Ординатура / Офтальмология / Английские материалы / Atlas of Aesthetic Eyelid and Periocular Surgery_Spinelli, Lewis, Elahi_2004
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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E R Y
CICATRICIAL ECTROPION AND ENTROPION
Contractures in the anterior lamella of the eyelid can cause cicatricial ectropion. These conditions can be seen secondary to chemical or thermal injuries, secondary to deficiencies or devascularization after surgery or trauma, after severe outbreaks of herpes zoster, or iatrogenically after aggressive lower eyelid laser procedures. The surgeon should not be beguiled into believing that a lateral canthal procedure will suffice in correcting ectropion and/or scleral show when there is a true deficiency in any of the lamellae of the lower lid, including skin. Traction on the lower eyelid in a cephalolateral direction, while observing the lower lid and cheek, is a reasonable test to assess the extent of external lamella deficiency. Generally, if elevation of the lower
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eyelid produces traction and notable movement in the cheek region, then a canthopexy alone will usually not suffice. In mild-to-moderate cases of anterior lamellar deficiency, a cheek or midface suspension, either by means of a lateral upper, lateral lower lid, or a preauricular facelift incision, may suffice. A free skin graft or transpositional flap (i.e., Trippier, Fricke) will be necessary when the external lamella deficiency exceeds the amount correctable by simply elevating the malar soft tissue. Free full-thickness skin grafts from donor sites that are as close to the lower lid as possible (i.e., upper eyelid) are quite satisfactory in the long run and look as good as transpositional upper lid flaps. Free skin grafts also avoid the distortion in the lateral canthal region that occurs with transpositional flaps. The key point in grafting the external lamellae of the lower eyelid is to re-create the defect and place the lower eyelid on cephalic traction, thereby overcorrecting the defect significantly (Fig. 3-10).
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Figure 3-10 Continued The upper lid approach to the lateral canthal tendon and midface. A, The lateral canthal tendon is held in the forceps, and the bony orbit lies beneath the retractor. B, Note that with the lateral retinacular elements lysed, the lateral canthus and the entire lateral commissure can be transposed along an arc delineated by the lateral orbital rim. C, Viewed from the upper lid down, the dissection can be carried inferiorly to approach the mid face and any plane of preference (e.g., subperiosteal, suborbicularis) may be accessed. A suture (green) is engaged to the lateral canthal tendon, and the supraperiosteal plane over the zygoma is visualized. D, The suture engaged to the lateral canthus is then passed through the periosteum of the orbit at a desired level. Note a second amber suture is visible at the edge of the retractor and onto the skin surface. This suture passes through the malar fat pad. E, Canthal suspension suture now engaging both the tendon and the periosteum of the orbit is ready to be tied down. The midface structures have been suspended, and the entire lateral canthus and commissure will be translocated cephalad and laterally. F, Contralateral procedure on the same patient with the lateral canthus engaged by the suspension suture and all elements of the lateral retinaculum freed. Exposure to the infraorbital and midface region is demonstrated with the use of a retractor. G, Patient who had a previous blepharoplasty and now has midface ptosis and a relative deficiency of lower lid skin. She has scleral show, bowing of the lower lids laterally, especially on the right, and wide lateral commissure angles. H, The same patient as in G after a lateral common canthoplasty and midface suspension (as seen in operative views) now demonstrates obliteration of the preoperative scleral show, loss of lateral lid bowing, acuteness to the lateral commissure angles, and midface elevation.
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Cicatricial entropion usually presents as the opposite rotation of the eyelid margin as found in ectropion and is caused by foreshortening of the internal aspect or posterior lamellar eyelid structures. The etiology may include chemical burns, iatrogenic or surgical injuries, ocular pemphigoid, Stevens-Johnson syndrome, and other scarifying processes. As in ectropion, replacement of the lamella deficiency with a free graft (mucous
membrane or composite) is the treatment of choice. This may be combined with a lateral canthotomy and cantholysis or division of the inferior crus of the lateral canthal tendon. This allows access to the entire fornix of the lower lid. A canthopexy to further suspend the lower eyelid may be performed after grafting is complete (Figs. 3-11 and 3-12).
