How NOT to get smaller eyes after ectropion repair?

Question

Aggressive lower bleph caused the middle part of my eyelid to lag about 2-3mm..I was told in order to repair them they would get even smaller because of a lateral tarsal strip.. Why do some people have smaller eyes after a repair and others do not when in comparison they had the exact same complication. Is a lateral tarsal strip the cause of a small eye? When there’s only 2-3 mm retracted does someone need a whole reconstruction or is it the whole reconstruction NOT to have that small eye.

Kenneth D. Steinsapir, MD · Answer

Complicating this is that these eyelids can have a component of ectropion.  However, there is typically also full thickness lower eyelid scaring, lateral canthal tendon disinsertion, paralysis of the lower eyelid orbicularis oculi muscle from a transcutaneous lower eyelid incision, outward rotation of the lower eyelid margin waterline, distortion of the lower eyelid shape with a loss of the almond shape.  In addition there is almost always a deficiency of skin and soft tissue in the lower eyelid and a lack of bone projection to support the lower eyelid.  For this reason, reconstruction in my opinion, needs to address each of these factors to achieve a natural reconstructive result.  When these factors are ignored, the surgical correction will be disappointing.  Commonly, eyelid surgeons simply focus on the eyelid tissues and not the reality of the mid face issues.  That is why surgeons try to over correct the lateral canthoplasty.  They are substituting what should be a three prong approach to simply trying to fix every thing with an over aggressive lateral canthoplasty.  In some cases, the surgeon will use steel suture in the belief that a stronger lateral canthoplasty is all that is needed.  These half approaches are not only disappointing and disfiguring, they also do not hold up.  For this reason, I pioneered my approach to repair these injuries using a three pronged approach: Midface lift over ePFTE rim implant, hard palate graft, and  lateral canthoplasty.  By anchoring the vertically lifted soft tissue from the mid face to the rim implant, the weight of the cheek is removed from the compromised lower eyelid tissue.  The shape of the eyelid is also controlled with a hard palate graft that is hidden from view behind the lower eyelid, and finally a canthoplasty can be performed under no tension because it does not need to support the weight of the lower eyelid and cheek.  There is help out there and you are right to question what is being proposed to you.

Mehryar (Ray) Taban, MD, FACS · Answer

Lower eyelid ectropion or retraction repair should NOT make the eyes smaller with proper canthoplasty technique. Most of the work should be on the lower eyelids themselves rather than the canthus.

Samuel Baharestani, MD, FACS · Answer

Thank you for sharing your case.  Are you able to share photos?  There are many different ways to repair ectropion after lower blepharoplasty.  Usually, the  surgery is planned to improve comfort of the eye and to protect it from infection.  While the final appearance is very important, ectropion repair is considered a reconstructive procedure.  Consider a consultation with a board certified oculoplastic surgeon to discuss your condition.  Good luck!

Darab Hormozi, MD · Answer

Repair of ectropion after blepharoplasty, can be tricky !!  All depend on the cause !  id excess skin is removed, then a graft procedure is needed.  If the cause is a loose lateral tendon , then a tarsal strip procedure is the right one.  If the lateral cants is too low , then a lateral cantal elevation might be the correct approach.  You need to see an oculoplastic surgeon with wast experience with these issues to get the proper treatment .

How NOT to get smaller eyes after ectropion repair?

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