[Rari Plastic Surgery] The Textbook Surgical Method of Ectropion Correction in Plastic Surgery

Today, let’s look at the surgical methods for ectropion correction as described in plastic surgery textbooks.

This is a surgical method that does not fit the present era or Korean patients, so it is not used much now. However, it was used in the past, and mainly for Western patients.

Unlike East Asians, Western patients have thinner skin and age more quickly, so they often developed degenerative ectropion due to aging.

Unlike cicatricial ectropion, degenerative ectropion occurs without skin excision of the lower eyelid or scar contracture, but rather because of skin laxity and stretching of the orbicularis muscle. So it could be corrected without a skin graft in particular. However, in Korea today, cicatricial ectropion is much more common than degenerative ectropion, and because some cases also involve degeneration on top of scar tissue, a skin graft is usually considered first.

Degenerative ectropion begins gradually from the medial canthus side of the eye and progressively spreads toward the center. For that reason as well, ectropion correction is better done sooner.

Let’s look at the three surgical methods listed in the textbook.

1. Conjunctivectomy

Correction of ectropion on the medial canthus side, when not severe, was relatively simple. The lower eyelid was turned inside out, and part of the anterior conjunctiva was excised in a diamond shape and then sutured.

This method was performed with a thin probe inserted into the lacrimal gland in order to prevent damage to the lacrimal gland, and the topmost apex of the diamond-shaped area to be excised had to be about 0.5 mm to 1 mm below this duct.

When the inner conjunctiva was excised and sutured, the length of the conjunctiva became relatively shorter compared with the everted outer skin, thereby correcting the ectropion. This method is good for restoring the lacrimal gland to its original position, but because recurrence is common, slight overcorrection was considered better for the outcome.

2. Lazy T

This method is an extension of conjunctivectomy, and a corrective approach developed for more definite correction.

Whereas conjunctivectomy involves removing a small diamond-shaped area of conjunctiva from the front, this method makes a horizontal incision along the lower eyelid conjunctiva and then draws it together to excise the overlapping portion in a long segment.

Then, based on the lacrimal gland area as a landmark, adequate vertical incisions are made in the skin on the lateral side, the skin is pulled in the same way, and the overlapping portion is removed in a triangular shape.

After that, the surgeon sutures in order using the designated thread, starting from the inner conjunctiva, then the mucosa, skin muscle, and outer skin.

This method is effective for degenerative ectropion like the one described above, but it may leave a long vertical scar near the inner corner of the eye, so it can be considered a surgical method that is difficult to apply in Korea.

3. Lateral canthal tendon fixation

This surgical method, which is also one of the most commonly used, is the opposite of the “Lazy T” method and corrects ectropion by pulling the lower eyelid on the lateral canthus side. The skin and ligament at the lateral canthus are partially incised and released, then the ligament is pulled to an appropriate degree and fixed, and the excess skin is removed together with the eyelashes and sutured.

Although the “Lazy T” method is more difficult as a procedure itself, it only involves the conjunctival and skin layers, so lateral canthal tendon fixation, which creates horizontal tension by pulling the ligament, was more firmly fixed and more commonly used for correcting degenerative ectropion.

This surgical method was also sometimes combined with the conjunctivectomy described above to be used more effectively.

According to a paper published in a journal, the causes of ectropion were cicatricial in 60.1%, paralytic in 23.2%, and senile in 16.7%. Source: https://doi.org/10.3341/jkos.2014.55.7.953

As such, because today’s Korean ectropion patients are more often cicatricial than degenerative, there may be limits to ectropion correction, or cases in which correction is not possible, if surgery is performed using only the methods above without a skin graft.

Therefore, for patients who have lower eyelid shortening due to surgery or burns and lack sufficient skin, a skin graft is used. For patients who need not only a skin graft but also internal support due to accidents or bone abnormalities, a cartilage graft may be added to the skin graft.

It is important to find the correct corrective method according to the cause and perform surgery appropriate to the patient’s condition.