[Rari Plastic Surgery] Correcting triangular scleral show, a type of lower eyelid ectropion, with cartilage grafting

Now that you have been following the Rari blog, I think you have become fairly familiar with the term ectropion.

As mentioned in earlier posts, ectropion is not a very common condition.

Rather than true ectropion, where the lower eyelid turns outward, there are more people who complain of ectropion-like symptoms but actually have triangular scleral show caused by lower eyelid shortening.

Lower eyelid shortening refers to a shortened lower eyelid due to burns, scars, or some other reason. When the lower eyelid becomes shorter, it is pulled downward, exposing the white part below the eye and creating triangular scleral show. This also falls within the broader category of ectropion.

Triangular scleral show that develops in this way increases the exposed area of the eyeball, naturally leading to dry eyes, stinging, and, in more severe cases, corneal damage accompanied by redness.

In triangular scleral show caused by lower eyelid shortening, although not as much as in ectropion, slight scleral show and eyelid separation may also be present, so it is natural for patients to complain of symptoms similar to ectropion.

There are several ways to correct triangular scleral show in this condition, including skin grafts, skin + muscle grafts, ear cartilage grafts, and rib cartilage grafts.

This patient had undergone repeated skin grafts over the past decade after a chemical burn under the left eye. Even after several skin graft procedures, the effects of lower eyelid ectropion correction and triangular scleral show correction were minimal.

So this time, our clinic corrected the triangular scleral show using a composite graft procedure combining autologous ear cartilage grafting and skin + muscle grafting.

To accurately determine the degree of lower eyelid shortening, we first made an incision as close as possible to the lower eyelashes and thoroughly dissected the skin and muscle layers.

After checking the dissected area and the degree of lower eyelid shortening, we harvested cartilage from the ear’s conchal area as much as needed for support, placed it in the dissected lower eyelid area, and fixed it in place. Then we identified the empty skin area at the incision site, harvested skin from the double-eyelid line, and grafted it into place.

• Concha

When harvesting ear cartilage, it should be taken in an appropriate amount from an area that will not change the shape of the ear and will not distort it. The cartilage used is mainly conchal cartilage around the external auditory canal inside the ear.

The cartilage fixed inside the lower eyelid here prevents the lower eyelid muscle from sagging and dropping downward, while the grafted skin adds the missing skin that had been lost due to shortening. These two effects provide both clear correction of triangular scleral show and prevention of recurrence.

At the beginning of surgery, it may look as though the triangular scleral show has been overcorrected, but considering that scar contracture may occur at the surgical site, it is better to slightly overcorrect at first.

As shown earlier, one week after surgery it looked as if the left lower eyelid had been overcorrected, but in the photo taken one month after surgery above, you can see that as time passed and the incision scar healed, the overcorrected lower eyelid became more natural.

This is the appearance 10 months after surgery. The reddish color of the surgical site has improved significantly, and the suturing scar of the grafted skin has become almost unnoticeable compared with the early postoperative period.

Even though the patient had undergone several skin grafts before visiting our clinic, the lower eyelid ectropion and triangular scleral show had not been corrected or had recurred. However, with the composite graft of skin and cartilage, the surgical site has remained well maintained even 10 months after surgery, without recurrence of triangular scleral show.

Some people do not want to leave additional scars on the body when having cartilage grafting, so they prefer donor cartilage rather than autologous cartilage for surgery. However, donor cartilage has a higher absorption rate than autologous cartilage ( it does not mean it will absolutely all be absorbed; absorption probability: donor cartilage > autologous cartilage ) so if possible, it is safer to use autologous cartilage during surgery^^

If you have any more questions after reading this post, please leave them in the comments!!