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Ectropion Lower Eyelid Reconstruction Treatment & Management

  • Author: Mounir Bashour, MD, PhD, CM, FRCSC, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Dec 01, 2015
 

Medical Therapy

Provide medical therapy if surgical therapy is not warranted or not possible.

  • Symptomatic therapy can be achieved using artificial tear ointment or drops; moisture shields are also helpful. In addition, the lower lid can be taped back into position using either specially designed or normal skin tape. If the lacrimal system is blocked, performing a dacryocystorhinostomy alone or in combination with an ectropion procedure may produce better results than treating the ectropion alone.
  • If the conjunctiva is markedly keratinized, use a lubricating ointment or mild steroid ointment several days or weeks prior to ectropion repair. Corneal epithelial defects and prior herpes simplex infection are relative contraindications to use of steroid-containing ointments.
  • Instruct patients with tearing and incipient ectropion or early punctal ectropion to wipe the eyelids in a direction up and in (toward the nose) to avoid worsening medial ectropion.
  • With cicatricial ectropion following trauma or lid surgery, digital massage may help stretch the scar. If not, consider steroid injection into the scar.
  • External paste-on upper lid weights are available and are useful for patients who have seventh nerve palsy. Lid weights can be approximately matched for different skin colors. A double-sided tape is used to apply the lid weight. Removing the lid weight at night may avoid irritation of the lid skin. External lid weights are not a good option in patients with upper lid dermatochalasis or poor manual dexterity.
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Surgical Therapy

The correct surgical treatment of ectropion depends on the etiology. Horizontal lid laxity is often observed with ectropion and can usually be corrected with a lateral tarsal strip procedure. Mild-to-moderate cases of medial ectropion may respond to a medial conjunctival spindle procedure. However, tarsal ectropion requires reinsertion of the lower lid retractors, and an augmentation of the anterior lamellae (along with excision of any cicatrix) is required for cicatricial ectropion.[5, 6]

The author recommends the use of a corneal protector during oculoplastic procedures. The surgeon must be wary of the remote possibility of flash burns whenever oxygen is on the surgical field. Failure to use a corneal protector may transform an elective lid repair into a much more complicated problem.

Ensuring patient comfort during surgery is important. Since most cases of ectropion involve the lower lid, supplemental infraorbital nerve block is a useful adjunct to direct injection and subconjunctival injection.

Tarsorrhaphy

This procedure can be performed as a temporary fix for corneal exposure; however, the author believes better surgical alternatives are usually available.

Electrocautery

Electrocautery at the junction of conjunctiva and lower margin of the tarsus is not commonly advocated, as this procedure is usually only a temporary measure.

Hyaluronic acid gel injection repair

In our experience, hyaluronic acid gel is a nonsurgical, minimally invasive, and safe technique that improves cicatricial ectropion, but with a poor cosmetic result that limits its use. This treatment could be considered only in patients who decline surgery or are poor surgical candidates, as the aesthetic result would not be acceptable to many.[7]

Suture repair

Double-armed chromic sutures are passed through the inferior border of the tarsus, emerging at the skin surface near the orbital rim; the Leicester modified suture technique is described here.[8] In some cases, this repair can give good and lasting results, but this author does not advocate this method of repair as it is usually temporary.

Congenital ectropion

Ensure corneal lubrication. If the condition does not resolve after a few days, consider placing lid margin sutures. A lateral tarsorrhaphy may be required if suture techniques do not work; however, be careful to avoid iatrogenic amblyopia. More severe cases of congenital ectropion may require a skin flap or graft.

Ichthyosis is a well-described cause of congenital ectropion, and although it is sometimes managed conservatively with lubrication, skin grafts may be required.[9]

Lateral tarsal strip

Horizontal lid laxity is a component of most ectropion cases, especially involutional ectropion. Numerous methods for correcting horizontal lid laxity exist. Older methods include wedge resections and the Kuhnt-Szymanowski procedure. Whenever feasible, however, the author prefers a lateral canthal-tightening procedure. Surgery at the lateral canthus avoids the possibility of lid notching with noncanthal procedures and decreases the risk of trichiasis.

