Lower Lid Ectropion Blepharoplasty 

Updated: Dec 22, 2015
Author: Mounir Bashour, MD, PhD, CM, FRCSC, FACS; Chief Editor: James Neal Long, MD, FACS 

Overview

Background

Lower lid ectropion is a common condition in older persons, increasing steadily in incidence with advancing age.

Ectropion is an eversion of the eyelid away from the globe.[1] It is classified according to its anatomic features as involutional,[2, 3, 4] cicatricial, tarsal, congenital, or neurogenic/paralytic.

Surgical approaches are directed toward the underlying etiologic factors.

Problem

Ectropion is an outward turning of the eyelid margin and occurs most often in the lower eyelid. It may be mild or severe and may involve all or part of the eyelid margin. See the image below.

Ectropion with keratinization of the lower lid. Ectropion with keratinization of the lower lid.

Etiology

Ectropion is most commonly seen as an involutional change associated with horizontal laxity of the involved eyelid. Ectropion may be subdivided into 5 types: congenital, involutional, cicatricial, paralytic, and mechanical.

Pathophysiology

Causal factors leading to ectropion include horizontal laxity of the eyelid (universal), dehiscence of the lower eyelid retractors, vertical shortening of the anterior lamella of the eyelid, paralysis of the orbicularis oculi muscle causing loss of eyelid muscular tone, and neoplasia within the lower eyelid pulling or forcing the eyelid away from the globe.[5]

Presentation

Presentation is usually either from 1) epiphora (see below), 2) ocular irritation, or 3) cosmesis.

There is generally a progression from eyelid laxity to punctal ectropion, medial ectropion, then generalized ectropion. If the punctum is slightly everted from the lacus lacrimalis, tears cannot effectively drain into the canalicular system. Horizontal eyelid laxity also may produce a flaccid canalicular syndrome or poor lacrimal pump, so that tears are not siphoned from the lacus lacrimalis.

This tearing malfunction is aggravated by the chronic ectropion and eyelid retraction that produce lagophthalmos and secondary exposure keratopathy. With time, the exposed conjunctiva thickens and keratinizes, producing further ocular irritation.

Relevant Anatomy

Thorough knowledge of eyelid anatomy is essential to appreciate the etiology and surgical intervention of lower eyelid abnormalities. The eyelid can be conceptualized to consist of an anterior and posterior lamella.

Anterior lamella

The anterior lamella consists of the skin and orbicularis muscle. The thin delicate skin of the eyelid lacks dermal-like connective tissue and pilosebaceous apparatus that would reduce eyelid mobility. The orbicularis muscle is categorized as either orbital or palpebral portions based on adjacent anatomic structures. Orbital orbicularis muscle overlies the orbital rim. Palpebral orbicularis muscle is further classified as preseptal or pretarsal based on the proximity of orbital septum or tarsus, respectively. At the eyelid margin a strip of orbicularis muscle, the muscle of Riolan, is directly associated with the eyelashes.

Posterior lamella

The posterior lamella consists of the eyelid retractor, tarsus, and conjunctiva. The lower eyelid is analogous to the upper eyelid with the main variation being the eyelid retractor system. The upper eyelid has a distinct eyelid retractor, the levator muscle, to enhance upper eyelid mobility. The lower eyelid does not have a specialized eyelid retractor. The lower eyelid retractor system originates as a fascia extension of the inferior rectus muscle (capsulopalpebral head). This fascial system splits to encapsulate the inferior oblique muscle and then reunites to form a dense fibrous sheet (capsulopalpebral fascia) to insert onto the inferior tarsal border. The inferior tarsal muscle is a smooth muscle analogous to the superior tarsal muscle (Muller muscle) of the upper eyelid. This muscle originates in the inferior fornical area and extends toward the inferior tarsal border but does not insert on the tarsal border as its counterpart in the upper eyelid does.

The inferior tarsal muscle provides sympathetic innervation to the lower eyelid, and interruption of its innervation results in a slightly elevated position of the lower eyelid margin as observed in Horner syndrome. Otherwise, the inferior tarsal muscle has little pathologic significance. The tarsus provides the primary support or foundation for the eyelids. Although degeneration of the tarsus may promote eyelid laxity, the principle focus of weakness of the eyelids is at the lateral and medial canthal tendons.

