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Ectropion
Ectropion
Lower lid ectropion after blepharoplasty is a troublesome postoperative complication. It has traditionally been associated with the subciliary approach, but can also occur with a tranconjunctival incision and in cases of aggressive laser resurfacing. While its
development is primarily related to unaddressed preexisting lid laxity, scarring of the middle lamella, and overzealous skin excision, there are more subtle preoperative clinical findings that may also be contributory. These include reduced orbicularis function, negative vector eyelid topography (as evidenced by the cornea extending beyond the border of the midface on sagittal head position), and volume deficiency of the inferior eyelid and/or orbit.164 A detailed preoperative assessment that includes these oculofacial features may help guide the surgeon toward creating additional lateral canthal support during blepharoplasty surgery. These patients should also be counseled regarding their higher risk of postoperative eyelid malposition.
While it continues to be difficult to reliably predict which patients will develop lower lid ectropion, the management of postblepharoplasty lower lid retraction and ectropion may be an even more challenging task. While treatment of severe cases usually involves posterior lamellar grafting, controversy exists regarding optimal surgical correction of lower lid retraction and long-term outcomes for each procedure. The transeyelid midface lift has been described in the context of lower lid retraction repair after blepharoplasty. It can be performed through a transcutaneous or transconjunctival approach. This technique takes advantage of the superficial musculoaponeurotic system (SMAS) to mobilize and anchor the midface superiorly through release of the orbicularis retaining and the zygomaticocutaneous ligaments. While this procedure alone can be effective in elevating the midface in mild cases of gravitational descent and volume loss, in moderate to severe postblepharoplasty lower lid retraction, it is more effective and long-lasting when combined with posterior lamellar grafting.165 Graft materials may include hard palate, ear cartilage, or nonautologous substitutes, such as xenografts, cadaveric dermis, or dura.166,167 Nonautologous graft materials can be covered with conjunctiva which may reduce the incidence of graft resorption.166 In rare instances, skin grafting may need to be employed to restore anterior lamellar vertical length. Techniques have been described to minimize complications associated with skin grafting.132,168,169
For mild cases of lower lid retraction and massage, there is anecdotal support of digital massage in the early postoperative period.170 While not specifically described for postblepharoplasty ectropion, lid injection of antimetabolites such as 5-fluorouracil (5-FU) and corticosteroids have been used to successfully treat thyroid eye diseaserelated lid retraction and cicatricial ectropion from anterior lamellar skin grafting.168,171 While injectable 5-FU can reduce cicatricial changes that lead to ectropion, topical and systemic 5-FU have been associated with the induction of lower lid ectropion as well.172โ174 Injection of hyaluronic acid filler has also been successfully used to treat lower lid retraction.175
Case 1. A 65-year-old woman (A) preoperatively and (B) 7 months after bilateral upper and lower lid blepharoplasty, lower lid laser resurfacing with Sciton dual erbium laser, autologous structural fat transfer (0.8 cc/tear trough, 1 cc to SOOF, 1-cc lateral cheeks), and lateral canthal tightening.
Case 2. A 60-year-old woman (A) preoperatively and (B) 11 months after bilateral upper and lower lid blepharoplasty,
periocular microneedling, full face laser with Sciton dual erbium laser, autologous structural fat transfer (0.8 cc/tear trough, 1 cc to SOOF, 1-cc lateral cheeks), facelift, submentoplasty, and neck liposuction.
Case 3. A 73-year-old man (A) preoperatively and (B) 6 months after endoscopic bilateral brow lift and upper lid blepharoplasty.
Case 4. A 55-year-old woman (A) preoperatively and (B) 7 months after bilateral upper and lower lid blepharoplasty, autologous structural fat transfer (0.8 cc/tear trough, 1 cc to SOOF, 1-cc lateral cheeks), and lateral canthal tightening.
Case 5. A 54-year-old woman (A) preoperatively and (B) 7 months after bilateral endoscopic brow lift, midface lift, upper and lower lid blepharoplasty, full face laser with Sciton dual erbium laser, lateral canthal tightening, face lift, and submentoplasty.
Case 6. A 66-year-old woman (A) preoperatively and (B) 1 month after bilateral upper and lower lid blepharoplasty, lateral canthal tightening, autologous structural fat transfer (0.8 cc/tear trough, 1 cc to SOOF, 1-cc lateral cheeks), and endoscopic brow lift.
CONCLUSIONS
Blepharoplasty is a very common procedure, and has the potential to have a major impact on patientsโ quality of life. Perhaps even more than with other surgical approaches, preoperative evaluation and careful measurements and markings are of paramount importance in order to maximize the chance of a pleasing aesthetic outcome and minimize the risk of complications, and a thorough appreciation of periorbital anatomy is an absolute prerequisite to blepharoplasty.