The most common variation of lateral canthal-tightening is the lateral tarsal strip procedure, as follows:

  • The lateral canthus can be clamped prior to canthotomy. Then perform inferior cantholysis with Westcott scissors. The lower lid should then be freely mobile.
  • If excess lid skin is present, drape the skin over the lateral canthus and excise an appropriate triangle of full-thickness lid.
  • Split about 3 mm of the lateral lid at the gray line with either sharp Westcott scissors or a 15 blade.
  • Trim away the meibomian orifices of the lateral strip.
  • Scrape the lateral conjunctiva to avoid epithelial inclusion cysts.
  • To secure the lateral strip of tarsus to the periosteum, 2 sutures (or a single horizontal mattress suture) can be placed about 4-5 mm posterior to the lateral orbital rim near the Whitnall tubercle (ie, at or above the level of the inferior pupil). Suitable sutures with small semicircular needles include 5-0 Vicryl on a P2 needle or 4-0 Prolene on a PS-5 needle.
  • Retracting the upper lid superotemporally and placing a cotton swab at the lateral canthus to palpate the inner lateral orbital rim may be helpful.
  • Before tying the suture, remove the corneal shield.
  • The orbicularis layer can be closed with 6-0 Vicryl. The skin can be closed with 6-0 plain gut suture. A stitch through the lateral-most gray line of the upper and lower lateral lid helps to keep the lateral canthus sharp.
  • If the patient requires topical drops (eg, glaucoma therapy) postoperatively, instruct the patient not to retract the lower lid during drop instillation for the first month.

It is not uncommon for patients to experience prolonged discomfort at the lateral canthus following the lateral tarsal strip procedure.

Kuhnt-Szymanowski (Smith modification)

When marked inferior dermatochalasis accompanies ectropion and the lateral canthal tendon is not dehisced, an inferior subciliary blepharoplasty skin incision can be combined with a pentagonal wedge excision of the orbicularis and posterior lamellae.

Precise closure is required to prevent a lid notch.

Tarsal ectropion

This complete eversion of the lower lid occurs when disinsertion of the capsulopalpebral fascia from the inferior tarsal border is present.

In addition to horizontal lid tightening, reinsert the retractors (ideally from a conjunctival approach). A spindle of redundant conjunctiva, no more than 3 mm in vertical height, can be excised if necessary.

A double-armed 5-0 chromic suture can be used to reattach the capsulopalpebral fascia to the inferior tarsus in a running fashion.

Medial ectropion

If tearing is the primary problem in patients with punctal ectropion, a one-snip or two-snip inferior punctoplasty may be beneficial. Easily performed with Vannas scissors and topical anesthetic, punctoplasty restores continuity between the lacus lacrimali and the medial canthal angle.

For mild-to-moderate medial ectropion, a medial conjunctival spindle procedure (excision of the medial conjunctiva and retractors) can be performed.

  • Following anesthetic injection into the medial inferior fornix, the inferior canaliculus can be guarded with a lacrimal probe.
  • Excise a horizontal ellipse or diamond of conjunctiva and underlying lid retractors inferior to the punctum, approximately 3-4 mm high and 6-8 mm wide.
  • Close the defect with double-armed 5-0 chromic inverting sutures. This can be accomplished by engaging the inferior lip of the wound, then the superior lip of the wound; then, redirect the needle from the inferior lid to the cutaneous surface.
  • Alternatively, buried interrupted 6-0 polyglactin stitches can be used to close the medial conjunctival spindle.

Byron Smith lazy-T procedure

This well-described procedure for repairing prominent medial ectropion combines a lower lid full-thickness pentagonal wedge resection, 3-4 mm temporal to the punctum, with resection of a medial triangle of conjunctiva and lower lid retractors (similar to medial conjunctival spindle).

  • Usually, 5-8 mm of lower lid is excised in the pentagonal wedge. When closed, the incisions resemble a "T" lying on its side, hence the name "lazy T."
  • If marked medial canthal laxity is present, medial canthal tendon plication is generally performed with a lid-shortening procedure.
  • Place a lacrimal probe to guard the lower canaliculus. Make a skin incision, extending from just medial to the medial canthus to just temporal to the punctum, inferior to the canaliculus.
  • Place a double-armed 5-0 nylon suture from the medial inferior tarsus to the medial canthal ligament near the anterior lacrimal crest.
  • Remove the lacrimal probe and tighten the plication suture enough to prevent lateral excursion of the puncta. Overtightening the stitch may cause a kink in canalicular outflow. The skin incision can be closed with 6-0 fast-absorbing gut sutures.

