A Nightmare in the Aesthetic Surgery of the Lower Eyelid: Ectropion
19 March 2020 onur
The only ultimate goal of plastic surgery is to make sure individuals are “happier and healthier”. Unfortunately, as in all surgical procedures, complications and undesirable results are possible in operations around the eyes. In the preoperative information process, getting information about such complications and knowing what we do and how we think to prevent them will give you a more comfortable postoperative period.
What is Ectropion?
Ectropion is one of the most feared and unfortunately one of the most common complications in lower eyelid surgery. Ectropion means that the ciliated border of the lower eyelid turns downward and outward, moving away from the eyeball. When the eyelid borderline turns downward, the white part of the eye becomes more visible. Just type “ectropion” on Google images to see what ectropion is. It is a nightmare for both patients and physicians. It can be corrected but requires a difficult treatment process.
What’s the downside?
Ectropion presents an unpleasant visual appearance. So much so that after an aesthetic surgery to look more beautiful, to reduce under-eye bags and wrinkles, you may suddenly become unable to sustain your social life. You may have to stay away from social relations for up to 3 months or walk around in a camouflage such as sunglasses for the sake of sociability, as you have never planned before. When the lower eyelid moves away from the eye, the moisture balance in the eye is disturbed, and the eye may dry out. In some cases, the eye muscles cannot move freely and complaints such as blurred vision and double vision may develop. The problem in the lower eyelid often disrupts the dynamics of the upper eyelid as well.
What is the reason?
Excessive skin removal from the lower eyelid during lower eyelid surgery is the most “usual” reason. Plastic surgeons know this very well and rarely remove more than 3-4 millimeters of skin. Therefore, if you have developed ectropion after surgery, do not immediately think that a surgeon has removed too much skin and thus the terrible result. In the cases of ectropion I have seen and treated, the surgeon has actually removed skin excessively only in a few.
“The key point in the development of ectropion is the deficiency of the lower eyelid support systems.”
Deficiency of bone support: In cases where the bone skeleton around the eyes is deficient, the lower eyelid support is impaired. In some congenital diseases, ectropion can be observed even in childhood due to an incomplete development of facial bones. In elderly patients, bone support around the eyes decreases due to osteoporosis. We measure bone deficiency before surgery. In principle, if the bone under or next to the eye is behind your eye level, the risk of ectropion after lower eyelid surgery is high. If your eyes are ahead of the bone level (as in thyroid gland diseases), this increases the risk of ectropion as well.
Deficiency of muscle strength: Ectropion may develop independently of lower eyelid surgery in patients with facial paralysis or in cases where the branch of the facial nerve extending to the lower eyelid is injured.
Deficiency of connective tissue: This is one of the most common causes in the elderly patient group. Sometimes, the lower eyelids of elderly patients may turn down or out, despite no history of surgery. Connective tissue deficiency concerns all layers of the lower eyelid. The most common form of connective tissue deficiency is the deficiency in the outer edge. The outer edge is called the “lateral canthus” in medicine. This area is normally the place where the lower and upper eyelids come together and attach to the bone next to the eye with the help of a tendon. Normally, this tendon is quite tight, and the distance between the external angle and the bone is 2-3 mm. As the distance increases or the tendon relaxes, the support for the lower eyelid decreases.
Deficiency of eye tilt: There is a tilt of about 3-8 degrees between the inner and outer corners of the eye. The outer corner is usually above the inner corner. In cases where this tilt is zero degrees or even negative (i.e. if the outer corner is below the inner corner), the risk of “ectropion” is high.
Skin deficiency: Anything that reduces or shortens the skin of the lower eyelid can turn the eyelid down and out in the presence of the aforementioned factors. Removal of skin from the lower eyelid for aesthetic purposes, tumor removal from the lower eyelid, lower eyelid burns, chemical peeling processes and traumas may cause skin deficiency in this area.
Abnormal tissue healing / Scar Contracture: Following any type of tissue trauma, the body produces a healing tissue. This healing tissue is sometimes overproduced, and sometimes a condition called scar contracture occurs during healing. Scar contracture means wound shrinkage. Healing tissue shrinks and deforms surrounding tissues. This is the reason for most ectropion cases we see after plastic surgery. In the first 3 months after surgery, the body constantly produces healing tissue. This tissue decreases and softens between months 3 and 6 and is completely dissolved by the body within a year.
Deficiency of cheek support: The lower eyelid is normally supported by cheek tissue from below. The risk of ectropion arises if the cheek tissue is developmentally low or if it is in a position that cannot support the eyelid during the aging process. In a study we conducted during my senior residency, we found that the risk of ectropion was less than 1% (10 times less than normal) in lower eyelid surgeries performed in combination with facelift surgery.
Extremely large bags under the eyes: In individuals with very large under-eye bags, these bags begin to support the lower eyelid from below, like a Pilates ball. This support is abnormal. When large bags are surgically removed, this support is lost and the lower lid droops down, now that it lacks support. Particularly male patients over the age of 60 should be very careful with this.
Lack of Surgical Experience: Aesthetic surgery around the eyes requires special experience. Although plastic surgeons are considered competent in this field, standard training may not be sufficient, especially in unusual and risky cases. This is so in every field of surgery, engineering, and craft. In principle, if you have had ectropion after aesthetic eyelid surgery, it would be wise to seek advice from another physician who have greater relevant experience after consulting with and getting the approval of your own doctor. No place for egos in such a case. In every specialty, there is always a doctor with more experience.
