Ectropión en cirugía dermatológica: exploración y técnicas reconstructivas / Ectropion in Dermatologic Surgery: Exploration and Reconstruction Techniques

El ectropión o eversión del párpado, es la malposición palpebral más frecuente. Al alterar la función protectora palpebral puede causar epífora, lagoftalmos, queratinización, irritación crónica, dolor o ulceración. Se distinguen 5 tipos de ectropión en función de su mecanismo causal: congénito, paralítico, involutivo, cicatricial y mecánico. Lo más habitual en dermatología, es la presencia de ectropión de tipo mixto, con elementos involutivos y mecánico-traccionales. Existen varias técnicas reparadoras de ectropión cuya indicación dependerá del componente patogénico principal. Revisamos la anatomía básica palpebral y exponemos la técnica exploratoria que nos permitirá analizar el riesgo de ectropión para prevenir su aparición o determinar la patogenia del ectropión ya establecido para definir la técnica reparadora más apropiada

Ectropion, or eyelid eversion, is the most common form of eyelid malposition. By impairing the eyelid's protective function, ectropion can cause epiphora, lagophthalmos, keratinization, chronic irritation, pain, and ulceration. There are 5 types of ectropion, each with a different cause: congenital, paralytic, involutional, cicatricial, and mechanical. The most common presentation in dermatology is involutional eversion with a mechanical or tractional element. Several options exist for the surgical repair of ectropion and choice of technique will depend on the main pathogenic component. We review the basic anatomy of the eyelid and describe examination techniques for assessing risk and preventing ectropion and for identifying the main pathogenic component in order to select the most suitable repair technique

Preventing Lateral Canthal Malposition in Modern Blepharoplasty.

Current goals in lower eyelid blepharoplasty include blending the lower eyelid-cheek junction, which is highlighted in the authors' six-step lower lid blepharoplasty technique. One major question in lower lid blepharoplasty is how to prevent lower lid malposition and ectropion, because these are untoward outcomes after an aesthetic procedure. In the authors' technique, they perform a superficial lateral retinacular canthopexy that is effective and safe and also prevents lower lid malposition or ectropion. A retrospective review of 104 patients who underwent six-step lower lid blepharoplasty was performed. In the authors' series, there was no significant difference between preoperative and postoperative intercanthal angles (p < 0.05), and the lateral canthal position did not change significantly from its preoperative position. The authors' six-step blepharoplasty technique addresses signs of midfacial aging, and the lateral canthopexy technique has been shown to have a minimal complication rate and maintains canthal position. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

The Need for Overcorrection When Using a Suborbital Cervicofacial Hike Flap.

BACKGROUND: The senior author has previously described a deep-plane cervicofacial hike flap as a workhorse for reconstruction mid-cheek defects. One important modification commonly used involves overcorrection of the defect in order to reduce the incidence of ectropion. This report outlines the senior author's experience in surgical treating complex cheek defects with an overcorrected deep-plane cervicofacial hike flap. METHODS: The authors performed a retrospective review of the senior author's patients with cheek and eyelid reconstruction. The authors initially identified all patients who had undergone a deep-plane cervicofacial hike flap, then filtered those charts for patients who had overcorrection of their deformity in order to prevent ectropion. RESULTS: A total of 3 patients had an overcorrected flap. Overcorrection was accomplished either by cheek advancement with suture fixation to the deep temporal fascia, or by placement of drill holes and bone anchors. Lower eyelid malposition was avoided in all 3 patients. Patient satisfaction at long term follow-up was very high, and no revision surgery was needed. CONCLUSION: If gravitational or cicatricial forces can potentially distort the eyelid in patients with cheek or eyelid reconstruction, it is necessary to overcorrect the cheek flap. This modification of the deep-plane cervicofacial flap is an important tool in reconstructing defects in this area.

[Lateral canthopexy - a simple addition to lower lid blepharoplasty]. / Die laterale Kanthopexie - eine wenig aufwendige, wertvolle Ergänzung der Unterlidblepharoplastik.

Rejuvination of the lower lid is a challenging procedure. Lower lid malposition and ectropion are serious postoperative complications. Therefore presurgical assessment of the lower lid function and laxity are a must before performing a blepharoplasty. Lateral canthopexy is an effective procedure to minimise the risk of postsurgical ectropion. Its necessity increases with rising age of the patients. The canthopexy supports the lower lid postion in the case of increasing vertical tension.

