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Cicatricial Ectropion Correction in the Inferior Eyelid with Cartilaginous Tissue

Graft: Case Report

Article · January 2014

DOI: 10.32457/ijmss.2014.026

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Int. J. Med. Surg. Sci.,
1(3):217-222, 2014.

Cicatricial Ectropion Correction in the Inferior

Eyelid with Cartilaginous Tissue Graft: Case Report

Corrección de Ectropión Cicatricial en el Párpado Inferior

con Injerto Libre de Cartílago. Reporte de un Caso

Aline Monise Sebastiani*; Guilherme dos Santos Trento*; Fernando Antonini*; Leandro Eduardo
Kluppel**; Rafaela Scariot**; Delson João da Costa** & Nelson Luis Barbosa Rebellato***

SEBASTIANI, A., M.; TRENTO, G., S.; ANTONINI, F.; KÜPPEL, L., E.; SCARIOT, R.; DA COSTA, D., J.;
REBELLATO, N., L., B. Cicatricial ectropion correction in inferior eyelid with cartilaginous tissue graft: Case
report. Int. J. Med. Surg. Sci., 1(3):217-222, 2014.

SUMMARY: Transcutaneous approaches of the lower eyelid are commonly used to provide adequate
exposure of the orbital floor and zygomaticomaxillary suture during treatment of facial fractures. Cicatricial
ectropion is a rare complication that results in a shortened eyelid. This condition can be temporary in some
cases but when it is permanent it must be surgically corrected, aiming to restore function, improve the
aesthetical outcomes and to prevent ophthalmological disorders such as epiphora and corneal ulceration.
The present study describes a novel surgical approach, associated with a concomitant cartilaginous graft, to
treat severe lower eyelid ectropion resultant from a previously performed subtarsal incision.

KEY WORDS: Ectropion; Postoperative complications; Cartilage; Nasal septum

INTRODUCTION

Ectropion is the retraction or eversion of blepharitis and hordeolum. Exposure of the

the ciliary margin in the opposite direction of tarsal conjunctiva can lead to hypertrophy and
the eyeball and can occur in different degrees, keratinization of the conjunctival mucosa∏.
just as a point eversion with small scleral show Furthermore, increased scleralshow is
or with full rotation of the eyelid with the unaesthetic and is frequently associated with
conjunctival surface facing out (Eliasoph, inadequate drainage of tears and excessive
2005). Moreover, it can be classified as dryness (Schaudig, 2012).
congenital or acquired. The latter can be
subdivided into involutional, cicatricial, When this condition is permanent, it must
mechanical and paralytic (Matayoshi et al., be corrected surgically. Surgical treatment of
2004). Cicatricial ectropion is the result of severe ectropion aims functional and aesthetic
shortening of the anterior lamella (Veloso et restoration, preventing ophthalmological
al., 2006) and is a complication associated with complications and improving facial appearance.
transcutaneous incisions ofthe lower eyelid. As Among various techniques for correction of
a result of the lack of contact between the ectropion (Eliasoph; Goel et al., 2013; Garza et
eyeball and the everted lid, eyelid glands al., 2012) the use of an autogenous cartilage
become ectatic accumulating their secretions. graft to provide support to the eyelid has been
Consequently, keratitis can occur culminating described (Carraway & O’Loughlin, 1994;
in corneal ulcer, chronic conjunctivitis, Krastionova et al., 2002).

*
Resident, Department of Oral and Maxillofacial Surgery at Federal University of Paraná (UFPR), Curitiba, Brasil.
**
Associated Professor, Department of Oral and Maxillofacial Surgery at Federal University of Paraná (UFPR), Curitiba, Brasil.
***
Chairman, Department of Oral and Maxillofacial Surgery at Federal University of Paraná (UFPR), Curitiba, Brasil.

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 SEBASTIANI, A., M.; TRENTO, G., S.; ANTONINI, F.; KÜPPEL, L., E.; SCARIOT, R.; DA COSTA, D., J.; REBELLATO, N., L., B. Cicatricial ectropion
correction in inferior eyelid with cartilaginous tissue graft: Case report. Int. J. Med. Surg. Sci., 1(3):217-222, 2014.

The aim of this study is to demonstrate a observed. The patient was instructed to perform
novel surgical technique for cicatricial ectropion massages in the region and was prescribed
correction after a subciliary incision, through ophtalmological ointment to prevent ocular
grafting of cartilaginous tissue from the nasal dryness.
septum.
After three months of follow-up, the patient
showed facial symmetry with good zygomatic
CASE REPORT projection demonstrating correct fracture
reduction. However, clinical signs and symptoms
of permanent ectropion were evident (Fig. 3). At
A 51 years old, leucoderma, male patient this time, surgical correction was indicated.
presenting the left zygomatic-orbital complex
fractured, reporting being a victim of physical
agression (Figs. 1 and 2). He underwent surgery
under general anesthesia for fracture reduction
through intra-oral, supraciliar and subtarsal
incisions.

