Overview of Ectropion Lower Eyelid Reconstruction
Ectropion is when the eyelid turns outward, which makes it unable to fully close. Various types of ectropion can occur for different reasons such as birth defects, aging, nerve damage, scar tissue, or even the effect of gravity and tumors.
A common type of ectropion, called involutional ectropion, happens due to looser eyelids, which is part of the aging process. Scar-causing (cicatricial) ectropion is caused by the shortening of the tissue layers in the front and middle of the eye. Paralytic ectropion happens when the facial nerve, which controls the eyelid muscle, is unable to function, leading to loss of muscle tone. Mechanical ectropion can be caused by gravity, the weight of a tumor, fluid buildup, fat herniation, or even ill-fitting glasses.
People with ectropion may have symptoms like dryness, irritation, and excessive tearing due to exposed corneal tissue and issues with eye lubrication. Health conditions involving the eyelid, like skin diseases, eyelid injuries, and previous surgeries, along with factors like aging, rubbing the eyelids, excessive pulling, and contact lens use can increase the risk of ectropion.
Doctors can use medical treatments to manage the underlying causes of ectropion. However, surgery is the only permanent solution to fix ectropion.
Anatomy and Physiology of Ectropion Lower Eyelid Reconstruction
The eyelid is made up of seven different layers of tissue, creating a structure that is unique to the face. From the outermost layer towards the inside, these layers include: skin, underneath the skin (subcutaneous tissue), the muscle that helps us to blink or close the eyes (orbicularis oculi), a wall of fibrous tissue (orbital septum), a layer of fat, the muscle that helps us open the eyes, a stiff plate (tarsus), and the thin membrane that covers the eyelid and white part of the eye (conjunctiva). The skin of the eyelid is much thinner compared to the skin on other parts of the body.
The eyelid is powered by several different nerves, which allow us to perform actions like blinking and provide sensations. The upper eyelid receives signals from four different nerves, namely infratrochlear, supratrochlear, supraorbital, and lacrimal nerves. These are all parts of the trigeminal nerve (also known as the fifth cranial nerve). Similarly, the lower eyelid receives signals from the infratrochlear and infraorbital nerves, which too, are divisions of the trigeminal nerve.
The blood supply to the eyelids comes from different branches of two major arteries: the internal carotid artery through the ophthalmic artery and its offshoots, and the external carotid artery through the angular and temporal branches of the facial artery. These branches join together to form a network of smaller arteries, which provide fresh, oxygen-rich blood to the upper and lower eyelids.
Why do People Need Ectropion Lower Eyelid Reconstruction
Ectropion refers to a condition where your eyelid turns outward. This condition can produce uncomfortable symptoms such as the feeling that something is in your eye, redness, excessive tearing, sensitivity to light or wind, and even eye sores or corneal damage. The underlying cause often lies in the shortening of the front layer of your eyelid, often referred to as anterior lamellar shortening. If this is happening because of a disease that affects your connective tissue (the material that helps hold your body together), it’s critical to manage that condition before considering surgery to fix the eyelid.
Different types of ectropion, whether because of genetic reasons (congenital), muscle weakness (paralytic), physical blockages (mechanical), or just aging (involutional), require different kinds of surgeries. These surgeries aim to not only place the eyelid back in its normal position but also to restore its function. This highlights the importance of accurately understanding the exact cause of your ectropion before planning any form of surgery. For instance, if the condition affects the medial tendon (the inner corner of your eyelid) or the punctum (the tiny hole in your eyelid that helps drain your tears), specific procedures are needed to correct these issues besides the surgery that repositions your eyelid.
When a Person Should Avoid Ectropion Lower Eyelid Reconstruction
Before resorting to surgery to fix an ectropion (a condition where the edge of the eyelid turns outwards), doctors try to treat the root cause that led to the condition. This is because if issues like inflammation (swelling) or infection aren’t managed before surgery, the chances of a successful outcome can decrease. This is due to increased risk of complications and the disease potentially getting worse.
Additionally, surgery may not be a suitable option for everyone. For instance, people who can’t withstand a general anesthesia (a medication that makes you unconscious for surgeries) or those who can’t bear a local anesthetic (a medication that numbs a specific area) due to other health problems or psychological reasons might not be candidates for this surgical correction.
Equipment used for Ectropion Lower Eyelid Reconstruction
For the procedure that we are going to perform, the following tools will be used. These are all standard in eye-related surgeries to help the process run smoothly, allow the doctor to work efficiently and maintain the safety of your eye during the procedure. First, a Bard-Parker scalpel will be used; it’s a type of very sharp, precise knife that has a blade labelled ‘No. 15’. This type of scalpel is frequently used in medical procedures because it enables detailed, controlled cutting.
We’ll also use Westcott tenotomy scissors, which are special thin, small scissors ideal for delicate surgeries, and tiny 0.5 mm forceps, which are like tweezers to gently hold or pick up things during the surgery. Another tool is the monopolar or bipolar cautery, which are used to stop bleeding by heating tissue. It’s a safer and less damaging method than manually tying off blood vessels.
During the closing part of the procedure, we will use 4-0 silk suture and 5-0 and 6-0 polyglycolic acid (Vicryl) suture. “Suture” is just a fancy word for stitches – this is what we use to close up the incisions. The numbers before the type of suture like 4-0, 5-0 and 6-0 tell us the size of the suture material. The smaller the number is, the larger the suture threads are. So 4-0 silk suture has a thicker thread than 5-0 and 6-0 polyglycolic acid suture.
