Maximal Repair of Involutional Lower Lid Ectropion
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This is Richard Allen at the University of Iowa. This video demonstrates repair of significant lower eyelid involutional ectropion with a combination of horizontal tightening, inverting sutures, cheek support, and a medial tarsorrhaphy. A 4-0 silk suture is placed through the lower lid at the level of the meibomian gland orifices. A lateral canthotomy and inferior cantholysis are then performed. A transconjunctival incision is then made inferior to the inferior border of the tarsus extending from the punctum medially to the lateral canthotomy incision laterally. Dissection is then carried out between the orbicularis muscle and orbital septum to the inferior orbital rim. A freer periosteal elevator is then used to dissect in a preperiosteal plane inferior to the inferior orbital rim. A 4-0 vicryl suture is then used to engage the soft tissue of the cheek followed by the periosteum of the inferior orbital rim to support the cheek. This is essentially a SOOF lift. An additional suture is placed in the same manner centrally and then laterally. This results in adequate support of the cheek. Inverting sutures are the placed through the skin and orbicularis muscle, followed by the inferior border of the tarsus. The 5-0 vicryl suture is then placed through the orbicularis and skin to exit out next to the entry site. This is approximately one cm inferior to the inferior border of the tarsus. Three sutures are placed along the width of the lower eyelid. These sutures are left untied. The transconjunctival is then closed with interrupted 7-0 vicryl sutures. Usually about 4 sutures are needed.
Attention is then directed to the lateral tarsal strip. Dissection is carried out between the anterior and posterior lamella for approximately one cm. The mucocutaneous junction of the posterior lamella is excised followed by scraping the posterior surface of the posterior lamella. The strip is then shortened the appropriate amount and a double armed 4-0 mersilene suture is used to engage the strip. This suture then engages the periosteum of the lateral orbital rim at the level of Whitnalls tubercle. Prior to tying the strip, the lateral portion of the mucocutaneous junction of the upper eyelid is excised. This is then engaged with a 5-0 Vicryl suture followed by passing the suture through the superior edge of the strip. The results in incorporation of the lateral upper lid into the lateral tarsal strip. Tying the mersilene suture results in tightening the lower and upper eyelids. The excess portion of the anterior lamella is excised. The canthotomy incision is then closed with interrupted 7-0 vicryl sutures.
A medial tarsorrhaphy is then performed by making a V shaped excision extending from the lower lid to the upper lid. Dissection is then performed between the anterior and posterior lamella. The posterior lamella is then sutured together with interrupted 5-0 Vicryl suture. Two sutures are usually needed. The anterior lamella is then closed with interrupted 7-0 vicryl sutures.
The inverting sutures are then tied. These can be tied over bolsters if desired. In this case bolsters are not used. The suture is tied at a tension in order to make the lower eyelid lashes vertical. At the conclusion of the case the eyelid appears to be in good position. Antibiotic ointment is placed over the repair and the patient returns in one week for suture removal.