0 Bowman probe into the canaliculus to mark its location. Cut a horizontal V-shaped segment of conjunctiva and capsulopalpebral fascia 4 mm below the canaliculus. The excised wedge should measure about 5 mm vertically by 8 mm horizontally, and should have its broad base laterally, at the previously cut vertical eyelid defect.

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The modified "lazy-T" procedure. (A) Hold the lid margin with 2 forceps, and, with scissors, make a full-thickness vertical cut through the lid 4 mm lateral to the inferior punctum. Cauterize the marginal artery. (B) With forceps, grasp the 2 free tarsal edges and overlap them with moderate tension. On the lateral side of the wound, mark the amount of excess lid to be resected. (C) Cut along the mark with scissors to excise a V-shaped segment of full-thickness eyelid. (D) Evert the medial portion of the eyelid with forceps. Place a number 00 or 0 Bowman probe into the canaliculus to mark its location. Cut a horizontal V-shaped segment of conjunctiva and capsulopalpebral fascia 4 mm below the canaliculus. The excised wedge should measure about 5 mm vertically by 8 mm horizontally, and should have its broad base laterally, at the previously cut vertical eyelid defect.

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Media file 8: The modified "lazy-T" procedure. (E) Close the horizontal incision with several 6-0 plain or chromic gut sutures to shorten the posterior lamella. Bury the knots to prevent corneal abrasion. (F) Pass a 6-0 silk vertical mattress suture across the tarsal defect at the eyelid margin for alignment. Reapproximate the cut tarsal surfaces with several 6-0 Vicryl sutures, keeping them beneath the conjunctiva. (G) Place a second marginal 6-0 silk suture through the lash line. Tie the marginal sutures with enough tension to evert the wound edges slightly, and leave the suture ends long. Tie together the remaining tarsal sutures. (H) Close the orbicularis muscle with interrupted 6-0 chromic gut sutures and the skin with 6-0 nylon stitches. Tie the long ends of the marginal sutures to these stitches to keep them off the cornea.

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The modified "lazy-T" procedure. (E) Close the horizontal incision with several 6-0 plain or chromic gut sutures to shorten the posterior lamella. Bury the knots to prevent corneal abrasion. (F) Pass a 6-0 silk vertical mattress suture across the tarsal defect at the eyelid margin for alignment. Reapproximate the cut tarsal surfaces with several 6-0 Vicryl sutures, keeping them beneath the conjunctiva. (G) Place a second marginal 6-0 silk suture through the lash line. Tie the marginal sutures with enough tension to evert the wound edges slightly, and leave the suture ends long. Tie together the remaining tarsal sutures. (H) Close the orbicularis muscle with interrupted 6-0 chromic gut sutures and the skin with 6-0 nylon stitches. Tie the long ends of the marginal sutures to these stitches to keep them off the cornea.

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Media file 9: Anterior lamellar lengthening with skin graft.(A) Mark the line of incision 3 mm below the eyelid margin or along the upper edge of the contracted area of skin if nonmarginal. Extend the line at least 6-8 mm on either side of the contracted area. Place a traction suture of 4-0 silk through the marginal tarsus.(B) Cut along the marked incision line with a scalpel blade. Sharply dissect the skin from the underlying orbicularis muscle for a distance of 5-6 mm beyond all areas of contraction. When free, the eyelid margin should overlap the corneal limbus without tension by 1-2 mm. Obtain meticulous hemostasis with pressure or epinephrine-soaked gauze. Avoid excessive cautery.(C) Mark an incision line in the supratarsal eyelid crease of the ipsilateral or contralateral upper eyelid. Outline an elliptical segment, as for upper eyelid blepharoplasty. The width of the graft should be 1.5 times the width of the recipient bed defect.(D) Cut the donor skin along the marked line with a scalpel blade. Undermine the graft with scissors and dissect it from the orbicularis muscle. It may be necessary to excise part of the muscle to allow closure of the wound. Close the donor site with a running suture of 6-0 nylon.

