Otolaryngol Clin N Am

38 (2005) 903–919

Current Techniques of Entropion

and Ectropion Correction
Ira Eliasoph, MD, FACSa,b,c,d,e,f,*
a
Department of Ophthalmology, Mount Sinai School of Medicine,
New York, NY, USA
b
Veterans Hospital, Bronx, NY, USA
c
Beth Israel Hospital, New York, NY, USA
d
Jewish Home and Hospital, Bronx, NY, USA
e
Manhattan Eye, Ear, and Throat Hospital, Manhattan, NY, USA
f
Mount Sinai Hospital, New York, NY, USA

Writing about entropion and ectropion gives one the opportunity to

discuss the ‘‘ins and outs’’ of eyelid surgery. These two conditions are tied
together insofar as the same anatomic structures are involved and certain
pathophysiology is shared. Constant awareness of the eye itself guides our
plans and their execution. Although cosmetic benefits result from most
eyelid operations, correction of these specific defects is for restoration of the
function of the lids as protectors of the eye. Some of the anatomy and
physiology is reviewed as pertains to these conditions and their origin and
repair. The major coverage is for the adult and aged patient and for
situations that facial plastic surgeons encounter rather than rare cases
handled by experienced oculoplastic specialists. The history of operations
for these conditions includes time-honored names in the field, including the
ancient writers Hippocrates, Susruta, and Celsus as well as Adams [1], Arlt,
Arruga, Blaskovics, Elschnig, Fox, Gaillard, von Graefe [2], Hotz, Hughes,
Jones, Kirby, Kuhnt, Meek, Snellen, Spaeth, Stallard, Streatfeild, Weeks,
Wheeler, and Ziegler. This list reveals a fraction of the interest and efforts
that have been put into solutions for these common disorders.
Some pertinent points follow. The relation between the skin and
orbicularis layer and the layer of tarsus and conjunctiva shifts with aging.
There is less tight adherence, along with general laxity of connective tissue
elements. It has been clearly demonstrated that the lateral canthal tendon
elongates as we grow older. This is readily understood if one places

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E-mail address: eyedoctor21@mac.com

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904 ELIASOPH

a fingertip lightly on the skin at the lateral canthus and then forcefully closes
the eye. There is a discernible pull toward the nose, which, repeated over
decades, stretches the attachments. The canthus drifts forward and down
[3,4], and the lid margin is no longer snug against the globe (Fig. 1). This
allows the hammock of the lower lid to turn in or out, depending on the
laxity of the lower lid retractors and the downward pull of the lower lid-
cheek complex (Fig. 2). With older individuals, loss of orbital fat results in
some enophthalmos, which may favor the development of entropion. The
possible role of diminished corneal sensation is not clear. The loss of facial
animation in Parkinson’s disease aggravates surface dryness problems. In
contrast, with marked rapid weight loss and thinning of the cheek fat pad,
ectropion has been reported as a consequence.
Anyone operating on the lower eyelid should be aware of how slight a bit
of traction draws the lid margin down and of the serious consequences of
this deformity. An average palpebral fissure is approximately 25 mm wide
and presents an area of approximately 125 mm2 to the air. Dropping the
lower lid margin by 1 mm increases the area by 25 mm2 (or approximately
20%). This not only increases evaporation but shifts the tear meniscus so
that the upper lid may not dip into it and thus not spread the tear film,
particularly the lipid secretion from the Meibomian glands, over the eye
surface. It is evident that a patient undergoing lower lid blepharoplasty, who
does not have dry eye symptoms before surgery, should not be symptomatic
after surgery, regardless of the Schirmer test results. If the level of the outer
canthus relative to the medial is lower and any hint of scleral show is

Fig. 1. Lateral orbit, canthal tendon emphasized.