The medial canthal tendon has a prominent anterior component firmly connecting the medial canthal angle to the maxillary process of the frontal bone. The posterior limb of the medial canthal tendon provides deep support to the posterior lacrimal crest. The superior branch of the medial canthal tendon also supports the canthal angle. The lateral canthal tendon has contributions from the lateral aspects of the tarsus and the preseptal and pretarsal orbicularis muscle; these insert on the inner aspect of the lateral orbital rim at the Whitnall (lateral orbital) tubercle. Posterior deep insertion of the lateral canthal tendon allows the lateral aspect of the eyelids to approximate the globe.

 

Workup

Other Tests

See the list below:

  • Snap-back test

    • Pull lower lid away and down from globe for several seconds and wait to see how long before it returns to original position without the patient blinking (if it does at all). See the image below.

      The snap-back test. The snap-back test.
    • This test result gives a good idea of relative lower lid laxity. In normal lids, it should spring back into original position immediately; the longer it takes, the more laxity is present. See the image below.

      Lower lid laxity obvious after snap-back test. Lower lid laxity obvious after snap-back test.
    • Grade 0-IV (0 = normal, IV = severe laxity): This scale is subjective and comes with clinical experience.

      • Grade 0 - normal lid that returns to position immediately on release

      • Grade IV - never returns to position and continues to hang down in frank ectropion after the snap-back test

      • Grade I - approximately 2-3 sec

      • Grade II - 4-5 sec

      • Grade III - >5 sec but does return to position with blinking

  • Medial canthal laxity test

    • Pull lower lid laterally away from medial canthus and measure displacement of medial punctum; the greater the distance, the more the laxity.

    • Normally, displacement should be only 0-1 mm.

    • Grade 0-IV (0 = normal, IV = severe laxity): This test uses the same scale as the snap-back test; it is also subjective and based on clinical experience.

      • Grade I - approximately 2 mm displacement

      • Grade II - approximately 3 mm

      • Grade III - >3 mm

      • Grade IV - does not return to baseline

  • Lateral canthal laxity test

    • Pull lower lid medially away from lateral canthus and measure displacement of lateral canthal corner; the greater the distance, the more the laxity.

    • Normally, displacement should be only 0-2 mm (grade 0).

    • Grade 0-IV (0 = normal, IV = severe laxity): This test uses the same scale as tests above.

      • Grade I - 2-4 mm

      • Grade II - 4-6 mm

      • Grade III - >6 mm

      • Grade IV - III and does not return to baseline even after blinking

  • Schirmer test: Having an idea of how dry the eyes are is helpful, as ectropion is only one of several conditions in the differential of epiphora.

  • Fluorescein test of cornea: Perform this test as a baseline for the same reasons one does the Schirmer test.

  • Irrigation of lacrimal system: If the system is blocked, a dacryocystorhinostomy alone or in combination with an ectropion procedure would be better than treating the ectropion alone.

  • Slit lamp examination: Specifically check corneal status and evidence of dryness. Also check for evidence of lagophthalmos.

  • Presence or absence of Bell phenomenon: Patient is told to attempt closure of eyes while examiner is holding lids open; if eye moves up, positive Bell is present.

  • Check status of seventh nerve.

    • With lower motor neuron seventh nerve palsy (eg, Bell palsy), the ipsilateral brow and lower facial musculature are weak. With an upper motor neuron seventh nerve palsy, brow elevation is relatively spared from bilateral innervation of the upper face.

    • In patients with suspected facial nerve palsy, test for orbicularis oris dysfunction by asking the patient to show his or her teeth rather than smile. Compare the elevation of the angles of the lips; there is often ptosis of the lateral lip on the affected side.

 

Treatment

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 also are helpful.

In addition, the lower lid can be taped back into position using either specially designed or normal skin tape.

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 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.

In patients with seventh nerve palsy, external paste-on upper lid weights are available and 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.