The V-Y advancement flap is equivalent to the Mustardé flap for ectropion prevention in the reconstruction of moderate-size lid-cheek junction defects.

BACKGROUND: Lid-cheek junction defects represent a reconstructive challenge because of the susceptibility of the lower eyelid to ectropion. To minimize the inferior tension placed on the lid margin, classic teaching advocates for the use of cervicofacial rotation-advancement flaps as popularized by Mustardé. Despite this approach, ectropion can still be problematic, and elevation of the cheek poses its own set of potential complications. An inferior-to-superior V-Y advancement flap has also been described, but its use is often limited because of the perceived increased risk of ectropion. This study attempts to define this risk by investigating the incidence of postoperative ectropion between cervicofacial and V-Y flaps for the reconstruction of lid-cheek junction defects. METHODS: All patients who underwent reconstruction of lid-cheek junction defects performed by the senior author (D.L.B.) between January of 2002 and March of 2009 were reviewed retrospectively. Only cervicofacial (n = 11) and V-Y flaps (n = 23) were included in the analysis. Patient demographics, defect size, operative time, hospital stay, and postoperative complications were extracted from the clinical record. RESULTS: Nine patients in the cervicofacial group (82 percent) and three patients in the V-Y group (13 percent) experienced a postoperative complication (p = 0.0002). Three cases of ectropion were observed, including two patients in the cervicofacial group (18 percent) and one in the V-Y group (4 percent, p = 0.24). All cases resolved with conservative management. CONCLUSIONS: No difference in ectropion rate was found between the cervicofacial and V-Y groups. The versatility of the V-Y advancement flap is perhaps underestimated in this clinical context. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Barbed suture suspension technique for prevention of lower eyelid ectropion after Mohs micrographic surgery.

Mohs micrographic surgery of the lower eyelid poses a risk of ectropion. Even though the lower eyelid is a very frequent location for basal cell carcinoma, prevention techniques for ectropion after Mohs micrographic surgery have rarely been introduced. After Mohs micrographic surgery of the lower eyelid, the authors applied a barbed suture suspension technique for the prevention of lower eyelid ectropion. Following primary wound closure, barbed sutures were prepared by cutting one side of a 4-0 Prolene suture and applied around the lower eyelid. Sutures were maintained for 7 days and then removed. Evaluation 10 weeks after surgery found that ectropion had been minimized or prevented entirely.

Orbitomalar suspension during high SMAS facelift.

BACKGROUND: Traditional facelift techniques have some limitations: superficial musculo-aponeurotic system (SMAS) dissection may be incomplete in the superior medial orbitomalar region, and the centrofacial approach does not incorporate SMAS elevation. OBJECTIVES: Orbitomalar suspension (OMS) during high SMAS facelift combines the best of other techniques and may enhance aesthetic results and improve blending of the eyelid-cheek junction while minimizing the risk of lower eyelid ectropion. The authors examine the efficacy and complication rates of the OMS procedure. METHODS: Sixty patients underwent OMS as a primary component of high SMAS facelift and lower blepharoplasty. The technique is designed to accomplish superior-medial repositioning of the cheek while stabilizing lower eyelid position, reducing the risk of postoperative ectropion. RESULTS: Minor complications related to the OMS procedure occurred in three patients, all of whom had palpable and slightly visible Vicryl knots on one or both lateral upper eyelids. In one patient, the right side was reopened with a limited incision and the knot was removed. One case of lower eyelid malposition occurred and required revision. This patient presented on day three with unilateral left ectropion (2 mm), but the broken suture was easily replaced under local anesthesia, and the patient had no further ectropion. Two patients had transient lower eyelid malposition, which resolved within four weeks of surgery after gentle massage and lateral eyelid support with steri-strips. Two patients with prominent eyes and inferior orbital rim recession (negative vector) were not fully corrected; however, their lid position was no worse than the preoperative position and curvature. CONCLUSIONS: OMS during high SMAS facelift complements the deeper plane by adding a medial and superior vector of elevation to the cheek. Blending of the lower eyelid-cheek junction is accomplished with little risk of lower eyelid malposition.

[Prevention and management of locoregional complications of botulinum A toxin injections in cosmetic treatment]. / Prévention et gestion des complications locorégionales des injections de toxine botulique A en esthétique.