 ENTROPION AND ECTROPION CORRECTION 905

Fig. 2. Lower lid cross section, retractors emphasized.

present, these are danger signals. By gently pulling on the lower lid and
observing the return to its initial position, laxity is easily revealed and steps
are planned to keep this from becoming a complication.
Examination of the face starts with a general view in regard to the overall
appearance, symmetry, and blemishes. The eyelids, brows, cheeks, and their
condition are examined. The eyelids are evaluated, and pathologic findings
like entropion and ectropion are carefully noted. The patient’s complaints
and history are essential to determine what steps are appropriate for
therapy. Proper medical evaluation, cessation of use of aspirin and similar
agents that may promote bleeding, photographs, and chart notations of the
pathologic findings are all seen to before surgery.

Entropion
There are several subdivisions of entropion, which is an abnormal inward
rotation of the eyelid. Congenital entropion is rare and may really be
epiblepharon or excess of the skin and orbicularis overlying and inverting
the margin. Entropion may occur after trauma and scar contraction or after
surgery, particularly on the inner lamina of the lid, with shortage of tissue.
Long-term use of medications, such as some for glaucoma, may produce
tissue shrinkage and entropion (and punctal stenosis). This may happen
with enucleation and shortage of conjunctiva.
In many parts of the world, trachoma is still endemic; the upper lid is
usually involved and curls in, with fibrosis and contraction. This is
a problem of serious interest to the World Health Organization and charity
groups of international scope. More than 5 million people are blind, or near
blind, from trachoma. On the Internet, there are more than 30,000 items
906 ELIASOPH

that appear in response to a ‘‘trachoma/surgery’’ inquiry. Thousands of

operations are performed each year, for example, in Vietnam and Tanzania
[5,6]. In my own experience as a Navy medical officer, the donation of
a bottle of tetracycline to the port doctor, to be used for trachoma
treatment, ensured our swift passage through the Egyptian control station
of the Suez Canal. For many decades, the United States Immigration
Service officers were the experts on trachoma. Crowded conditions and poor
hygiene in parts of Europe made for transmission of trachoma to many
people. It was a reason for exclusion from the United States.
In this part of the world, we see lower lid entropion frequently. The
condition is usually symptomatic, with eye discomfort to the point of pain,
tearing, photophobia, discharge, secondary infection, and varying degrees
of corneal surface breakdown (with visual loss). Occasionally, the lid is
inverted so much that the lashes are tucked down into the fornix, but the eye
is not particularly uncomfortable. Frequent use of lubricating eye ointment
as well as taping the lid into a relatively normal position may serve as
effective temporary palliation.
The pathophysiology has been commented on for centuries, and so have
surgical procedures. There are three changes that must be assessed in each
case. The first is thinning out and weakening of the pull of the lower lid
retractors (see Fig. 2). The second is the elongation and stretching of the
lateral canthal tendon. The third component is the shift and contraction of
the pretarsal orbicularis muscle toward the margin of the lid.
Examination of the lid and manipulating it with a cotton-tipped
applicator or fingertip demonstrates the changes as well as what may be
needed surgically. When the condition is intermittent, asking the patient to
close the eyes forcefully brings out the problem and the need for correction.
Pressing at the level of the inferior orbital rim may evert the margin easily
and leave the margin in proper apposition to the globe at the lower limbus.
This may indicate that only rotation is needed. If the lid margin and the
lateral canthus are displaced down and medially, laxity of the tendon needs
to be addressed. The lateral canthus should be slightly above the medial to
provide a low slope toward the nose and the lacrimal drainage system. A
rounded and thickened margin may require resection and realignment of
a band of orbicularis muscle, and possibly of skin. There are features in
common with what has been termed reverse ptosis of the lower lid [7]. This
failure of the lower lid to retract on downgaze causes obstruction of vision
and needs restoration of the function of the retractors. With entropion, the
patient should be instructed to look down, and movement of the lid should
be observed to assess retractor function.
For an unimaginable time, entropion was treated by many reputable
surgeons with a double line of hot cautery burns into the lid. This ‘‘Ziegler’’
cautery procedure was done by my chief when I started my residency [8]. I
can remember vividly the hissing sound, the steam and smoke, and the smell
of burning flesh. I was dismayed that what I envisioned as a field of precise
 ENTROPION AND ECTROPION CORRECTION 907