Use of steroids for patients with Bell palsy remains controversial, since a high likelihood of spontaneous recovery exists. Steroid use early in the disease's course may decrease the risk of subsequent aberrant regeneration (eg, crocodile tears). Acyclovir in combination with prednisone has greater benefit than prednisone alone in Bell palsy.

Surgical Therapy

Correct surgical treatment of ectropion depends on the etiology. Horizontal lid laxity often is seen with ectropion and usually can be best corrected with a lateral tarsal strip procedure. Mild-to-moderate cases of medial ectropion may respond to a medial conjunctival spindle procedure. Tarsal ectropion occasionally requires reinsertion of the lower lid retractors. Augmentation of the anterior lamellae (along with excision of any cicatrix) is required for cicatricial ectropion.

The authors recommend using a corneal protector during oculoplastic procedures. Always be wary of the remote possibility of flash burns whenever oxygen is on the surgical field. Failure to place a corneal protector may transform an elective lid repair into a much more complicated problem.

Assuring 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 in patients who are particularly sensitive.

Lateral tarsorrhaphy

This can be performed as a temporary "quick fix" for corneal exposure, but the author believes better surgical alternatives are available. A 4-mm lateral tarsorrhaphy yields an approximately 75% reduction in lagophthalmos. After topical anesthesia and local injection of lidocaine with epinephrine into the lateral canthus and lateral portions of upper and lower lids, split each lid laterally along the gray line with a No. 15 blade for 4 mm. First, remove a thin strip of margin conjunctiva from the posterior lamella strip of both lids using Westcott scissors, and then suture the posterior lamella together using 5-0 interrupted Vicryl sutures. The anterior lamella is brought back together with a single Vicryl suture, which is removed in 3 days.

Electrocautery

Electrocautery at the junction of conjunctiva and lower margin of the tarsus is not commonly advocated. It is used only as a temporary measure in patients who are expected to die soon and are not candidates for surgery.

Suture repair

The authors also do not advocate this temporary method of repair except as an augmenting procedure to a lateral tarsal strip to increase its power. With a heavy needle driver, pass 4-0 double-armed chromic sutures through the inferior border of the tarsus. Emerge at the skin surface near the orbital rim and tie the two arms tied together. Usually 2-3 sutures are sufficient. The Leicester modified suture technique may be a little more long lasting.[6]

Congenital ectropion

Assure 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 but be careful of iatrogenic amblyopia. More severe cases of congenital ectropion may need a skin flap or graft.

Ichthyosis is a well-described cause of congenital ectropion. It is occasionally managed conservatively with lubrication but skin grafts may be required.

Horizontal lid laxity

Horizontal lid laxity is a component of most ectropion cases, especially involutional ectropion.

There are numerous methods for correcting horizontal lid laxity. Older methods no longer used include wedge resections and the Kuhnt-Szymanowski procedure.[7] Whenever feasible, the authors prefer 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.

Lateral tarsal strip[8, 9]

The most common variation of lateral canthal-tightening is the lateral tarsal strip procedure. The lateral canthus can be clamped prior to canthotomy, and inferior cantholysis is then performed with Westcott scissors. The lower lid should be freely mobile at this point.

  • If excess lid skin is present, it can be draped over the lateral canthus, and an appropriate triangle of full-thickness lid can be excised.

  • Approximately 3 mm of the lateral lid is then split at the gray line with either sharp Westcott scissors or a No. 15 blade.

  • The conjunctival margin of the lateral strip is then trimmed away. See the image below.

    Preparing the lateral tarsal strip. Preparing the lateral tarsal strip.
  • The lateral conjunctiva is scraped 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 approximately 4-5 mm posterior to the lateral orbital rim near the Whitnall tubercle (at or above the level of the inferior pupil). Suitable sutures with small semicircular needles include 5-0 Vicryl on a P-2 needle or 4-0 Prolene on a PS-5 needle. See the image below.

    The 4-0 Vicryl suture is paced through the tarsal The 4-0 Vicryl suture is paced through the tarsal strip in a horizontal mattress fashion.
  • Retracting the upper lid superotemporally and placing a cotton-tipped swab at the lateral canthus to palpate the inner lateral orbital rim may help.

  • Before tying the suture, remove the corneal shield.

