Ectropion is condition in which the eyelid is loose or turns out. This usually occurs in the lower eyelid. Patients may notice that the lower eyelid appears to droop showing too much of the white of the eye. In more severe ectropion, the eyelid may turn out to the point that the inside lid appears red and inflamed. Patient with ectropion often complain of red eyes, irritated eyes, or tearing. Severe ectropion may cause the eye to get so dry that corneal abrasion, scarring, or infection may occur.
Ectropion has many causes, but is most commonly due to age related loosening of the eyelid tendons and support structures (involutional ectropion). Ectropion can also be caused by scarring or tightening of the lower eyelid skin (cicatricial ectropion). Nerve injuries can cause ectropion (paralytic ectropion), and tumors can cause ectropion as well (mechanical ectropion).
Ectropion can occur after lower eyelid surgery or lower eyelid belpharoplasty. Ectropion repair is a commonly performed revision eyelid surgery.
Ectropion repair surgery involves tightening and rotating the eyelid into its natural position. Most ectropion surgery is performed under twilight anesthesia as an outpatient procedure or in the office. Pain is usually minimal and swelling or bruising can last 1-3 weeks. It is common for the lower eyelid to appear “over corrected” for the first week or two after ectropion surgery. This over tightened appearance disappears during the healing process.
The technique used for ectropion repair depends on the cause of ectropion itself. A canthoplasty, or lateral tarsal strip is a commonly performed eyelid surgery used to repair ectropion. These procedures involve repairing and reattaching the tendons and tissues on outer corner of the lower eyelid. If the tear duct opening (the punctum) is turned out, then it can be rotated back by a medical spindle procedure. If scarring of the lower eyelid skin is present, then a skin graft or cheek lift may also be necessary. Lower eyelid scarring is a cause of ectropion after prior eyelid surgery or blepharoplasty. If facial paralysis is present, then a lower eyelid spacer graft can be added for support. Ear cartilage, hard palate, and synthetic grafts can all be used as lower eyelid spacers.
Types of Ectropion
Involutional Ectropion (“Age Related” Ectropion)
Involutional ectropion is very common. With age, the tendons and supporting tissues of the lower eyelid can become loose. If these structures become too loose, an ectropion may result. Involutional ectropion is a common cause of irritated or dry eyes. Mild involutional ectropion is a very common cause of tearing and if often mistaken for dry eye. More severe involutional ectropion is very obvious as the lower eyelid turns out and becomes red and irritated. The tear duct opening (the punctum) may turn out as well.
Eyelid surgery for involutional ectropion is usually involves tightening of the lower eyelid tendon by a procedure called a canthoplasty or lateral tarsal strip. If more extensive eyelid surgery is necessary, then a skin graft can be placed. Sometimes the lower eyelid muscle of cheek can be lifted for added support (“orbicularis plication, SOOF lift, or midface lift) to lessen the need for a skin graft. In addition, the tear duct opening (punctum) may need to be rotated back into position by a medial spindle procedure.
Cicatricial Ectropion (Ectropion due to lower eyelid scarring)
Cicatrical Ectropion occurs when scarring of the lower eyelid tissue and skin pull the eyelid down. It usually occurs in combination with a loose eyelid tendon. Cicatrical ectropion may be caused by anything that causes scarring of the lower eyelid skin, including prior lower eyelid surgery, sun damaged skin, and burns. The lower eyelid appears “pulled down” and patients often complain of red, irritated, or watery eyes.
Cicatricial ectropion surgery must address all causes of the problem. Scar tissue within the lower eyelid needs to be released. Then the supporting tendons of the eyelid can be tightened with a canthoplasty or lateral tarsal strip. Finally, a skin graft can by placed to lengthen the lid or a midface lift can be performed to bring additional skin up into the eyelid.
Paralytic Ectropion (Ectropion due to nerve injury)
A nerve called the facial nerve (or 7th nerve), controls the muscle that closes the eye (the orbicularis muscle). When this nerve is damaged, then several problems can occur, including a paralytic ectropion. The lower eyelid loses muscle tone and can drop and turns out. Sometimes the facial nerve can heal, and because of this eyelid surgery is not performed until recovery stops.
Eyelid surgery for paralytic ectropion usually involves tightening the lower eyelid with a canthoplasty or lateral tarsal strip. A lower eyelid spacer graft can also be used if additional support is necessary. The spacer graft is placed with an incision on the inside of the lower eyelid. Ear cartilage, hard palate (the roof of the mouth), or synthetic tissue can be used for the spacer graft.
Mechanical Ectropion (Ectropion due to excess weight of the eyelid)
Mechanical ectropion is usually caused by a growth or tumor that pulls down and turns the eyelid out. Treatment of mechanical ectropion involves surgical removal of the tumor and reconstruction of the resultant defect. This may involve MOHS surgery and eyelid reconstruction.