Surgical Correction of Ectropion Following Blepharoplasty
The most effective surgical treatment for ectropion following blepharoplasty is a lateral tarsal strip procedure combined with appropriate management of the anterior lamella, which may require skin grafting in cases of cicatricial ectropion with vertical skin shortage. 1, 2, 3
Understanding Post-Blepharoplasty Ectropion
Ectropion following blepharoplasty is characterized by eversion of the lower eyelid margin, exposing the tarsal conjunctiva. This complication typically occurs due to:
- Excessive skin removal during lower lid blepharoplasty
- Scarring and contracture of the anterior lamella
- Horizontal lid laxity not addressed during the original procedure
- Damage to the lower lid retractors
- Scarring and hemorrhage in adjacent tissue
Evaluation of Ectropion
Before surgical correction, a thorough assessment should include:
- Determination of ectropion severity (mild retraction vs. frank ectropion with marked eversion)
- Evaluation of horizontal lid laxity (snap test, distraction test)
- Assessment of vertical anterior lamella shortage
- Examination for scarring of the orbital septum
- Forced duction testing to assess for restrictive components 4
Surgical Correction Options
1. Horizontal Lid Laxity Management
Lateral Tarsal Strip Procedure:
- First-line surgical treatment for most cases of post-blepharoplasty ectropion
- Involves shortening and tightening the lateral canthal tendon
- Secures the tarsus to the lateral orbital tubercle
- Addresses the common horizontal laxity component 2
Bick Procedure:
- Alternative to lateral tarsal strip
- Horizontal lid shortening with full-thickness wedge resection 2
2. Anterior Lamella Management
For cicatricial ectropion with vertical shortage of skin:
Skin Grafting:
- Required when there is significant vertical skin shortage
- Typically uses full-thickness skin from upper eyelid, retroauricular area, or supraclavicular region
- Must be combined with release of scar tissue 3
Superotemporal Skin Transposition (STS):
- Novel technique for severe or recurrent ectropion
- Combined with lateral tarsal strip or Bick procedure
- Involves transposing anterior lamella of lateral lower lid after excising triangular bed of skin superotemporally
- Particularly effective for tarsal ectropion 2
Cheek-Midface Lift:
- Alternative to free skin grafting
- Provides both functional and aesthetic improvement
- Can be performed under local anesthesia 5
3. Adjunctive Techniques
Inverting Sutures:
- Help maintain proper lid position during healing
- Often used in combination with other procedures 2
Non-Ablative Fractional Laser Resurfacing:
- Non-surgical alternative for selected cases of mild cicatricial ectropion
- Works by remodeling periocular scar tissue
- May be considered before surgical intervention in appropriate cases 6
Timing of Surgical Intervention
Conservative management with massage may be effective for up to 6 months postoperatively. If ectropion has not resolved or shown improvement within 6 months, surgical correction is recommended as spontaneous resolution becomes less likely beyond this timeframe. 4, 3
Surgical Approach Algorithm
For mild ectropion with predominant horizontal laxity:
- Lateral tarsal strip procedure alone
For moderate to severe ectropion with both horizontal laxity and mild vertical shortage:
- Lateral tarsal strip + inverting sutures
For severe ectropion with significant vertical shortage (cicatricial component):
- Lateral tarsal strip + skin grafting or
- Lateral tarsal strip + superotemporal skin transposition or
- Cheek-midface lift
Postoperative Care
- Head elevation for 48-72 hours
- Cold compresses intermittently for first 48 hours
- Aggressive corneal lubrication
- Avoidance of physical exertion
- Close monitoring for recurrence 1
Pitfalls to Avoid
- Failure to identify and address all components contributing to ectropion (horizontal laxity, vertical shortage, middle lamellar scarring)
- Inadequate release of scar tissue before grafting
- Insufficient horizontal tightening
- Overlooking pre-existing conditions that predispose to ectropion
- Delaying surgical intervention beyond 6 months when conservative measures fail 4, 3