  • The orbicularis layer can be closed with 6-0 Vicryl. Skin can be closed with 6-0 plain gut. A stitch through the lateralmost gray line of the upper and lower lateral lid helps to keep the lateral canthus "sharp."

    The suture is tied to the periosteum of the latera The suture is tied to the periosteum of the lateral orbital rim and tightened.
  • If the patient requires topical drops (eg, glaucoma therapy) postoperatively, do not retract the lower lid for the first month during drop instillation.

  • It is not uncommon for patients to complain of prolonged discomfort at the lateral canthus following this procedure.

Tarsal belt

Pascali et al described the successful use of a tarsal belt procedure for ectropion repair, in which a transtarsal, nonabsorbable mattress suture was anchored to the lateral orbital rim periosteum and a small wedge excision was made in the lateral tarsus, near the lateral canthal tendon. A 100% success rate was reported for involutional and cicatricial ectropion, while the success rates for lid retraction and paralytic ectropion were 90% and 87.5%, respectively.[10]

Tarsal ectropion

See the list below:

  • This complete eversion of the lower lid occurs when there is disinsertion of the capsulopalpebral fascia from the inferior tarsal border.[11]

  • In addition to horizontal lid tightening through a lateral tarsal strip, the inferior retractors should be reinserted. 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

See the list below:

  • 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 in the medial inferior fornix, the inferior canaliculus can be guarded with a lacrimal probe.

  • A horizontal ellipse or diamond of conjunctiva and underlying lid retractors is excised inferior to the punctum, approximately 3-4 mm high and 6-8 mm wide.

  • The defect is then closed with double-armed 5-0 chromic inverting suture.

  • This can be accomplished by engaging first the inferior, then the superior lip of the wound; the needle is then redirected from the inferior lid to the cutaneous surface.

  • Alternatively, buried interrupted 6-0 polyglactin stitches can be used to close the medial conjunctival spindle.

  • The Byron Smith Lazy-T procedure is a well-described method for repairing prominent medial ectropion. It combines a lower lid, full-thickness pentagonal wedge resection, 3-to 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. A lacrimal probe is placed to guard the lower canaliculus. A skin incision, extending from just medial to the medial canthus to just temporal to the punctum, is made inferior to the canaliculus. A double-armed 5-0 nylon suture is then placed from the medial inferior tarsus to the medial canthal ligament near the anterior lacrimal crest. The lacrimal probe is removed and the plication suture tightened enough to prevent lateral excursion of the puncta. Overtightening the stitch may kink canalicular outflow. The skin incision can be closed with 6-0 fast-absorbing gut suture.

Paralytic ectropion

See the list below:

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

  • In patients with extreme paralytic ectropion, a fascia lata (or Gore-Tex) sling or temporalis transfer procedure may be required.

  • Chang and Olver have described an augmented lateral tarsal strip (LTS) tarsorrhaphy.[12] This comprises a long (10-15 mm) strip, attached to the outer temporal orbital rim at a point higher than that of a standard LTS. In order to pass the long strip high enough, a small portion of the upper eyelid anterior lamella laterally was removed.

  • Upper lid gold weight implantation is a helpful adjunct for patients with lagophthalmos.

  • Usually, a 1-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.

  • Since the gold weight works by gravity, patients should sleep with their head slightly elevated.

  • Gold weights are not a contraindication for MRI investigation.

Cicatricial ectropion

See the list below:

  • 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 there is dermatochalasis; pre- or postauricular skin is another alternative. The skin graft should be thinned and buttonholed (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.

  • Xu et al[13] have described a surgical technique for lower eyelid cicatricial ectropion repair using a bipedicle orbicularis oculi muscle or myocutaneous flap from the upper eyelid. 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.

Postoperative Details

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

Applying cold compresses to the eyelids every 15 min (as tolerated) while 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. The patient is asked to use acetaminophen 325-650 mg PO q4h prn. Patients are asked to avoid aspirin-containing products if possible.

Follow-up

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

Complications

Complications are primarily related to corneal and conjunctival exposure. As listed above, these 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.

Outcome and Prognosis

Outcome and prognosis usually are excellent.