Bad Luck: Ectropion may sometimes occur even when all conditions are optimal. It may not develop in 10 people with the same conditions, but you may still experience it. Unfortunately, in medicine, as in life, one can complain about bad luck. One of my current scientific research areas is what we can do to not leave our work to chance, and I will inform you a little more about it.
How Can It Be Prevented?
When evaluating patients for lower eyelid surgery, the aforementioned risk factors should be reviewed. What’s key is not to operate on patients in the risk group. Experienced physicians are better able to discern risky patients and the surgeries to avoid. Negative past experience distracts them from unnecessary “self-confidence”. In some series, complications in lower eyelid surgery range between 15-30%. This is because most patients have one or more of the aforementioned risk factors. If you only operate on risk-free patients, you will have to reject 8 out of 10 patients. The absence of preoperative risk factors in the remaining 2 patients does not reset the risk of ectropion.
My Personal Prevention Strategy
- For the reasons I mentioned above, I analyze the risk factors in each patient and include preventive maneuvers in surgery.
- We do not remove more than 4 millimeters of skin in any patient. This size certainly does not exceed 1-2 mm in the inner half of the eyelid. My advice to my younger colleagues goes as follows: Set your patients’ expectations to a realistic level before surgery. It is completely normal and necessary to have some wrinkles on the lower eyelid skin after the operation. Never remove skin excessively, just to satisfy patients’ obsession with tight/wrinkle-free skin. Make sure you tell them that it is “inevitable” for some lower eyelid wrinkles to occur after surgery along with mimic wrinkles. Lower eyelid surgery does not remove mimic or compression wrinkles. Excessive resection may look good on the operating table, but remember that when the patient stands up, the cheek and the entire face will come down by 3-4 mm.
- I support the bone structure with implants in patients who have bone support deficiency.
- In cases where muscle strength is insufficient, I shorten the muscle under the eye, tighten it and suspend it upwards. I have a surgical technique that I have developed myself and called Extended Lateral Access Lower Blepharoplasty. This technique is particularly designed for patients whose eyes are ahead of the bone structure.
- We fix the external angle of the eye to the bone in order to support the eyelid in every patient regardless of whether they have a deficiency of connective tissue.
- We reconstruct the external angle of the eye at a higher position on the bone in patients with an insufficient eye tilt.
- In individuals with insufficient cheek support and excessively large under-eye bags, we combine the surgery with procedures such as midface lift or high SMAS face lift, which lift the cheek upwards and support the lower eyelid from below.
- We use microcautery at microsurgical precision to minimize pathological scarring.
My approach is a little more comprehensive and therefore aggressive. Additional protective procedures such as orbicularis muscle flaps, canthopexy on the bone, midface lift, canthal reconstruction and bone implants extend the postoperative recovery period. The operation takes longer and its cost increases. The recovery period is normally 7-10 days but may extend up to 3-6 weeks. Eyes may remain slanted for a long time, with facial edema staying up to 3 months. This is the only way we can keep complications at a minimum.
How Is Ectropion Treated?
Ectropion treatment is cumbersome.
The simplest treatment is to wait. Most of the “mild” cases of ectropion automatically gets better within 3-6 months. In mild cases, it is best to avoid additional surgery if the person is fine with a social standby. This is because repetitive surgeries may increase scarring.
In advanced cases of ectropion, waiting may not be an option in terms of the person’s eye health and psychological health.
In most revision surgeries, it is necessary to lift the cheek tissue with a midface lift, fix the external angle to the bone at a high position and correct the tissue deficiencies in the skin and inner layers of the eyelid through tissue transfer. Inner layer deficiencies can be eliminated by harvesting tissue from the inner mouth, and skin deficiencies can be eliminated by harvesting skin from the upper eyelid or behind the ear. This is an operation that takes 5-6 hours and takes 3 months to heal. Even with this surgery, it will not be possible to achieve a hundred percent improvement or a hundred percent symmetrical eye shape.
Ophthalmologists frequently prefer the “tarsorrhaphy” procedure, in which the upper and lower eyelids are permanently sutured together to protect eye health in case of ectropion. It is a very reasonable alternative from a health perspective, but it permanently narrows down the horizontal opening of the eye and creates the appearance of a smaller eye. Therefore, I prefer to use the “tarsorrhaphy” procedure as a last resort.
The skin transplants we perform while eliminating eyelid skin deficiencies may look like a patch in the early period, but in the long run (3-6 months), they heal well enough to be camouflaged under a single layer of foundation.
There are geometric tissue transfer techniques that transfer the cheek skin to the lower eyelid, particularly in elderly patients. These methods are both simple and very effective. However, they leave a distinct mark on the cheek. In elderly patients, these scars both heal very well and are camouflaged between natural wrinkles. We frequently prefer such options, which we call “local flaps”, especially in cases of ectropion that occur after tumor surgery.
Even that was too much detail.
If you are suffering from ectropion, you will think, “No Doc, you haven’t written enough.”
If you are a candidate for lower eyelid surgery, what you read probably frightened you.
But at least you have an idea about the seriousness of this problem and the vastness of our field of science.
Please feel free to contact us for more detailed information on complications in eyelid surgery and treatment alternatives.
Take good care…
… of yourself and your beauty.
All maneuvers not performed during primary surgery should generally be performed in revision surgery.