Correction of Ectropion in Secondary Blepharoplasties Trough the Transconjunctival Approach

Goals/Purpose: Lower eyelid malposition is the most common long-term complication following transcutaneous lower eyelid blepharoplasty. The malposition may include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, or ectropion. The result is cosmetically unacceptable and may be associated with tearing, irritation, and other exposure keratitis symptoms. We present the transconjunctival approach for secondary lower eyelid blepharoplasty presenting ectropion in 27 patients based on the mobilization of the orbicularis oculi muscle and canthopexy.

Methods/Technique: From January 2004 to January 2013, 27  patients, 21 females and 6 males, from 46 to 74 years old, were treated with this technique. All patients presented bilateral different degrees of scleral-show, lower lid laxity and ectropion. The majority of the patients were submitted to associate facial surgeries. A horizontal line 2 cm of extension is marked laterally beginning at the lateral cantus. Inside this line is marked a 1.5 cm extension line that begins at the point where the lateral orbital rim is palpable through the medial direction. This line represents the extension of the orbicularis oculi miotomy. (Fig. 1) A vertical distance is marked beginning at the lateral border of the eyebrow.(Fig. 1) The surgery begins with the superior bepharoplasty with the excision of skin and when necessary fat. In the lower lid a transconjunctival horizontal incision is made 6 mm below the lid margin with the CO2 laser. (Fig. 2) The incision transfixes the conjunctiva and the orbicularis oculi muscle. The margin of the muscle is pulled gentle upward with two hooks. At this point the scars are released and a degree of lid elevation is achieved.  This procedure also exposes the posterior border of the muscle and septum and provides visualization to perform the fat treatment by resection or transposition. Patients maintained the muscle integrity after the first surgery a defocused CO2 laser bean may be passed across the posterior exposed border of the orbicularis oculi muscle and septum using the cutting hand piece. (Fig. 3) After this the muscle is dissected and released from the medial and lateral malar periosteum whiteout damaging the connections to the arcus marginalis.  In the lateral malar area the orbicularis oculi muscle is isolated from the skin. At this point a sub-muscular dissection is done through the superior blepharoplasty lateral incision in order to expose the temporalis fascia and the orbital lateral border. This procedure allows the union of the dissected area at the inferior and superior eyelid. (Fig. 4) A miotomy is done in the lateral portion of the orbicularis muscle with 1.5 cm extension according to the outer skin previous mark. The muscle border is now pulled upward. The traction shows the amount of flap can be elevated. (Fig. 5) The inferior muscle flap is fixed to the fascia temporalis and the orbital lateral border. (Fig. 6) The superior muscle edge is sutured over the inferior muscle flap with nylon 5-0 in order to overlap both muscles fragments to prevent skin depression in this area. The lateral canthal ligament is attached to the periosteum of the orbital rim with two braided polyester sutures through the upper blepharoplasty without canthotomy, The incision in the superior eyelid is closed with non-absorbable 5-0 suture. The transconjunctcval incision is left unclosed. The vertical distance is again evaluated. (Fig. 7) In selected patients with excess skin, laser resurfacing of the marked area (fig. 1) is performed one pass with feather touch set at 22 watts. Occlusive dressing is used up to 10 days.

Results/Complications: From the 27 patients, 26  achieved an improving of the ectropion, scleral show or lid laxity, one patient presented unilateral recurrence 20 days after the surgery. Fig 8, 9, 10 and 11 show 1 year follow-up. The transient postoperative intercurrences are listed in the Table 1.The vertical marked distances diminished in all patients as shown an example in fig. 7. (4.5 cm to 4,.0 cm), showing the efficacy of the muscle flap elevation.

Conclusion: The correction of the complications following inferior blepharoplasty through the transcutaneous access may be more difficult and promote skin retraction. The ability to perform all the surgical steps through the transconjunctival access including the muscle mobilization, scar release and canthopexy prevents most of these complications. The important step of this procedure is the facility to mobilize the orbicularis oculi muscle and the possibility to excise, to elevate and to fix it in the superior orbital area exactly as described by other authors through the transcutaneous approach. In conclusion, it is possible to perform blepharoplasty revision including the necessary muscle procedures with success through the transconjunctival approach.

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