Paralytic ectropion

A tarsal strip procedure is often helpful. At least 5 mm of the lateral lower lid may require excision. With lower lid ectropion, suborbicularis oculi fat (SOOF) lifts are also an option.

In patients with extreme paralytic ectropion, a fascia lata (or Gore-Tex) sling or temporalis transfer procedure may be required. An upper lid gold weight implantation is a helpful adjunct for patients with lagophthalmos. Usually, a 1.0- to 1.2-g weight is implanted superior to the tarsus and inferior to the orbicularis. Extrusion of the gold weight occasionally occurs with time as well. Since the gold weight uses gravity, patients should sleep with the head slightly elevated. The gold weights are not a contraindication to MRI investigation.

Cicatricial ectropion

An enhanced tarsal strip (ie, a tarsal strip without the traditional lateral skin excision) may help correct some degree of cicatricial ectropion. If an enhanced tarsal strip is insufficient, Z-plasties, V- to Y-plasty, skin grafts, or advancement flaps may be used to lengthen the anterior lamella.

Skin grafts may be obtained from the upper lid, if dermatochalasis is present; preauricular or postauricular skin is another alternative. Thin and buttonhole the skin graft (for drainage). Place a compressive bolster over the graft to enhance graft survival and to decrease hematoma formation. The bolster is left for 5 days. A superior traction suture decreases the risk of recurrent cicatrix postoperatively.

A retrospective study by Choi et al found full-thickness skin grafts to be effective in the treatment of lower eyelid cicatricial ectropion developing secondary to actinic skin, with donor sites including the upper eyelid, supraclavicular skin, postauricular skin, inner brachial skin, axilla, and preauricular skin. The study included 24 patients (29 eyelids), most of whom underwent the graft in conjunction with one or more additional procedures, such as punctoplasty, canthoplasty, and the use of lateral tarsal strips.[10]

Xu et al described a surgical technique for lower eyelid cicatricial ectropion repair using a bipedicle orbicularis oculi muscle or myocutaneous flap from the upper eyelid.[11] A strip of orbicularis oculi muscle or a myocutaneous flap from the upper eyelid with 2 pedicles attached in the medial and lateral canthus is advanced to the lower eyelid to suspend the eyelid and repair the skin defect.

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Postoperative Details

For the lid sutures, the author prefers an antibiotic steroid combination, such as Maxitrol (neomycin, polymyxin, bacitracin), 3 times a day.

Applying cold compresses to the eyelids every 15 minutes (as tolerated) while the patient is awake decreases bruising and swelling. Frozen peas in a plastic bag are a useful alternative to traditional cloth compresses.

The author generally does not prescribe narcotics postoperatively. Ask the patient to use acetaminophen 325-650 mg by mouth every 4 hours as needed. Ask the patient to avoid aspirin-containing products if possible.

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Follow-up

Patients are usually reviewed on the first postoperative day. Patients then return 5-7 days later for suture removal.

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Complications

Complications are primarily related to corneal and conjunctival exposure. Complications can involve conjunctival keratinization, corneal breakdown, epiphora, and pain. Surgical complications may include bleeding, hematoma, infection, wound dehiscence, pain, and poor positioning of the tarsal strip.

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Outcome and Prognosis

Outcome and prognosis are usually excellent.

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Contributor Information and Disclosures
Author

Mounir Bashour, MD, PhD, CM, FRCSC, FACS Assistant Professor of Ophthalmology, McGill University Faculty of Medicine; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD

Mounir Bashour, MD, PhD, CM, FRCSC, 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, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David W Stepnick, MD Associate Professor, Departments of Otolaryngology-Head & Neck Surgery and Plastic Surgery, Case Western Reserve University School of Medicine, MetroHealth 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 Medical Association, Society of University Otolaryngologists-Head and Neck Surgeons, American College of Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

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, The Triological Society, American Medical Association, American Medical Student Association/Foundation, Medical Society of the District of Columbia, New York Academy of Medicine, Vermont Medical Society

Disclosure: Nothing to disclose.

References
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  2. Neuhaus RW. Anatomical basis of "senile" ectropion. Ophthal Plast Reconstr Surg. 1985. 1(2):87-9. [Medline].

