This video demonstrates the surgery of an entropion repair and lateral canthoplasty with skin excision in a patient with lower spastic entropion in both eyes.
Surgery Location: on-board the Orbis Flying Eye Hospital, Kingston, Jamaica
Surgeon: Dr. Bradford Lee, Bascom Palmer Eye Institute, USA
DR LEE: Classic entropion, there’s three different potential causes, and they can all be contributing at the same time. So one is excess skin and orbicularis muscle, or overriding skin and orbicularis muscle. And if you see her in clinic, she actually has what we call a little bit of festoons, so a little baggy extra skin. And that’s further causing this to roll inwards. The second thing that contributes to it is horizontal laxity of the eyelid. And she doesn’t have horrible horizontal laxity, but we will be tightening up her lower lid just a little bit. Horizontal laxity can cause ectropion or entropion, and tightening it can help entropion or ectropion. And then the final mechanism is that there can be disinsertion of the lower lid retractors onto the inferior border of the tarsus, and that can also cause ectropion or entropion. We’re not gonna address that generally, because I find that excising the skin and muscle is a very powerful rotator. And then we’re also gonna tighten her. So I think addressing two out of the three things should be sufficient to help her. I’m gonna top her up with a little bit more local anesthetic underneath the lower lid, along the lashes here. This is the same way that I excise extra skin in my patients coming in for lower blepharoplasty. Normally for aesthetic enhancement. But in her case, it’s contributing to a functional problem. So what I do here is that I’m gonna do what’s called a skin pinch excision. And you’re trying to crimp it up right along the lash line, because when you excise it, then you have a nice subciliary incision that is virtually imperceptible. The idea is that we’re gonna excise a little bit of skin and muscle. And aesthetically, normally there’s more tissue laterally than medially. So for lower blepharoplasty patients, I typically excise just a little bit more over here, laterally. Because there’s always more. If you get too aggressive over here, you can cause ectropion. And as I come past the lateral canthus, I taper down just a little bit down this way, into one of the crow’s feet lines. That helps it to hide really nicely. So again, I’m trying to get right up under the lashes. And sometimes it’s a little bit hard the first time, where your skin fold’s not behaving. It’s no problem going back for a second pass to get even closer to the lash line. Because aesthetically, we want the incision to be about a millimeter right below the lashes. And that way it’s virtually imperceptible. You make it like 4, 5 millimeters below the lashes, it leaves a visible scar, which — you know, she probably wouldn’t complain about, but we always go for elegance whenever possible. The skin, as we get more medially, is thinner than the lateral canthal skin, so it’s easier for me to cut, keeping my blades right below the lashes here. Without surgery, this is a very difficult problem for patients. They’d have to literally hold their eyelids down, or they have to use a bandage contact lens. Just so that the lashes are not rubbing on the cornea. So you can see we took off a fairly substantial amount of skin and orbicularis here. You can see there’s no fat coming out. I haven’t violated the septum. It’s just the skin and orbicularis. It’s all preseptal. So I think I actually did a decent job with my subciliary. I don’t think I need to go for a second pass. And let’s just see if we want to take off any more. I think that’ll be fine, because there’s always, when it heals, it always contracts a little bit. And so it’s better to be a little bit conservative. You can always take off more. Ideally you don’t cause them to have consecutive ectropion after this. So we’ll take the 6-0 fast suture. She has a little bit of horizontal laxity, a little bit of disinsertion of the lateral canthal tendon, so I’m gonna show you a method how to horizontally shorten the lower lid, as well as reinsert the entire lateral canthal tendon complex onto the periosteum. So I’ll take the 15 blade. Just make a short lateral canthal incision here. About a centimeter long. So I’m gonna cut the — do my canthotomy now. Connect it. So this is a little bit different than a lateral tarsal strip. So I’m gonna release the inferior crus now. So now my eyelid is fairly mobile. I just completed the inferior cantholysis a little bit more. So now you can see her lid is very mobile here. So I’m gonna, like I said, rather than fashioning a true lateral tarsal strip, I’m gonna just excise a full thickness triangular wedge of the eyelid here. It’s an S2 needle, so this is a really nice, tight semicircular needle that can do a limited canthal incision. We can go way posterior and really reinsert it on the periosteum, inside the rim. You can see the needle here. It forms a very tight half circle. I grabbed the tarsus here. And I’m gonna make a pass. I’m not coming through the skin here. I’m coming in just behind the skin here. Oh, sorry. Just behind the skin. And out, just about 1 to 2 millimeters below the lid margin. So that it comes together with a nice sharp angle. If you come too far from the lid margin, you’re not gonna get a sharp angle to the corner of the eye. And then this is where I reinsert my… I’m attaching things now to the superior crus of the lateral canthal tendon. So here you can see the conj edges about here. This is a skin edge. And I’m trying to take a little whip of tissue in between the conj and the skin, so they come just behind the conj, at the top part. And come out without coming through the skin. Just in front of the skin. You know, if you look at her canthus now, it’s still a little bit floppy, right? It’s not really retroplaced, where it ideally should be. So this next pass — you don’t cut the suture. You just continue with another pass, and then tie off the whole complex. So I’m loading my suture here, and I’m feeling for the orbital rim here. I’m going as far back as I can, trying to scrape the bone. I’m feeling the bone here. And then I’m just trying to externalize my needle without coming through the skin. That’s how you can get really posterior with a very limited canthal incision. It really tightens it further and retroplaces it. So here I’m just closing the skin here. Making sure the canthus aligns well. This is 6-0 fast absorbing gut, which dissolves over the course of about two weeks or so. Sometimes patients tend to rub their eyes, even though you tell them not to. And so for that reason, I tend to leave the tails just a little bit longer here, so that it’s less likely to dehisce the suture or break the suture. Sometimes I’ll do a 2-1-1-1, just for a little extra security. So leave the tails about 3 to 4 millimeters, a little shorter than that as well. That’s good. Yeah. Okay. Good. The other thing that you could sometimes do is to reinsert the lower lid retractors on the anterior-inferior border of the tarsus. And that further can rotate things. I used to do that more commonly than taking off the skin and muscle, but I find that taking off the skin and muscle is a very, very, very powerful rotator. Pretty much I think that you really don’t need to mess with the lower lid retractors, if you’re doing this. In fact, sometimes you say — oh, they don’t have that much eyelid laxity. Maybe we can skip the lid tightening part. I’ve tried that. And sometimes you get away with it. But sometimes they can even have a little bit of consecutive ectropion, and then you have to go back and tighten it. So nowadays, if I’m even on the fence about it, I just do a little bit of tightening, just to help prevent consecutive ectropion. Which honestly — the patients are way more happy to have ectropion than entropion, because with ectropion they have a little bit of redness, tearing, mucus, but it’s nowhere near as uncomfortable as this spastic entropion. But obviously for us we want them to be just perfect.
April 13, 2019