Fig. 3. Ectropion after subtarsal approach.

Surgical Technique

Under general anesthesia, a 4cm maxillary

Fig. 1. Admission to Hospital with orbital fracture. vestibule incision was performed to expose the
nasal floor and septum. After dissection, the
anterior portion of the cartilaginous septum was
clamped and removed (2x1cm) with the aid of
a Metzenbaumscissor. Simple continuous suture
was performed, using absorbable thread (Vicryl
3-0). After that, a left subtarsal incision was
performed (Fig. 4). Undermining just anterior
to the tarsal plate created a “pocket in the lower
eyelid. The graft was shaped like a semi-circle,
mimicking the lid (Fig. 5), and properly
positioned and sutured in the tarsal plate
extremities (Figs. 6 and 7). Suture was
performed by planes with 5-0 poliglactine
thread and later intra-dermal suture with 6-0
mononylon (Fig. 8).
Fig. 2. Deficencie en vertex projection with a low level
in the left side. Twelve months after the grafting procedure
on the left inferior eyelid, the patient had
adequate eyelid anatomy and function
During postoperative follow-up, gradual performing complete sealing of the eyelids and
eversion of the inferior eyelid margin was no aesthetic complaints (Fig. 9).

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 SEBASTIANI, A., M.; TRENTO, G., S.; ANTONINI, F.; KÜPPEL, L., E.; SCARIOT, R.; DA COSTA, D., J.; REBELLATO, N., L., B. Cicatricial ectropion
correction in inferior eyelid with cartilaginous tissue graft: Case report. Int. J. Med. Surg. Sci., 1(3):217-222, 2014.

Fig. 7. Graft sustained over the tarsal plate.

Fig. 4. Surgical approach to make a cartilage free
graft.

Fig. 5. Cartilage from nasal area.

Fig. 8. intraoperative result after suture.

Fig. 9. One year follow-up

showing aesthetic result
and funcitonal situation
without ocular lession.

Fig. 6. Cartilege free graft put into the low eyeled.

DISCUSSION

Currently, there is a great discussion about approaches to the orbital floor whereas the
the advantages and disadvantages of transconjunctival approach has been reported
transcutaneous and transconjunctival access to in less than 0.5%9.
the orbital floor and infraorbital rim. Ectropion
is a complication that develops temporarily at For Wilson & Elis III (2006),
least in 28% to 42% of the transcutaneous transcutaneous incisions provide the surgeon

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 SEBASTIANI, A., M.; TRENTO, G., S.; ANTONINI, F.; KÜPPEL, L., E.; SCARIOT, R.; DA COSTA, D., J.; REBELLATO, N., L., B. Cicatricial ectropion
correction in inferior eyelid with cartilaginous tissue graft: Case report. Int. J. Med. Surg. Sci., 1(3):217-222, 2014.