Botulinum toxin serotype A injections used in treating dynamic wrinkles is one of the least invasive cosmetic procedures. High patient satisfaction and low onset of always moderate side effects contribute to the growing popularity of botulinum toxin injections in cosmetic treatment over the past few years. Years of experience and use, in therapeutics [1,2] and esthetics (20 years) have proven the efficacy and the safety of this wrinkle treatment. Today, no severe or long-term side effects have been reported in esthetics. This article discusses only the most frequent locoregional effects. They are rare, moderate, transitory, and totally reversible. Properly informing and selecting patients will contribute to successfully preventing and managing these effects.

Cantopexia lateral como procedimento primário em blefaroplastia inferior / Lateral canthopexy as primary procedure in lower lid blepharoplasty

Introdução: A retração cicatricial da pálpebra constitui complicação comum do pós-operatóriode blefaroplastia inferior. Objetivo: Neste artigo, discute-se a importância de associarsistematicamente a cantopexia lateral à blefaroplastia inferior para reduzir sua incidência.Método: Estudo retrospectivo de 200 pacientes submetidos a blefaroplastia inferior transcutâneaou transconjuntival associada ou não à cantopexia lateral proposta por Lessa, comseguimento de 12 meses. Resultados: No grupo de pacientes submetidos a blefaroplastiainferior com cantopexia lateral observou-se índice de 1% de retração cicatricial, contrastandocom 16% dessa complicação no grupo que realizou a blefaroplastia inferior isolada.Discussão: A indicação sistemática da cantopexia lateral associada à blefaroplastia inferiordivide as opiniões de diversos autores. Por sua fácil execução, baixa morbidade e eficáciacomprovada na prevenção da esclera aparente, do arredondamento do canto lateral do olhoe do ectrópio pós-blefaroplastia inferior, os autores defendem a opinião de que a cantopexialateral deve constituir procedimento primário em cirurgia de blefaroplastia inferior.

Introduction: The lid scar retraction constitutes usual complication of the postoperativelower lid blepharoplasty. Objective: This article discusses the importance of the systematicassociation of the lateral canthopexy in lower lid blepharoplasty to reduce its incidence.Method: In this retrospective study, 200 patients were assigned to the transcutaneous ortransconjunctival lower lid blepharoplasty linked or not to the Lessa’s lateral canthopexy,with a follow-up of 12 months. Results: The patients group submitted to lower lid blepharoplastywith lateral canthopexy had 1% of scar retraction against 16% in the isolated lowerlid blepharoplasty group. Discussion: The systematic indication of the lateral canthopexyin association with lower lid blepharoplasty brings different opinions of many authors.For its easy execution, low morbidity and confirmed effectiveness in the prevention of thescleral show, rounding of the lateral canthus and ectropion post lower lid blepharoplasty,the authors conclude that the lateral canthopexy must constitute primary procedure in lowerlid blepharoplasty surgery.

Full-thickness lower eyelid reconstruction with a conchal chondro-perichondral graft and local coverage with Mio-cutaneous flaps--our divisional experience.

BACKGROUND: Eyelid reconstruction represents a challenge because of the complexity of this structure. Full-thickness eyelid defects demand the reconstruction of 2 fundamental elements: anterior and posterior lamellae. The available reconstructive techniques are all associated with the attention to restore the support and responsibility of eyelid stability, represented physiologically by the tarsus. In 1987, Matsuo proposed a reconstructive technique that involved the use of a chondro-perichondral graft harvested from the auricular concha to reconstruct the posterior lamella, and an adjacent skin flap to restore the anterior lamella. MATERIALS AND METHODS: We report our divisional experience of a series of 28 patients operated on from 2000 to 2004, whose eyelid restoration was achieved with the use of Matsuo's technique modified with the purpose to avoid complications such as ectropion or lagophtalmus. RESULTS: All the grafts survived, and no major complication such as ectropion or lagophthalmos has been detected. Our specialistic judgment has ranged from good to excellent regarding symmetry, eyelid closure, and donor site morbidity. Patients were entirely satisfied with the functional result obtained, and generally with the esthetic outcome also, judged as ranging from good to extremely satisfactory. CONCLUSIONS: The success of eyelid reconstruction using modified Matsuo's technique depends, in our minds, on an adequate knowledge of traditional eyelid reconstruction methods, and on a few technical fine points that help to reduce postoperative complications and to optimize the quality of the end result; hence, this technique has become the gold standard in lower eyelid reconstruction in our division.