and exacting surgery involved this crude and barbaric assault. The fact that
the procedure often worked was based on the fibrous adhesions achieved
between the skin and the lower lid retractors.
Trichiasis, or misdirected eyelashes, is treated by simple epilation,
microelectrolysis, laser ablation, cryosurgery, and, sometimes, surgical
excision. Microelectrolysis is generally the best alternative and is easily
done, with minimal local anesthesia and a small electrosurgical unit, at the
slitlamp microscope. Epilation is prone to regrowth. Cryosurgery produces
a lot of tissue reaction. Laser ablation poses extra risk to the eye and the lid
margin. Surgical excision is usually performed in posttrauma cases with
some distortion of the lid margin, which requires repair.

Upper lid entropion

Upper lid entropion with cicatricial changes can be helped by a marginal
rotation procedure. The Wies procedure involves making an incision through
the full thickness of the lid, approximately 3 mm from the lash line and
extending from just lateral to the punctum to the end of the tarsus [9]. After
careful hemostasis is accomplished, sutures are placed to bring the skin edge
on the marginal side of the incision to the conjunctival edge on the main lid
side of the cut. This turns the margin and lashes away from the globe and
eliminates the source of the irritation. The bare area on the inner side of the
lid epithelializes after a short time. Several variations of this operation are
used in different parts of the world.
A marginal rotation of the tarsus can be done with lesser rotation by
making a skin incision 2 mm from the lashes. A wedge of tarsus can be cut
out through this incision along the length of the tarsus, and the gap so
formed can be sutured closed, with outward turning of the margin. The
skin can then be closed, often with excision of a long thin band of skin to
enhance the effect.
In cases in which the skin and some orbicularis muscle have migrated
over the lashes and turned them in, skin and orbicularis removal, with
sutures to the tarsus further from the lid margin, can correct the defect. This
procedure and the prior technique can be combined with an upper lid
blepharoplasty or ptosis correction.

Lower lid entropion

This extremely common deformity has been the source of an endless
parade of operative procedures. There is hardly a name known in the fields
of ophthalmology and plastic surgery without an article and procedure
attached. Fine strips of bamboo or other materials have been stitched to the
surface to turn the lid outward. Cautery, as referred to previously, was used
for centuries. In a more humane and rational time, some suture methods
have been proposed. The method developed by Feldstein [10,11] is based on
908 ELIASOPH

the pathophysiology and was designed to do what that percentage of

successful cauteries did, namely, to bring the lower lid retractors back into
play. Other procedures place sutures obliquely through the lid and may
provide some improvement; however, the improvement is not adequate in
most cases, with less probability of lasting effect.
Correction of congenital entropion, or epiblepharon, is treated with
sutures as in the Feldstein procedure [10,11] or supplemented by excision of
a spindle-shaped segment of skin and orbicularis muscle as determined by
the pinch technique.

Entropion surgery
Feldstein suture procedure
After appropriate local and topical anesthesia is given, sutures of 4-0
chromic are placed; as they are absorbed by the body, they leave a track of
fibroblasts that contract and produce an adhesion. The needle is introduced
downward into the inferior conjunctival fornix and inserted to catch the
retractor tissue. The needle is then rotated so that the point passes up
through the lid to exit the skin just below the level of the lower tarsal border.
The second arm is passed a couple of millimeters to the side of the first
and exits the skin similarly spaced from the first. The suture is tied firmly on
the skin, dimpling the surface, and the ends are cut off. Three such sutures
are usually required, but, on occasion, two may suffice. The lid should be
slightly everted at the end of the procedure. No dressing or ointment is
required. The suture knots fall away in a few days, and in a month, no
external sign of the operation usually remains.
The Feldstein suture method is used widely even in veterinary surgery [12]
but is usually attributed to Quickert and Rathbun [13]. Feldstein’s method
was published much earlier. Quickert subsequently stated that the procedure
as described by Feldstein was better than the technique he had reported. In
seeking simplicity, this is certainly achieved. No dissection is needed, and no
tissue is excised. The result can last for many years, but other more elaborate
operations also have recurrences. This operation may be done at the bedside
in debilitated patients and can easily be repeated if necessary. The elaborate
operations make repeat correction much more difficult. In myasthenia
gravis, there may be total failure of the retractor fibers comparable to loss of
levator function. Surgical correction thus cannot rely on the retractors.