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Anterior lamellar lengthening with skin graft.(A) Mark the line of incision 3 mm below the eyelid margin or along the upper edge of the contracted area of skin if nonmarginal. Extend the line at least 6-8 mm on either side of the contracted area. Place a traction suture of 4-0 silk through the marginal tarsus.(B) Cut along the marked incision line with a scalpel blade. Sharply dissect the skin from the underlying orbicularis muscle for a distance of 5-6 mm beyond all areas of contraction. When free, the eyelid margin should overlap the corneal limbus without tension by 1-2 mm. Obtain meticulous hemostasis with pressure or epinephrine-soaked gauze. Avoid excessive cautery.(C) Mark an incision line in the supratarsal eyelid crease of the ipsilateral or contralateral upper eyelid. Outline an elliptical segment, as for upper eyelid blepharoplasty. The width of the graft should be 1.5 times the width of the recipient bed defect.(D) Cut the donor skin along the marked line with a scalpel blade. Undermine the graft with scissors and dissect it from the orbicularis muscle. It may be necessary to excise part of the muscle to allow closure of the wound. Close the donor site with a running suture of 6-0 nylon.

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Media file 10: Anterior lamellar lengthening with skin graft. (E) An alternative donor site is retroauricular skin. Center the graft at the posterior base of the ear so that half extends onto the retroauricular skin and half onto the non–hair-bearing supramastoid skin. Mark the graft the appropriate shape and 1.5 times the width of the recipient defect. Cut the skin with a scalpel blade and dissect skin from subcutaneous tissue with scissors. Close the donor site with a running stitch of 4-0 Vicryl. (F) Remove all subcutaneous tissue from the skin graft with sharp dissection. If needed, trim the graft to fit the defect, keeping it 1.5 times the required width. (G) Suture the graft into the recipient bed using interrupted 7-0 Vicryl stitches. If the graft is larger than 2 cm in diameter, cut 1 or more stab incisions in its central portion for drainage. Place a 4-0 silk Frost suture through the eyelid margin and tape it to the brow to keep the eyelid closed and the graft flat. (H)Pass a 5-0 nylon vertical mattress suture through the skin beyond the graft edges centrally and put additional mattress sutures on either side. Place a Telfa pad soaked in antibiotic solution over the graft, and position a rolled sterile sponge over the pad. Tie the mattress sutures snugly to keep the graft immobile.

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Anterior lamellar lengthening with skin graft. (E) An alternative donor site is retroauricular skin. Center the graft at the posterior base of the ear so that half extends onto the retroauricular skin and half onto the non–hair-bearing supramastoid skin. Mark the graft the appropriate shape and 1.5 times the width of the recipient defect. Cut the skin with a scalpel blade and dissect skin from subcutaneous tissue with scissors. Close the donor site with a running stitch of 4-0 Vicryl. (F) Remove all subcutaneous tissue from the skin graft with sharp dissection. If needed, trim the graft to fit the defect, keeping it 1.5 times the required width. (G) Suture the graft into the recipient bed using interrupted 7-0 Vicryl stitches. If the graft is larger than 2 cm in diameter, cut 1 or more stab incisions in its central portion for drainage. Place a 4-0 silk Frost suture through the eyelid margin and tape it to the brow to keep the eyelid closed and the graft flat. (H)Pass a 5-0 nylon vertical mattress suture through the skin beyond the graft edges centrally and put additional mattress sutures on either side. Place a Telfa pad soaked in antibiotic solution over the graft, and position a rolled sterile sponge over the pad. Tie the mattress sutures snugly to keep the graft immobile.

More on Lower Eyelid Reconstruction, Ectropion

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References

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References

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Keywords

lower lid ectropion, lower lid laxity, eyelid eversion, involutional, cicatricial, tarsal, congenital, neurogenic, paralytic, lower eyelid reconstruction, eyelid laxity

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Contributor Information and Disclosures

Author

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS, Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD
Mounir Bashour, MD, CM, FRCS(C), PhD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

Richard V Smith, MD, Director of Clinical Affairs, Associate Professor, Department of Otolaryngology, Division of Head and Neck Surgery, Einstein College of Medicine, Montefiore Medical Center
Richard V Smith, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Laryngological Rhinological and Otological Society, American Medical Association, American Medical Student Association/Foundation, Medical Society of the District of Columbia, New York Academy of Medicine, and Vermont State Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David W Stepnick, MD, Associate Professor, Departments of Plastic Surgery and Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals of Cleveland Case Medical Center
David W Stepnick, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
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Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
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eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Lower Eyelid Reconstruction, Ectropion: Multimedia

Multimedia

Sagittal section through orbit.

Horizontal section through orbit.

Medial spindle tarsoconjunctival resection. (E) Pass both needles anteriorly through the center of the spindle-shaped defect to emerge on the skin surface. (F) Tie the suture on the skin surface with enough tension to pull the wound edges together and to invert the lid margin and punctum.

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CME Editor

Chief Editor