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Figure 3-11 A, A 51-year-old woman presented with bilateral cicatricial ectropion from an external lamellar deficiency. She has had a number of past surgical procedures by other surgeons, including a lower lid blepharoplasty at 44 years of age (7 years before presentation) and an endoscopic browlift and lower lid blepharoplasty 4 months before presentation. Approximately 1 month before presentation she underwent a lower lid suspension procedure (type unknown) that did not correct her problem. She presents with significant signs and symptoms of corneal exposure, including corneal edema and decreased visual acuity. Note the scleral show and ectropion of the lower lid, especially on the right side. B, On close-up view of the patient’s eyes, note lateral lower lid bowing, scleral show, ectropion, and conjunctival injection, especially in the temporal quadrant of the right eye. C and D, Lateral view of the left and right eyes, respectively, demonstrating displacement of the lower lid away from the globe in two planes (vertical and horizontal) and the resulting signs of an eye that is not well covered and wet (i.e., conjunctival injection).
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Figure 3-12 A and B, Front and right lateral views of same patient after bilateral lower eyelid full thickness grafts obtained from the retroauricular sulci along with a canthoplasty. Note bowing in the lateral third of each lid with almost normal central lower lid position. On both views the ectropion is completely corrected. Note also there remains midface ptosis, and on the lateral view the orbital rim is visualized in relief owing to excess orbital fat resection in the past and midface ptosis. Her symptoms were relieved and her corneal edema and epithelial problems resolved with a corrective procedure. Subsequently, a midface suspension was performed to address the orbital rim and midface junction as well as to provide additional external lamella tissue for the lower lid. These postoperative photos are shown to demonstrate the potency of external lamella replacement by way of skin graft.
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INVOLUTIONAL ENTROPION
The causes of senile or involutional entropion are often analogous to those of senescent ectropion, with the dominant common cause being significant horizontal eyelid laxity. There is an associated net attenuation of the inferior lid retractors along with an override of the more loosely attached preseptal orbicularis muscles over the pretarsal orbicularis muscle. In most cases there is relaxation of the medial and lateral canthal tendons along with a secondary redundancy of the lateral orbital septum with pseudoherniation of orbital fat. The dehiscence of the lower lid retractors is analogous to levator aponeurotic dehiscence in the upper lid, which will be discussed in Chapter 8. The classic presentation of patients with involutional entropion is the patient who presents in the sixth or seventh decade of life with an inturning of the lower eyelid, especially on aggressive or forced closure. This repetitive turning in of the lid can cause corneal irritation and even breakdown, leading to significant morbidity and debilitation. Although a number of procedures have been described for the correction of involutional entropion, I have found them to be either insufficient, associated with a high recurrence rate of the entropion, or overly aggressive, incurring a significant amount of unnecessary surgery. Simply stated, these solutions are either too little or too much. My recommendation for correction of involutional entropion uses a few basic techniques already described in this text. The principle is to first address the lower lid laxity and second to address the preseptal orbicularis override. This procedure can be performed quickly, reproducibly, and safely with the patient under
local anesthesia and with or without sedation. A lateral canthotomy and cantholysis of the inferior crus of the lateral canthal tendon is performed. The lower eyelid is mobilized with a subtarsal dissection lysing the lateral inferior lid retractors. A suborbicularis preseptal dissection is performed in the potential space between the orbicularis muscle and the orbital septum, along with a subcutaneous or preorbicularis dissection (see Figs. 1-1 and 1-2). This dissection is carried out from the lateral canthus to the medial canthus, eliminating muscular override by creating fibrosis. The canthoplasty is then completed as previously described utilizing the denuded tarsal strip (see Fig. 3-5). The lower lid retractors are allowed to spontaneously adhere to the newly elevated lid position. In my experience, this definitive and simple procedure can be nearly 100% successful with limited or no morbidity (Fig. 3-13).
