Lateral canthal fixation using an oblique vertically orientated asymmetric periosteal transposition flap

Involutional ectropion: etiological factors and therapeutic management

PURPOSE

Involutional Ectropion is commonly prevalent disorder of eyelid malposition caused by age-related degeneration of the periocular tissues. This study conducted to provide a summary and review of surgical practice for the management of lower eyelid involutional ectropion and enlist various causative factors that explain the pathogenesis.

METHODS

The review of literature on risk factors and surgical approaches for involutional lower eyelid ectropion, searched on PubMed from 1980 onwards.

RESULT

Multiple factors contribute to horizontal and vertical lower eyelid involutional ectropion. Several surgical practices have been described over the last years to address these factors. Lateral tarsal strip is the most used and effective surgery to treat horizontal laxity.

CONCLUSION

Knowledge of various contributing factors and surgical procedures will enable to design the most effective therapeutic management for lower eyelid involutional ectropion. surgical approaches are individualized depending on preoperative clinical evaluation of possible causative factors and concerning the predominant location of the ectropion will result in a high success rate.

Lateral tarsal strip procedure for involutional ectropion: A retrospective analysis of 85 cases and a comprehensive literature review

Purpose

To evaluate the postoperative effect of the lateral tarsal strip (LTS) procedure in treating lower eyelid involutional ectropion.

Methods

A retrospective study was performed on 85 eyelids in 67 patients with involutional ectropion who underwent LTS procedure. Pre- and postoperative lower eyelid laxity and ocular symptoms as well as perioperative complications were evaluated. Snap back test was performed to evaluate the elasticity of lateral canthal tendon loosening and, a lower lid distraction test was performed to evaluate the degree of severity before surgery. Ocular surface diseases were evaluated by the Ocular Surface Disease Index (OSDI), and symptoms including conjunctivitis, corneal ulcer, dry eye syndrome, and ocular pain were recorded. All patients were evaluated within one week and during the follow-up period of 4.2 ​± ​8.3 months. Furthermore, we reviewed the studies that also investigated the surgical effect of the LTS procedure in the literature from 1979 to 2019.

Results

The success rate was 95%. Only four eyelids required a second surgical intervention. Seventy-three (86%) eyelids had an excellent position after surgery, 9 (11%) only little improvement, and three had no improvement. No significant difference was found in the postoperative effects between different degrees of ectropion (p ​> ​0.05). No statistical correlation was found between surgical improvements and the ectropion severity (P ​> ​0.05). Fifty-two out of 85 eyes had no discomfort after the surgery. Mild complications included epiphora in 13 eyes (three cases caused by lacrimal punctum eversion), ocular pain in 12 eyes, wound hemorrhage in 12 eyes, and edema in 9 eyelids immediately after surgery, in which 91.2% (n ​= ​21) disappeared within one week and did not need any further treatment.

Conclusions

The lateral tarsal strip procedure can provide an aesthetically pleasing result for correcting the mild to moderate lower eyelid ectropion while maintaining decent eyelid function.

Tarsal Strip Versus Tarsal Belt in Ectropion Correction: A Statistical Evaluation

Two surgical procedures for ectropion correction are compared: the widespread "lateral tarsal strip" and the more recently introduced "tarsal belt" techniques. A retrospective interventional patient series of 40 patients with mono or bilateral ectropion are investigated.Distances of lower lid margin from interpupillary line before surgery and after 1, 6, 12, and 24 months in tarsal belt and lateral tarsal strip surgical procedure are compared. The postoperative distance is reduced in both the groups of patients, but as regard the tarsal belt the amount of correction is greater and more stable over time and this difference is statistically significant.The ideal surgical technique for ectropion's correction must be focused simultaneously on the lid and on the canthal region because it is mandatory to tight and elevate the lower lid, rotate the tarsal plate, lift the lateral canthal ligament fixing it in a sure fashion. The tarsal strip technique can result in a more vulnerability to relapse. In fact, all the lower eyelid is maintained through the little strip that is assured with a single stitch to the orbital rim periosteum.The tarsal belt technique allows a more uniform distribution of the tissue excess. The suture, with its multiple intratarsal stitches, produces a real reinforcement of the eyelid. The double passage is an added value because it is the element that assures a precise regulation of the tarsal plate rotation. Thus, the tarsal belt technique guarantees a better result over time.

Upper Eyelid Reconstruction

Reconstruction of the upper eyelid is complicated because the eyelid must retain mobility, flexibility, function, and a suitable mucosal surface over the delicate cornea. Defects of the upper eyelid may be due to congenital defects or traumatic injury or follow oncologic resection. This article focuses on reconstruction due to loss of tissue. Multiple surgeries may be needed to reach the desired results, addressing loss of tissue and then loss of function. Each defect is unique and the laxity and availability of surrounding tissue vary. Knowing the most common techniques for repair assists surgeons in the multifaceted planning that takes place.

Double Lateral Flap: A New Technique for Lower Eyelid Reconstruction Alternative to the Tenzel Procedure

BACKGROUND

The final esthetic result is a common concern of patients with eyelid tumors, especially young patients and those with tumors affecting the medial edge of the lower eyelid.

METHODS

The procedure herein described combines two lateral flaps: one tarsoconjunctival and the other from the periosteum. The first step is removal of the tumor lesion. Preseptal dissection is then performed through a subciliary incision on both the lateral and medial halves of the eyelid up to the orbital rim. Next, the lateral canthal tendon, lateral attachment of the orbital septum, capsulopalpebral fascia, and conjunctiva are cut. This allows the medial displacement of the tarsoconjunctival flap, which is sutured to the defect area. The second flap, a periosteal strip, is used to reconstruct the tarsus and lateral canthal tendon, providing firm support for the posterior lamella. The orbicularis muscle is anchored to the orbital rim, and the skin of the lower eyelid is directly sutured to the subciliary incision and periosteal strip.

RESULTS

The author successfully carried out this procedure on nine patients. None of the patients developed ocular irritation or postoperative epiphora.

CONCLUSIONS

The defects that can be repaired by this technique are equivalent in size to those repaired by the Tenzel procedure. Unlike the semicircular flap procedure, this technique allows eyelid reconstruction with no vertical scarring and a smaller lateral incision, and it ensures soft contact between the palpebral rim and surface of the eyeball. This procedure confers an attractive eyelid appearance that may be crucial for some patients.

LEVEL OF EVIDENCE V

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Triple-Flaps for lateral canthus reconstruction: A novel technique

A 45 year old female presented with a pigmented lesion in the right periocular region. The mass was present on the lateral 1/3 of the lower eyelid and involving the lateral 1/8 of the upper eyelid. Full thickness excision with wide tumor-free margins was done and the residual defect was repaired. Histopathological examination confirmed the diagnosis of nodulo-ulcerative basal cell carcinoma. In this report, we describe a novel technique for reconstruction of large lateral canthus defect by using three local flaps. With triple-flaps technique extensive defects involving the lateral canthus can be repaired without difficulty with a good functional and aesthetic outcome.