adequate exposure without violating the lateral Evaluation of post-operative care of the
canthal ligament. Holtmann et al., argue that patient, consistent knowledge of periorbital
lateral canthotomy offers adequate surgical anatomy, proper use of existing surgical
exposure in transconjunctival access but inva- resources, concern with function and fashion
des the skin, and the main objective of using are some variables that prevent the
this incision is hidden scar. Lateral canthotomy development of ectropion after surgery
is often used during antransconjunctival (Kanski, 2004).
approach (56% to 83%). From researchs about
blepharoplasty (Spira, 1977; Spira, 1978; Rees The exposure arising from chronic
& Tabbal, 1981), the literature shows that ectropion may result in keratinization of the
transcutaneous approaches have the advantage conjunctiva which contributes to ocular
of reducing the chances of injury to the ocular irritation and can lead to vision loss. There
globe or cornea and are less risky to the deeper are specialized structures in the eyelids
orbital structures. promoting protection to the eyes, numerous
oils, mucus and aqueous producing-tears
Several authors (Rohrich; Feldman et al., glands present within the mucosal lining of
2011; Bahr et al., 1992) agree that subtarsal the tarsus – superior and inferior eyelid
approach in comparison with subciliary approach conjunctiva. The blinking of the eyelids
produce lower risk of vertical shortening of the distributes this complex forming a film on the
inferior eyelid and decreases the incidence of surface of the eyes (Bahr et al ., 1992).
scleral show and ectropion. According to Bahr According to Eliasoph, temporary palliative
et al. this approach provides the most direct treatments are essential for the protection of
and fastest way to the orbital floor compared to the cornea.He recommends the use of artifi-
others transcutaneous approaches. cial tears, ointments, eye protectors that retain
moisture and even temporary tarsorrhaphy,
Patients presenting inferior eyelid among others. The patient presented in this
retraction have in common the absence of report was followed for three months
eyelid support causing an imbalance in the performing massages on the inferior eyelid and
forces that control their position. Common making use of artificial tears, as long as no
causes of ectropion involve direct lacerating improvement was observed, was considered
injuries since when the laceration reaches a permanent ectropion opting for surgical
deep plans intraoperatively, thermal burns and intervention to correction.
chronic sun exposure, and postoperative after
blepharoplasty. The pathogenesis of retraction Treatment with sutures, skin grafts and
is multifactorial. However, the main factors even rotation flaps in the most serious cases
that cause retraction are deficient anterior of ectropion are described in the literature
lamella or skin, scar retraction of the middle (Eliasoph; Goel et al.; Garza et al.) but is
lamella caused by local inflammation and confident that to return the appropriate eyelid
fibrosis after incision, and ligamentous laxity. anatomy and function is necessary restore the
The vertical scar retraction of the middle inferior eyelid intrinsic support which can be
lamella leads to vertical entrainment of the accomplished by cartilaginous grafts. Carraway
eyelid retractor muscles leading to lower & O'Loughlin described a technique using na-
shrinkage with or without eversion of the sal septum cartilage to provide support for the
ciliary margin. As the septum retracts, it inferior eyelid structures attenuated,
shortens the distance between the ciliary emphasizing the importance of making the
margin and the inferior orbital arc (Bahr et release of the deep scar of the
al.). Presence of pellets and devitalized tissue, capsuloligamentous eyelid fascia on the
loss of substance without replacement, dissection for graft implantation and thus
scarification of the eyelids, sutures poorly achieve ideal reconstruction. About 20 eyelids,
made, neglect of post-operative care are some for a period of 12 years underwent
factors that contribute to the occurrence of reconstruction of severe ectropion using this
ectropion after transcutaneous access technique. Reconstructive satisfactory results
(Timoteo et al., 2009). with minimal complications were reported.
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 SEBASTIANI, A., M.; TRENTO, G., S.; ANTONINI, F.; KÜPPEL, L., E.; SCARIOT, R.; DA COSTA, D., J.; REBELLATO, N., L., B. Cicatricial ectropion
correction in inferior eyelid with cartilaginous tissue graft: Case report. Int. J. Med. Surg. Sci., 1(3):217-222, 2014.

Krastinova et al. also described a technique of CONCLUSION

cartilage tissue graftingfor ectropion correction
using auricular concha as donor area, also
reporting success of the technique.In this case, The technique of cartilage tissue grafting
we opted for the removal of cartilaginous tissue from the nasal septum in inferior eyelid is a sim-
as graft. Postoperative recovery was uneventful ple, safe and effective technique for the
with the return of the appropriate eyelid resolution of postoperative permanent ectropion
anatomy and function. of the inferior eyelid.

SEBASTIANI, A., M.; TRENTO, G., S.; ANTONINI, F.; KÜPPEL, L., E.; SCARIOT, R.; DA COSTA, D., J.;
REBELLATO, N., L., B. Corrección de ectropión cicatricial en el párpado inferior con injerto libre de cartíla-
go. Reporte de un caso. Int. J. Med. Surg. Sci., 1(3):217-222, 2014.

RESUMEN: El acceso transcutáneo del párpado inferior se utiliza comúnmente para proporcionar una
exposición adecuada al piso de la órbita y la sutura zygomaticomaxilar durante el tratamiento de las fractu-
ras faciales. Ectropión cicatricial es una rara complicación resultante de la reducción del párpado. Esta
condición puede ser temporal en alguns casos, pero cuando es permanentedebe debe ser corregida
quirúrgicamente con el objetivo de restaurar la función, mejorar los resultados estéticos y para prevenir
transtornos oftalmológicos tales como epífora y ulceración de la córnea. El presente estudio describe un
nuevo abordage quirúrgico, asociado con el injerto cartilaginoso concomitante, para tratar un grave ectropión
del párpado inferior resultante de la incisión subtarsal realizado anterior.

PALABRAS CLAVE: Ectropión; Complicaciones postoperatorias; Cartílago; Tabique nasal

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