SCLERAL SHOW OR LOWER LID RETRACTION
In severe cases of lower lid retraction or pseudoretraction, as in mild exophthalmos or proptosis secondary to Graves’ disease, the lower lid may be elevated with a combination of canthopexy and middle and internal lamellar spacer grafts to provide rigidity and support. This is especially the case when an external lamella or skin deficiency does not exist. The atonic lower eyelid found in facial paralysis is another example of an appropriate indication for this procedure.
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Figure 3-13 A, A 71-year-old patient presented with involutional entropion of the left lower lid. She also has chronic exotropia of her eye and ptosis of her upper lid with amblyopia. Note her left lower lid lash line is barely visible as the lid rolls in on lid closure and is exposed with upper lid retraction. Note also the contralateral right lower lid margin with lash line properly directed. This patient suffered from corneal erosion. B, Close-up view of the left lower eyelid involutional entropion. Note the distinct rolling in of the eyelid associated with lower lid laxity, orbicularis muscle override, and other factors (see text). C and D, Distant and close-up photographs of patient approximately 6 months later with left lower lid in good anatomic position with lash line everted away from the ocular surface. The underlying pathophysiology is addressed by tightening the lower eyelid with a canthoplasty, preorbicularis and postorbicularis undermining, and muscular stabilization.
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I prefer palatal mucoperiosteum as an interposition graft between the tarsal plate and lower lid retractors. A lateral canthotomy and inferior cantholysis is again performed, and the lower lid retractors are divided by way of a transmucosal approach. I prefer an insulated electrocautery to achieve this exposure. Easy access to the lower lid retractors and the inferior tarsal plate border is obtained with the lower eyelid mobilized and turned outward. The interposition graft is sutured into
place apposing deeper structures (eyelid retractors) and then mucosa separately. The lower eyelid is then suspended again with a canthopexy by way of the tarsal strip or other procedure (Figs. 3-14 and 3-15). A similar interposition type graft can be employed in upper lid retraction as in Graves’ disease and is described in Chapter 8. The difference in the case of the upper lid is that the graft need not provide rigidity nor mucosa unless there is an internal lamellar deficiency.
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Figure 3-14 A 61-year old woman presented with symptomatic left lower lid retraction and atonicity caused by facial nerve paralysis and multiple attempts to suspend the left face and lower lid in the past. Note lateralization of the lower lid punctum, scleral show, slight ectropion, a thinned lower eyelid compared with the normal right side caused by orbicularis atrophy, and left facial ptosis from resection of the seventh nerve on both far (A) and closeup (B) views.
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SPACER GRAFT FOR CONTRACTED LOWER LID
Mucoperiosteum
Lower lid retraction
A Harvest hard palate graft
Lower border of tarsal plate
B Conjunctiva divided and lower lid retractors disinserted
C Graft sutured to lower edge of tarsal plate and lower lid retractors
Figure 3-15 This patient has middle internal lamella deficiencies that will not respond to canthoplasty alone or in combination with a midface support procedure. Patients with these types of deficiencies usually have had several previously failed procedures. On examination, digital elevation of the cheek and canthus fails to correct the lower lid malposition; and in these cases a spacer graft, which also provides some central vertical support, is needed. The procedure requires a transconjunctival lysis of the lower lid retractors below the tarsal plate and the interposition of a palatal mucoperiosteal graft. The lower lid retraction is severe in this figure. A, Hard palate mucoperiosteum is harvested. B, The conjunctiva and lower lid retractors are incised and recessed. C, The space between the retractors and tarsal plate is grafted with free mucoperiosteum using a fine absorbable suture (i.e., 6-0). A lateral cantholysis (not shown) is usually helpful but not necessary for access and insetting the graft and adds little time and no morbidity. In most cases in which a spacer graft is used some type of canthal suspension should be performed.