Horizontal suture repair

The observation that with entropion, the lid margin is tucked in and the
middle part of the lid bulges forward gave Schimek [14] the idea of
tightening the orbicularis along this meridian. With two short horizontal
incisions carefully placed medially and laterally, a band of orbicularis is
 ENTROPION AND ECTROPION CORRECTION 909

tightened. At each incision, orbicularis muscle is dissected and sutured with

a suture passed across the lid under the skin and muscle. This shortens the
bowed-out arc of the muscle and snugs the lid toward the globe. This
tightening is akin, in a sense, to tightening with a base-down triangle
excision (see section on tarsal excision).

External imbrication of the retractors

This method advocated by Schaeffer [15] is performed through an
incision across the length of the lid approximately 6 mm below the lash line.
Dissection exposes the lower tarsal border and the thinned or dehisced
aponeurosis of the retractor. Five silk sutures are spaced along the lid, going
through the upper skin edge, the tarsus, the aponeurosis, and finally out
through the lower skin edge. When the sutures are tied, they bring together
the aponeurosis and the skin edges. The proper pull may then be restored,
and the lid is kept from its abnormal rotation. Schaeffer [15] states that the
sutures may need supplementation by tightening the lateral canthal tendon
and, at times, the medial canthal tendon. He stated, rather dogmatically,
that ‘‘this is the only procedure that directly attacks the retractor
pathophysiology’’ [15]. The procedure was reported by Jones and colleagues
[16] in 1972.
Lower eyelid reverse ptosis shares in the tissue changes of entropion [7]
and requires re-establishing the function of the attenuated or dehisced lower
lid retractors, much as is done in the Jones operation.

Orbicularis redirection procedures

Several different patterns of preparing a tongue or tongues of muscle and
suturing to the orbital rim have been used [17]. A lower lid incision across
the lid is made, and the skin is dissected free of the underlying muscle. A 4-
mm wide band or tongue of the muscle is dissected and cut free at one end,
which then is drawn across to the orbital rim and stitched to the periosteum.
The placement is planned to pull the external layers of the lid down and to
the side, causing outward rotation of the lid margin. Some horizontal
tightening may be achieved as well. The muscle strips are variable in the
resulting tension, and there is a marked tendency for the lid margin to be
pulled down, causing scleral show and added exposure.

Tarsal excision
Removal of a segment of tarsus has been used for many years [1]. The
removal of a base-down triangle of conjunctiva and tarsus was performed,
and with a modification by Fox [18,19], a triangle of skin at the lateral end
of the lid was added. A procedure designed to shorten the lid and rotate the
margin devised by Quickert [20] could deal with severe lid laxity and
910 ELIASOPH

entropion. An incision is made through the full thickness of the lid lateral to
the limbus, and from the lower end of this incision, cuts are made nasally
and temporally. The tongue of tissue on the nasal side is drawn temporally
to overlap, indicating what segment is to be removed. The overlap is cut off,
and closure is then achieved. Along the horizontal incision line, sutures as in
the Wies procedure are used to provide further eversion, and the vertical
incision is then closed in the usual manner. The lid is turned from its
abnormal rotation, but the lateral canthus is pulled medially and the
punctum is pulled laterally. The horizontal length of the palpebral fissure is
shortened, and the punctum may be out of position, impairing its function.