We will also use a corneal shield, which is like a protective cover that is placed over your eye to protect it from any invasive substances or accidental touches following your procedure. Lastly, we use antibiotic ophthalmic ointment. “Ophthalmic” refers to anything related to the eye, and “antibiotic” means it can help prevent infections.
All these tools will be arranged on a standard oculoplastic instrument tray within the surgeon’s easy reach, which holds all the equipment needed for eye surgeries. Remember, all these tools are used with your safety and the success of the procedure in mind.
Who is needed to perform Ectropion Lower Eyelid Reconstruction?
This procedure requires a specialized doctor, such as an eye doctor, or a facial or plastic surgeon. It’s also very helpful to have a surgical assistant on hand. A lot of the time, this operation can be done using local anesthesia, which is used to numb a specific part of your body while you stay awake. However, if the operation is a bit more difficult or depending on the patient’s health, it may be better to use a stronger sleep medicine or even put the patient to sleep fully. In situations like these, there will also be a specialist called an anesthetist present, whose job is to safely administer these types of medications.
Preparing for Ectropion Lower Eyelid Reconstruction
Before surgery, a qualified surgeon should thoroughly check and assess the patient to make sure they are in a good state for the operation. It’s important that patients are clearly informed about the pros and cons of their surgery, as well as other treatment options they could choose instead. The doctor should also talk about the potential side-effects or problems that could arise from the surgery. Finally, the surgeon should address any concerns or questions the patient has, making sure they fully understand what is going to happen.
How is Ectropion Lower Eyelid Reconstruction performed
The type of ectropion, which is a downward turning of the eyelid, determines the best surgical approach. The doctor tailors the corrective procedure to each patient based on their specific condition and characteristics diagnosed through an examination. There are four primary methods: cicatricial, involutional, medial and lateral tarsal strip with medial spindle.
Cicatricial Ectropion Repair:
In this technique, after administration of numbing medication, a shield is placed over the eye. Stitches are then placed in the eyelid line. The doctor makes a small incision along the eyelid (subciliary incision), and releases the scar tissue. This step allows the rear part of the eyelid to return to its normal location. Following that, a strengthening procedure (tarsal strip) is done to tighten the eyelid. The area needing a graft (transplanted tissue) is then measured and used to create a template. The template is then used on the donor site (often the skin from behind the ear or upper eyelid is used). Once the graft is sutured to the wound, the skin incision is closed, and evert protective measures like a corneal shield is removed.
Involutional Ectropion Repair:
After administration of numbing medication, this procedure begins with placing a shield over the eye. An incision is made on the outer corner of the eyelids to split the front and back parts of the lower eyelid. Excess skin, muscle, and conjunctiva (thin tissue that lines the inner part of the eyelids) are removed to form a tarsal strip (a strip of tissue from the dense plate in the eyelid called the tarsus). The redundant tissue is then discarded. The tarsal strip is attached to a dense type of tissue called periosteum located at the lateral rim of the eye socket. The skin incision is closed and then the eye shield is removed.
Medial Ectropion Repair:
Numbing medication is given followed by covering the eye with a corneal shield. An ellipse of conjunctiva and lower eyelid muscle tissue is cut out. During the procedure, stitches are passed through different important parts related to the eyelid anatomy. If needed, it is combined with the procedure known as caruncular recruitment, where more tissues are taken from the caruncle, which is a small, red elevation located at the inner corner of the eye. The sutures are fastened to correctly turn the punctum (a tiny hole in the upper or lower eyelid) inwards and then the shield is removed.
Lateral Tarsal Strip with Medial Spindle:
This procedure involves the administration of local anesthesia in the area around the outer corner of the eye. A lateral canthotomy is the act of cutting the outer corner of the eyelid, followed by a lateral inferior cantholysis which involves cutting the lower ligament of the eyelid. Surgeons also cut out a diamond-shaped area of conjunctival tissue. The surgeons then determine the necessary length of the tarsal strip, strip the epithelium (outer layer of cells), and divide the front and back of the eyelid. The lower eyelid retractors and conjunctival tissue are then disconnected from the strip and the front part of the strip is cut out to get rid of the hair roots. The strip is then connected to the periosteum on the inner side of the outer rim of the eye socket. The surgery ends with the closure of the skin.
Possible Complications of Ectropion Lower Eyelid Reconstruction
There are several possible side effects that can happen after a surgery to fix ectropion, a condition where your eyelid turns outwards. These can include:
1. Infection: This happens when bacteria gets into the area operated on.
2. Bleeding: Some amount of bleeding is normal, but sometimes it becomes too much.
3. Pain: Most people feel some discomfort after surgery, but it usually goes away with time.
4. Poor cosmesis: This means that you might not be happy with how your eye looks after the surgery.
5. Corneal abrasion: This is a scratch on the clear, front part of your eye, caused by your eyelid rubbing against it.
6. Suture dehiscence or erosion: These are fancy words for when the stitches break or wear away before the wound is fully healed.
7. Retrobulbar hematoma: It’s a very rare complication that leads to a build-up of blood behind the eye, causing pressure and pain.
8. Lower eyelid retraction: This means the lower eyelid might get pulled down.
9. Canthal dystopia: This describes an uneven look between the two eyes, usually because the tear-duct corners of the eyes do not align.
Please remember, all procedures carry certain risks, but your doctor will be taking all necessary precautions to minimize these risks.
What Else Should I Know About Ectropion Lower Eyelid Reconstruction?
Ectropion repair is a procedure that fixes a condition where the lower eyelid turns outward. The goal is to put the eyelid edge and the tiny hole that drains tears (punctum) back in their correct spots. This helps protect the eye from harm and decreases symptoms like dryness or feeling like something is in your eye. Surgery is the only surefire way to treat this condition.