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P E A R L S A N D P I T F A L L S
1.All lower eyelid malpositions (refraction, entropion, ectropion) should be identified and then addressed by their pathophysiology.
2.Involutional lower eyelid malpositions are the most common and are associated with lateral canthal laxity.
3.Descent of the lateral canthus leads to intercommissure shortening and septal laxity.
4.Involutional entropion shares all the contributing components with involutional ectropion, but also has retractor dehiscence.
5.Lower lid shortening procedures should be avoided in the treatment of lower lid laxity.
6.Canthoplasty and canthopexy are different procedures, and each may be subdivided into one that applies to a single crus or to the common element.
7.The lower eyelid can be fully mobilized only when the lateral retinacular components (i.e., orbital septum, lid retractors) are lysed.
8.A commissuroplasty is important for proper alignment of the upper and lower eyelids when completing a tarsal strip procedure.
9.Tarsal plication is effective only in mild lower lid laxity and, when employed in more severe cases, can lead to buckling of the lower eyelid.
10.The lateral horn of the levator may be entrapped during a lateral canthal suspension, leading to upper lid retraction or lagophthalmos.
11.Overelevation of the lateral canthus can produce an unacceptable appearance and impinge on the visual axis.
12.Lateral canthal suspension procedures alone will not correct a significant lamella deficiency of the lower eyelid.
13.One should consider midfacial suspension or even grafts in treating significant anterior lamella deficiencies.
14.The ideal treatment for involutional entropion is to tighten the lower lid and prevent orbicularis override.
15.Spacer grafts of the middle and inner lamella of the lower lid are ideal in providing central support and can be combined with canthal and midface suspension.
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REFERENCES
Aldave AJ, Maus M, Rubin PA: Advances in the management of lower eyelid retraction. Facial Plast Surg 15:213-224, 1999.
Caldato R, Lauande-Pimentel R. Sabrosa NA, et al: Role of reinsertion of the lower eyelid retractor on involutional entropion. Br J Ophthalmol 84:606-608, 2000.
Dagum AB, Antonyshyn O, Hearn T: Medial canthopexy: An experimental and biomechanical study. Ann Plast Surg 35:262-265, 1995.
Glatt HJ: Follow-up methods and the apparent success of entropion surgery. Ophthalmic Plast Reconstr Surg 15:396400, 1999.
Kim JW, Kikkawa DO, Lemke BN: Donor site complications of hard palate mucosal grafting. Ophthalmic Plast Reconstr Surg 13:36-39, 1997.
Lemke BN, Cook BE Jr, Lucarelli MJ: Canthus sparing ectropion repair. Ophthalmic Plast Reconstr Surg 17:161168, 2001.
Lisman R, Campbell J: Tarsal suspension canthoplasty. Aesthetic Surg J 19:412-424, 1999.
Matsuo K: Stretching of the Mueller muscle results in
involuntary contraction of the levator muscle. Ophthalmic Plast Reconstr Surg 18:79-83, 2002.
Mommaerts MY, De Riu G: Prevention of lid retraction after lower lid blepharoplasties: An overview. J Craniomaxillofacial Surg 28:189-200, 2000.
Olver JM, Barnes JA: Effective small-incision surgery for involutional lower eyelid entropion. Ophthalmology 107:1982-1988, 2000.
Patel BC, Patipa M, Anderson RL, McLeish W: Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip. Plast Reconstr Surg 99:12511260, 1997.
Patipa M: The evaluation and management of lower eyelid retraction following cosmetic surgery. Plast Reconstr Surg 106:438-453; discussion 454-459, 2000.
Rougraff PM, Tse DT, Johnson TE, Feuer W: Involutional entropion repair with fornix sutures and lateral tarsal strip procedure. Ophthalmic Plast Reconstr Surg 17:281-287, 2001.
Yip CC, Choo CT: The correction of oriental lower lid involutional entropion using the combined procedure. Ann Acad Med Singapore 29:463-466, 2000.
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