Cicatricial entropion
When there is scarring, the initial surgical step is to open the scar and
excise scar tissue as is done elsewhere in the body. Some intervening material
must then be placed to fill the gap and allow restoration of contour.
Materials used have been banked sclera, mucous membrane, dermis-fat
grafts, and synthetic implant materials. Ear cartilage in the substance of the
lid has also been used but is often unsightly, because the thickness required
is not accommodated within the usual thin eyelid structure.
The occurrence of entropion associated with aging often needs correction
of the stretched lateral canthal tendon. If this is not recognized and taken
care of, along with something like the Feldstein sutures, the operation is
doomed to failure. In the subsequent section on ectropion, I have included
my method of lateral canthal suspension.

Ectropion
Ectropion is defined as a turning out of the eyelid. This can be of varying
degree and may involve only a portion of the eyelid margin. There may be
only punctual eversion, a degree of scleral show, or a frank rotation with the
conjunctival surface facing out.
There are many causes of this condition and many recommended
corrective procedures. The aging process is at the root of many cases, which
occur spontaneously. A great number of cases of serious concern are those
that result from surgical interventions of different sorts. The most frequent
disappointment or complication of lower lid blepharoplasty is scleral show,
ocular discomfort, and tearing, basically an ectropion. The deformity of the
eyelids in mandibulofacial dysostosis (Treacher-Collins syndrome) is severe
lower lid ectropion. Ectropion has been reported with acute weight loss, as
stated previously [21]. In cases of orbital fat presenting under the temporal
conjunctiva on the globe, there is obviously a defect in the connective tissue.
This fat is easily removed with a small conjunctival incision; however,
ectropion may be present and need repair when the bulge has been taken
 ENTROPION AND ECTROPION CORRECTION 911

away. There are recurrent reports of ectropion caused by the lower rim of
the patient’s spectacles touching the upper cheek or the lid skin and pushing
the lid down [22]. This is the reverse of the intentional (but questionable) use
of a ptosis crutch for the upper lid. Conditions affecting the facial skin, such
as burns or ichthyosis, result in contractions that evert the lid. The recent
use of laser energy to resurface facial and eyelid skin is also the culprit in
shrinking the lid and pulling the margin down. Direct trauma, such as
lacerations, dog bites, and blunt trauma, may end up with lid shortening and
eversion. The use of malar implants is a recent cosmetic procedure of great
popularity. The malar implant lifts the overlying tissues to achieve a new
contour. The surgeon must precisely determine whether or not the lid
margin is going to be shifted from its normal position. Damage to the eyelid
innervation has occurred, and scleral show and ectropion have also resulted
[23]. The lid retraction of thyroid disease is in a special category but
similarly needs correction. With seventh nerve palsy, there is often brow
ptosis, lagophthalmos, and ectropion. Associated conjunctival chemosis or
conjunctivochalasis needs care. In almost all cases, the anophthalmic socket
develops a sagging lower lid over time attributable to the weight of the
prosthetic shell.
Ectropion of the upper eyelid is infrequent and often attributable to
an abnormal pull on the skin. Trauma to the upper lid is often followed
by contracted scars, which need skin grafting and other reconstructive
techniques. There are rare congenital upper lid eversions and colobomas.
Correction of upper lid ptosis can turn the lid margin out and pull the lid
away from the globe. In most current texts, the frontalis suspension
operation shown is not physiologic. The three incisions just above the lash
line for placement of the suspensory ribbon are unsightly and, worse,
produce a pull at the lid margin. This can be compared with the can-can
dancer grasping the hem of her skirt to flip it up. Above the brow, the
temporal incision is inappropriately placed lateral to the frontalis muscle.
Upper lid retraction is comparable to scleral show below and is the hallmark
of thyroid ophthalmopathy. In myasthenia gravis, uncommonly, there is
weakness of the orbicularis muscle and retained good function of the
levator, producing lid lag.
Temporary palliation with teardrops and ointment is critical for corneal
protection, even if the patient’s complaint is tearing. Taping the lid into
position, a frost suture, or a temporary tarsorrhaphy with sutures or glue
may be useful. Eye shields, which seal in the moisture, particularly for
nighttime, are often a big help. In some cases of postoperative ectropion,
placing a scleral ring that lies in the fornices and repeatedly massaging
over this stretches out the skin and the subjacent scar and corrects the
problem.
The pathophysiology is based on stretched canthal tendons, loss of
retractor pull, and downward pull on the outer layers of the eyelid. A short
septum, often the result of surgery, can be a significant causative factor.
912 ELIASOPH

