INTRODUCTION

An ectropion is an eversion of eyelid margin in which the eyelid is pulled away from the globe. Most commonly occurs in the lower eyelid. It may be unilateral or bilateral. Ectropion can be congenital or acquired. Acquired ectropion constitutes of four categories: involutional, paralytic, cicatricial, and mechanical. Cicatricial lower lid ectropion is characterized by vertical shortening and/or scarring of the anterior lamella of eyelid and can be the result of thermal or chemical burns, mechanical, or surgical trauma/scars, medications, sun damage, chronic inflammation, and involutional changes.[1]

In maxilofacial surgery, it is most commonly found in patients operated through lower lid approaches, especially the subciliary approach to access midface trauma or orbital pathology.[234]

Ectropion repair presents a challenge to surgeons. Therefore, an individualized surgical approach based on thorough preoperative evaluation considering the etiology and the predominant location of the ectropion is necessary. We would like to describe two cases of lower lid cicatrical ectropion with two different causes, which were managed in two different ways.

CASE REPORT 1

A 29-year-old patient reported to our department with a draining sinus and exposed miniplate in the right infraorbital region [Figure 1]. The patient was operated for right zygomtico-maxillary complex fracture 4 years ago and plating was done via lower eyelid approach. On examination, there was cicatricial ectropion with the scleral show and epiphora with no evidence of chemosis or keratoconjuctivitis.

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Figure 1

Preoperative photograph of patient with cicatricial ectropion of lower eyelid following infection

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SURGICAL TECHNIQUE

After the local infection was controlled with antibiotics, the patient was taken up for correction of cicatricial ectropion under general anesthesia. The scar tethering the lower eyelid just above the sinus region was released. Another incision was taken over the exposed plate to remove it [Figure 2]. Skin grafting was planned to cover the raw area left after the first incision. Template was marked at the right preauricular donor site measuring about 2 cm × 1 cm and full-thickness skin graft was harvested [Figure 3]. Graft was defatted and sutured to the defect using 4.0 ethilon [Figure 4]. Compressive bolster over graft was placed for 5 days postoperatively. Frost suture was placed securing the lower eyelid to forehead for 5 days. Bolster dressing was removed after 7 days and skin graft take was good. The patient was followed up for 1 year and was satisfactory with the outcome [Figure 5].

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Figure 2

Defect left after release of ectropion and removal of manipulate

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Figure 3

Foil used to measure the size of skin graft from preauricular region

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Figure 4

Skin graft sutured to the recipient site

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Figure 5

Postoperative photograph at 1-year follow-up

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CASE REPORT 2

A 18-year-old patient came to our department with a history of facial abrations sustained 1 month ago following road traffic accident . On examination, multiple scarring over left side of face was noticed along with lower lid eversion due to scarring from healed abrasions [Figure 6].

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Figure 6

Preoperative photograph of patient with left lower eyelid cicatricial ectropion following facial abrasion

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Surgical technique

Similar to the first case, the scar was released [Figure 7] Defect left after scar release was deep. Covering this defect with skin graft would have left her with unesthetic appearance. Hence, plan was changed and transposition flap from adjacent cheek was raised and rotated into the defect [Figures 8 and 9]. At 1-year follow-up, the patient was happy with the outcome [Figure 10].

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Figure 7

Defect after release of ectropion

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Figure 8

Marking of a transposition flap

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Figure 9

Transposition flap rotated into the defect

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Figure 10

Postoperative photograph at 1-year follow-up

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DISCUSSION

The surgical management of cicatricial ectropion depends on the situation after the release of the scar traction in the lower lid area.[5] Various techniques have been described for correcting cicatricial ectropion by lengthening the anterior lamella with transposition flaps or with full-thickness free skin grafts[56789] [Table 1].

The defects resulting from the release of ectropion include the skin and orbicularis oculi, which comprise the anterior lamella of the eyelid. Skin grafting in conjunction with tightening of the lower lid, especially in elderly patients, has been the standard method of reconstruction in these cases.[10]

The ideal donor site for skin graft for eyelid reconstruction is the periocular region, which is characterized by the same color and thickness.[6] Skin graft can also be obtained from the postauricular and preauricular region. Choi et al.[7] performed a retrospective, noncomparative chart review of patients who underwent lower eyelid ectropion repair with placement of a full-thickness skin graft between June 2004 and March 2014. They noticed 100% viability of the skin grafts.

A traditional skin graft is a simple and convenient method, but the texture, thickness, and color of skin grafts in the repaired region are not in harmony with the surrounding skin, especially in East Asians. In the long term, the different degrees of contracture of grafted skin affect the lower eyelid function and appearance. Also adaptation of the graft to the recipient bed needs utmost care postoperatively.[10]

To overcome the disadvantages of skin grafts, a great variety of cutaneous and mycocutaneous flaps from face and scalp close to the eyelids have been used to repair lower eyelid wounds after correction of ectropion to improve the function of the lower eyelid. The main advantages of these flaps are one-stage reconstruction, good color and texture match, and reliable vascularity leading to success of the flap.[11] Each flap has its advantages and disadvantages, and the surgeon has to decide and justify his flap selection.

In our cases, both the defects were near the infraorbital region. Unipedicle or bipedicle flap from upper eyelid is a good option for lower eyelid reconstruction due to good skin color match and texture. The disadvantages are limited width of skin flap and two-stage reconstruction. In the first case, skin grafting was done after ectropion release as defect was more than 1.5 cm and to avoid two stage. But in the second case as the scar was below the infraorbital rim; the defect was found to be deep and skin graft would have given a crater effect after healing; hence, a local transposition flap was decided and executed and results were satisfactory. A lateral canthal tightening procedure for lateral eyelid laxity is sometimes required in managing cicatricial ectropion. In our cases, the second patient would have benefitted from the lateral canthal tightening procedure.

CONCLUSION

Cicatricial ectropion management is challenging and each case needs to be treated individually.