Introduction

Cicatricial ectropion is characterized by a deficiency in the anterior lamellae of the eyelid. This condition may occur on the upper and/or lower eyelids. With a shortage of the skin, the eyelid everts, resulting in ectropion. Functionally, this can result in tearing from poor lacrimal outflow, corneal exposure, and keratinization of the palpebral conjunctiva.

A careful history to elucidate the cause of the cicatricial ectropion is necessary to prevent recurrence after treatment. Chemical burns or thermal injury are particularly challenging to treat and often require repeated skin grafting. Chronic dermatologic conditions should be maximized medically before considering surgical treatment. Periocular reconstruction after skin cancer removal may also result in cicatricial ectropion if excessive tension is present in the vertical meridians. Blepharoplasty with excessive skin removal can result in cicatricial ectropion as well as eyelid retraction particularly when eyelid laxity is not concurrently treated.

Lysis of the anterior lamellar cicatrix followed by placement of a full thickness skin graft is the mainstay of treatment for cicatricial ectropion. Lower eyelid tightening with a subperiosteal midface lift and posterior lamellar spacer graft is useful for eyelid retraction alone, but with severe cicatricial ectropion, a skin graft is often necessary. For patients who are not candidates for skin grafting, a Z-plasty with the central limb oriented vertically can be used to treat lower eyelid cicatricial ectropion.

The decision between a full thickness or split thickness skin graft as well as donor site choices are discussed in Chapter 1 . The primary benefits of a full thickness skin graft are minimal contraction, improved color and texture, and no need for a dermatome. Multiple donor sites are available such as upper eyelid, preauricular, retroauricular, and supraclavicular ( Figure 1.22 , Figure 1.23 , Figure 1.24 , Figure 1.25 , Figure 1.26 , Figure 1.27 , Chapter 1 ). When possible the upper eyelid should be used for the most ideal match.

Postoperative management of a full thickness skin graft is equally as important as the surgery itself. Full thickness skin grafts exchange nutrients and metabolic wastes through diffusion by a process known as plasma imbibition. Within the first 24 to 48 hours, vascular inosculation between the graft and recipient bed occurs. Between 48 and 72 hours, capillary buds start to grow into the graft and, by 5 days, a blood supply has been established. Several conditions can adversely affect this process. Shearing of the graft can cause bleeding and disrupt neovascularization. A hematoma between the graft and bed affects diffusion and firm immobilization of the graft with a pressure patch is essential to maximize graft survival. Antibiotic prophylaxis can minimize infection at the interface and strict avoidance of smoking to prevent ischemia is essential.

Surgical Technique

Lateral canthotomy and inferior cantholysis

Lower eyelid laxity is often a component in cicatricial ectropion in addition to the anterior lamellar deficiency. Eyelid distraction greater than 6 mm indicates significant laxity and should be treated. A 1-mm lateral canthotomy and inferior cantholysis is performed to release the canthal attachment of the lower eyelid ( Figures 27.1A and 27.1B ). There are several options for lower eyelid tightening. For mild to moderate eyelid laxity with 8 mm or less of eyelid distraction, a horizontal full thickness wedge of the eyelid can be excised and secured to the superior crus of the lateral canthal tendon, as described in Chapter 9 , Figure 9.8. For moderate to severe eyelid laxity with greater than 8 mm of eyelid distraction, a lateral tarsal strip or even drill hole fixation of the canthus can be performed ( Chapter 28 ). In this case, a tarsal strip procedure is chosen with the patient’s moderate eyelid laxity.

Formation of tarsal strip

After lateral canthotomy and inferior cantholysis, the eyelid is divided at the gray line into the anterior and posterior lamellae ( Figure 27.2A ). Care is taken to not incise the tarsus during the separation of the two lamellae. The eyelid is split according to the desired amount of shortening. The inferior border of the tarsal strip is then cut to release the lower eyelid retractors and conjunctival attachments ( Figure 27.2B ). The mucosa at the eyelid margin is then carefully excised with Westcott scissors ( Figure 27.2C ). Removal of this mucosa is essential to prevent formation of epithelial inclusion cysts after fixation of the tarsus deep within the orbit. A #15 blade can be used to debride the epithelium on the posterior surface and eyelid margin ( Figure 27.2D ). Finally, the tarsal strip is pulled to the lateral orbital rim to determine the amount of shortening needed. A slight overcorrection is desired.

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