Ectropion surgery
A time-honored method of correction of ectropion is the Snellen suture
technique. This is simply passing sutures through the lower fornix and out
on the skin inferiorly. This is like inverting a trouser pocket that was pulled
out. Using chromic suture material gives some fibrosis and a longer lasting
result. Snellen sutures alone fail in many cases because the other anatomic
changes have not been addressed. After a drop or two of anesthetic to the
eye, a moistened cotton-tipped applicator or a muscle hook inserted inside
the lid can show what Snellen sutures can be expected to accomplish. This
suture technique, possibly with some excision of conjunctiva, is used to
correct conjunctival chemosis or conjunctivochalasis, a cause of ‘‘moist eye’’
and tearing.
The concept of eyelid shortening is often incorrect in re-establishing
normal anatomy. When the lateral canthal tendon has elongated, that is the
anatomic structure needing correction. A century ago, a wedge of full-
thickness eyelid was removed to treat this deformity. This created a new,
and sometimes worse, situation with a central lid scar contracted and pulling
the margin down. Taking out a triangle of skin at the lateral end of the lid
and a triangle of tarsus and conjunctiva in the center of the lid followed.
Many variants and names accompanied this operation.
An elaborate procedure sometimes used in severe cases is a modified
Tripier flap [24]. This is also called a ‘‘bucket handle flap’’ because it remains
attached at both ends. It is done by making two parallel incisions across the
full extent of the upper lid and swinging the tissue in between into a
prepared bed in the short lower eyelid.
Less complex but also infrequently performed is placement of a ribbon of
fascia from the medial canthal tendon through the space under the
orbicularis to the lateral canthal tendon. This strip can be adjusted and can
be enhanced by Snellen sutures and other procedures.
Skin grafts are often used with donor sites from another eyelid as well as
retroauricular, supraclavicular, and other areas of fine hairless skin. Tissue
expansion is not often used but is helpful in certain cases and can be
accomplished by repeat injections that stretch out the skin. Vertical shortage
of tissue in the lid is often really downward migration of the cheek with the
aging process. Through a classic blepharoplasty incision, or otherwise,
a cheek lift can be done, sometimes just with one or two stitches anchored to
the lower orbital rim periosteum.

Horizontal shortening
The hammock of the lower lid can be better approximated to the globe by
shortening the lid. This is not always desirable, however, because the
procedures often leave their own new blemish where a vertical full-thickness
incision has been made and the horizontal length of the palpebral fissure
is significantly shortened. There is widespread use of the tarsal strip or
 ENTROPION AND ECTROPION CORRECTION 913

