This month’s article is a continuation of my article written in May. Below is a discussion of some of the new techniques described for ptosis repair, ectropion repair and entropion repair.
Blepharoptosis Repair
Levator advancement and conjunctival-mullerectomy surgeries are the most popular methods to raise eyelids that have good levator function. Variations described include the small incision levator advancement, and the levator aponeurectomy described by John Martin.
In this technique, through the traditional blepharoplasty incision, the septum is incised and the levator aponeurosis and muscle are exposed. A small rectangle of orbicularis and levator aponeurosis at the superior edge of the tarsus is removed. The cut edge of the levator is then advanced to the lower edge of the subcutaneous deep tissues, thereby advancing the central portion of the levator and effectively raising the lid.
Vrcek et al published their technique of a conjunctiva sparing posterior ptosis surgery back in 2015. This technique allows conservation of anatomically normal tissue, retention of goblet cells, and reduction of suture related complications such as corneal irritation or abrasion. An incision is made just above the superior tarsal plate and a conjunctival flap is dissected and reflected away so that the underlying Mullers muscle is revealed. The appropriate preoperative measurements are marked and the Mullers muscle is clamped with a ptosis clamp.
A suture is run in a serpentine fashion as usual beneath the ptosis clamp. The suture is externalized then reinternalized and run again along the base of the clamp. The suture exits the skin and they are tied to themselves. Mullers muscle within the clamp is excised. The conjunctival flap is then draped in position over the posterior ptosis suture and the lid is everted. There is no need for suturing of the conjunctiva. The group performed this surgery on 30 eyes. There were no corneal abrasions or irritation.
As well as alterations to surgical technique, different variations of the ptosis clamp used for conjunctival mullerectomies have been developed. I took part in the design of the Erickson-Lee ptosis clamp, which is the same concept as the Putterman Ptosis Clamp, but has a curve to the clamp that conforms to the natural shape of the tarsal plate, allowing for a natural and even purchase of tissue. Dr. Sara Wester also developed a variation of the ptosis clamp that allows for the marking suture to be suspended in the clamp to draw up the tissues that will be resected. There are also measurements on the side of the clamp for accuracy.
Ectropion Repair
Dr. Dane Genther, et al. described their technique using a transposed corrugator supercilii muscle-tendon unit flap for contralateral paralytic medial ectropion repair. This study was done in cadavers, so was preclinical and aimed to demonstrate the reasonable feasibility of flap dissection and transposition, as well as the adequacy of length of the corrugator supercilii muscle flap.
We have experience at Bascom Palmer Eye Institute treating cicatricial ectropion secondary to burns, trauma, and post Mohs surgery with reconstruction. We used ablative fractional laser resurfacing on the scar area, followed by topical 5-FU with or without steroids and saw a significant improvement in the tone of the skin and position of the eyelid. Patients were treated at least three times and had improvement each time, with more complete closure, increased comfort and better cosmesis.
Entropion Repair
One of the hardest eyelid conditions to treat is cicatricial entropion. Ron Mancini and Trevor Kerr recently published their data on the use of a shared buccal mucosal graft for simultaneous repair of severe upper and lower eyelid cicatricial entropion.
One week post-operatively, the shared mucosal graft was split. Post-operative photos were taken as well as a description of eyelid position at six weeks, three months and six months. Patients had resolution of entropion and improvement of ocular surface irritation without adverse events or graft failures.
Antonio Cruz et al published their experience using a lid crease approach to upper eyelid margin rotation. Not only does this approach allow the surgeon to address other common lid problems, such as dermatochalasis, retraction and ptosis, but it also allows the sutures to be buried beneath the skin, obviating the need to externalize the sutures and use bolsters. A typical lid crease incision is made. If a blepharoplasty is to be performed, it is done at this point. The anterior lamella is dissected off of the tarsal plate. A 4-0 silk traction suture is placed and the lid is everted. A scalpel is used to make a full thickness incision parallel to the lid margin about 3 mm above the lash line. The lid is returned to its normal position. 6-0 Vicryl sutures are then passed through partial thickness of the distal tarsal plate centrally, medially and laterally. The suture is then thrown through the orbicularis near the lash line. This allows the distal portion of the tarsus to be advanced over the marginal tarsus and correcting the abnormal eyelid position. Ptosis repair or correction of lid retraction can then be performed.
Next month’s article will be a continuation of trends in oculoplastic surgery and will focus on eyelid reconstructive techniques.