  3. Bashour M, Harvey J. Causes of involutional ectropion and entropion--age-related tarsal changes are the key. Ophthal Plast Reconstr Surg. 2000 Mar. 16(2):131-41. [Medline].

  4. Michels KS, Czyz CN, Cahill KV, Foster JA, Burns JA, Everman KR. Age-matched, case-controlled comparison of clinical indicators for development of entropion and ectropion. J Ophthalmol. 2014. 2014:231487. [Medline]. [Full Text].

  5. Xue CY, Dai HY, Li L, Wang YC, Yang C, Li JH, et al. Reconstruction of Lower Eyelid Retraction or Ectropion Using a Paranasal Flap. Aesthetic Plast Surg. 2012 Jan 25. [Medline].

  6. Garza RM, Lee GK, Press BH. Tarsal ectropion repair and lower blepharoplasty: A case report and review of literature. J Plast Reconstr Aesthet Surg. 2012 Feb. 65(2):249-51. [Medline].

  7. Romero R, Sanchez-Orgaz M, Granados M, Arbizu A, Castano A, Romero A, et al. Use of hyaluronic acid gel in the management of cicatricial ectropion: results and complications. Orbit. 2013 Dec. 32(6):362-5. [Medline].

  8. Berry-Brincat A, Burns J, Sampath R. Inverting sutures for tarsal ectropion (the leicester modified suture technique). Ophthal Plast Reconstr Surg. 2013 Sep. 29(5):400-2. [Medline].

  9. Sigurdsson H, Baldursson BT. [Case of the month. Ichthyosis with ectropion]. Laeknabladid. 2009 May. 95(5):357-8. [Medline].

  10. Choi CJ, Bauza A, Yoon MK, Sobel RK, Freitag SK. Full-Thickness Skin Graft as an Independent or Adjunctive Technique for Repair of Cicatricial Lower Eyelid Ectropion Secondary to Actinic Skin Changes. Ophthal Plast Reconstr Surg. 2015 Nov-Dec. 31 (6):474-7. [Medline].

  11. Xu JH, Tan WQ, Yao JM. Bipedicle orbicularis oculi flap in the reconstruction of the lower eyelid ectropion. Aesthetic Plast Surg. 2007 Mar-Apr. 31(2):161-6. [Medline].

  12. Adenis JP, Grivet D. Ectropion of the lacrimal point: The shoe lace technique. Eur J Ophthalmol. 2005 Mar-Apr. 15(2):267-70. [Medline].

  13. Benger RS, Frueh BR. Involutional ectropion: a review of the management. Ophthalmic Surg. 1987 Feb. 18(2):136-9. [Medline].

  14. Carter SR, Chang J, Aguilar GL, et al. Involutional entropion and ectropion of the Asian lower eyelid. Ophthal Plast Reconstr Surg. 2000 Jan. 16(1):45-9. [Medline].

  15. Cherubini TD. Entropion and ectropion of the eyelids. Clin Plast Surg. 1978 Oct. 5(4):583-91. [Medline].

  16. Detorakis ET, Ioannakis K, Kozobolis VP. Corneal topography in involutional ectropion of the lower eyelid: preoperative and postoperative evaluation. Cornea. 2005 May. 24(4):431-4. [Medline].

  17. Frueh BR, Schoengarth LD. Evaluation and treatment of the patient with ectropion. Ophthalmology. 1982 Sep. 89(9):1049-54. [Medline].

  18. Hsuan J, Selva D. The use of a polyglactin suture in the lateral tarsal strip procedure. Am J Ophthalmol. 2004 Oct. 138(4):588-91. [Medline].

  19. Kersten RC, Kulwin DR. Paralytic ectropion of the lower eyelid [letter; comment]. Plast Reconstr Surg. 1995 Sep. 96(4):991-2. [Medline].

  20. Pidde WJ. Cicatricial ectropion. Can J Ophthalmol. 1976 Oct. 11(4):350. [Medline].

  21. Piskiniene R. Eyelid malposition: lower lid entropion and ectropion. Medicina (Kaunas). 2006. 42(11):881-4. [Medline].

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Sagittal section through orbit.
Horizontal section through orbit.
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.
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.
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.
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.
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.
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.
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.
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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