modified Bick procedure to shorten the lower lid [25]. The surgeon prepares
a narrow piece of the lateral tarsus by removing the skin and other tissues at
the margin. This shortens the palpebral fissure by at least 5 mm. The cut end
of the tarsus is then supposed to be stitched inside the lateral orbital rim.
Often, the stitches are not well placed, and the lateral-most part of the lid is
not in apposition to the globe. The horizontal dimension of the palpebral
fissure is shortened instead of restored to the state before stretching out of
the lateral canthal tendon. The outer portion of the upper lid can be seen to
override the lower, a kind of pseudoptosis.
The most popular procedure for the nasal third of the lid has come to be
known as the ‘‘lazy-T’’ operation. In 1975, English and Keats published
Reconstructive and Plastic Surgery of the Eyelids [26]. They present a clear
description of what they called the double-wedge technique for everted
punctum. A vertical full-thickness incision is made just lateral to the
punctum. ‘‘The temporal fragment is drawn nasalwards and the redundant
tissue highlighted by the resultant overlap. This full thickness wedge of eyelid
is removed, restoring the horizontal dimension to normal. Now, with a probe
placed in the lower canaliculus to ensure there is no injury to the drainage
mechanism, a horizontally oriented wedge of tarsus is outlined on the nasal
fragment from a conjunctival approach and dissected out. Closure of this
defect rolls the punctum in a backward direction. After the required amount
has been removed, interrupted 6-0 silk sutures close the wound, and the other
defect is then bridged by primary anastomosis. When completed, the
combined maneuver restores the inferior punctum to its anatomical location’’
[26]. The following year, 1976, witnessed the publication of a report on the
double-wedge resection under a new name, ‘‘the lazy-T procedure,’’ by Smith
[27], who had written the foreword to English and Keat’s book.
Meltzer reported a method of medial ectropion repair with a special
rotating flap that eliminates the need for a free graft (which does not match
the lid skin as well) [28].
Lid shortening procedures are necessary at times. Certain principles must
be followed to avoid a bad result. In Wiener’s book [29], a method is shown
for closure of a through and through laceration of the lid. On each side of
the cut, the tissue is freshly cut out along an arc from the margin to the
nether end of the defect. This alters the geometry by providing a closure line
along the arc longer than the chord length. At closure, this produces a small
protrusion of the margin. This counteracts the anticipated scar shrinkage,
which would cause a notch. Hecht [30] called this a ‘‘bowlegs’’ procedure,
and others called it a ‘‘corncrib’’ operation [31]. Later, the pentagonal pro-
cedure for tumor excision was proposed. The pentagonal technique relies on
the divergence of the cuts from the lid margin into the lid. Diagrams
showing parallel sides (the configuration of a baseball home plate) are not
correct. A true geometric pentagon (one edge being the lid margin) has
obtuse angles. A five-pointed star (a true pentagon rather than a square with
parallel sides) can be inscribed neatly into the pentagon.
914 ELIASOPH

Fig. 3. Suture closure of medial spindle, arrow indicates needle pass through, to be tied on the
skin.

Medial spindle excision

When the punctum is everted, it is possible to correct this with removal of
a diamond or ellipse of conjunctiva and deeper tissue from inferior to the
canaliculus. This can be done with an initial incision and then overlap to
determine how much needs to be removed, followed by suture closure. The
closure is accomplished with one or two fine double-armed sutures (eg,
6-0 Vicryl). The suture is first passed at the inferior edge of the excision
through the deep tissue and then out through the upper conjunctival edge.
The needles are next passed through the full thickness of the lid just below
the lower incisional edge and then down and out to be tied on the skin
(Fig. 3). This adds an element of suture rotation to the method.

Lateral canthal correction

Several currently popular operations are based on the Bick procedure
[25]. Webster and colleagues [32] used a suture at the outer canthal area as
part of a lower lid blepharoplasty. Shorr and Fallor [33] have advocated
what they have called the ‘‘Madame Butterfly’’ lateral canthal lift. Small [34]
has proposed the ‘‘extended’’ blepharoplasty with the lower lid incision
longer temporally, with a deep suspending suture.

Fig. 4. Bilateral scleral show, low lateral canthi, post blepharoplasty.

 ENTROPION AND ECTROPION CORRECTION 915

Fig. 5. Bilateral 3D canthal correction done.

Lateral canthal suspension

A lateral canthal suspension procedure has been my operation for more
than 30 years and 200 cases [35]. A postblepharoplasty patient presented
with a severe lower lid ectropion. The lid was not shortened, as easily shown
with an applicator gently rotating it into normal position. It was evident
that the lateral canthal tendon support was lost. The operation can give
lateral, upward, and posterior pull inside the orbital rimdthe third
dimension (Figs. 4–9).

Eliasoph three-dimensional canthal correction

The lateral end of the tarsus is inspected. Local anesthesia is given (into
the lateral one third of each lid and a small amount into the orbit). A 5-mm
incision is made approximately 3 mm below and parallel to the lash line (near
the lateral end of the tarsus). Each arm of a doubly armed suture of 5-0 white
braided polyester is passed through the lateral end of the tarsus from the
conjunctival side to exit through the skin incision. Adequate tarsal tissue
must lie in the loop. (The conjunctiva is sealed over the suture by the next
day). The needles are removed, and the suture ends are threaded on a half-
curved cutting needle approximately 25 mm long. This needle is introduced
into the incision pointing laterally and deep to the orbicularis.

Fig. 6. Male patient, ectropion post blepharoplasty.

916 ELIASOPH

Fig. 7. Male patient, after 3D canthal correction.

The plane of the needle is shifted to point into the orbit just inside the rim
and deep to the anterior portion of the lateral canthal tendon. The needle is
advanced along its curve, hugging the inside of the orbit, and is brought
around to tent up the upper lid skin. Here, an incision approximately 15 mm
long is made (or previously made) along a natural skin line, and the suture is
drawn through.
The bony orbital rim is exposed. One arm of the suture is threaded on
a small needle, and a firm bite of periosteum is taken inside the orbit. Both
ends of the suture are drawn up to tighten as needed and tied securely, and
the tag ends are cut away. Skin sutures are placed as needed, and cold
compresses are applied.
Graefe forceps are effective to hold the lid margin and evert it as needed.
A heavy surgeon’s needle holder is needed for the big needle to control it
properly. When the big needle has been passed most of the way, lifting
meets great weight, almost lifting the patient’s head. If the needle wiggles
and comes up easily, it was not passed deeply enough. There is, however,
no significant resistance to passing the needle around its curve and out the
upper incision. The anchoring bite in the periosteum is not critical in its
placement, but care must be taken in doing this, because improper rotation

Fig. 8. Ectropion post blepharoplasty.

 ENTROPION AND ECTROPION CORRECTION 917

Fig. 9. After 3D canthal correction.

can break the needle or tear the tissue. The pass should be inside the rim
(so that the knot is deep and better periosteum is found) and taken
pointing away from the globe. If traction on the suture, before anchoring
it, shows an unsuitable direction, it can be pulled and replaced or cut and
redone. Often, there is a bit of folding of the skin at the canthus, but this
always smoothes out. Some transient edema of the conjunctiva may occur.
If performed in conjunction with a lower lid blepharoplasty, any excision
of skin must be done after this. The superior incision can be the lateral
extent of an upper lid blepharoplasty incision. A cheek lift with this gives
good results.

Summary
The entities of entropion and ectropion have some important common
factors in their genesis. Preoperative examination requires similar careful
assessment and planning. The need for surgery must first be established, and
the changes in the anatomy must be evaluated. Prior local trauma or
surgery, conjunctival or skin changes, septal shortening, weakness of
muscles, retractor thinning or dehiscence, orbicularis muscle shift, and, most
importantly, the status of the lateral canthal tendon must all be considered.
In performing any eyelid surgery, entropion or ectropion should not be
produced, and preventive techniques must be incorporated into such
undertakings. Anesthetic injections should be subcutaneous and only as
deep as needed. The amount injected should not be excessive, because
distortion or stretching can occur. Dealing with orbital fat should never
involve any pulling, which can shear off a deep orbital vessel with serious
consequences. Immediate and adequate measures for intraorbital bleeding
should be familiar to the surgeon and instituted without delay. Restoration
of lid anatomy with precise surgical methods yields improved lid function,
comfort, and cosmesis.
918 ELIASOPH

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