Dr. Nitin Soni, S19234, Dr.Elesh Jain, Dr. Ram Kishore Shandilya, Dr. Narendra Patidar
Chief Author Dr. Nitin Soni , Co. Author Dr. Ram Kishore Shandilya , Dr. Elesh Jain
Department of Ophthalmology SadguruNetraChikitsalaya ,Chitrakoot
Introduction –
Ectropion is an eversion of the eyelid margin away from the globe and is commonly classified according to its etiology: involutional, cicatricial, paralytic, mechanical, or congenital.
Cicatricialectropion – CicatricialEctropion occurs due to scarring of the skin.Common causes are Thermal burns, Chemical Burns, Trauma (Lacerating Injuries) Skin Ulcers , Post surgical (Mass excision etc…) .
Grading of Ectropion- Grade 1 – Only punctum is everted ,Grade 2 – Lid margin is everted and palpebral conjunctiva is visible , Grade 3 – Above + Fornix is visible .
Management of cicatricial ectropion – Depending upon the the degree of ectropion it can be managed by following procedures – V-Y Procedure – mild ectropion , Z Plasty ( Elschnig’s procedure – mild to moderate ectropion and Full thickness Skin Grafting in cases of severe ectropion.
Full thickness skin grafting (FTSG) – FTSG is done in severe ectropion along with the removal of scar tissue . Graft can be taken from – post auricular area , upper lid , upper arm , supra clavicular area.
Successful surgical management of eyelid ectropion depends on measures that lengthen the vertically shortened anterior lamella, in addition to addressing coexisting anatomic abnormalities. Lysis of subcutaneous adhesions with placement of a full-thickness skin graft is one surgical option. The purpose of this study is to
provide a detailed description of the surgical technique, and to retrospectively review the outcomes of a series of patients.
Aim:
To retrospectively review full thickness skin grafting for repair of eyelid cicatricial ectropion.
Methods: Study Design – A retrospective, noncomparative chart review of all patientswho underwent lower eyelid ectropion repair with full-thicknessskin grafting betweenbetween april2012&march2015.
Patient lists were generated using billing codes for repair of ectropion and full thickness skin graft as well as by reviewing surgicallogs. The medical records were reviewed for the identified patient’setiology of lower eyelid ectropion, demographic information includingage, gender, , laterality, skin graft donor site, and additional
surgical procedures.
Patients were included who had cicatricialectropion secondary to stricture aftertrauma,burn ,postsurgical,chronic blepharitis,HZO,insect bite,chronic dacryocystitis . Patients were excluded who had congenital skin anomalies ,anophthalmic Socket Contracture.
The primary outcome measure was the surgical success rate, definedby resolution of ectropion on follow-up clinical exam as judgedby the surgeon. An additional outcome measure included viability ofthe skin graft, which was defined as survival of the initial graft withoutreplacement or removal and without complications including hematomaformation, graft contracture, or need for additional surgery.
Surgical Technique –
Release of Eyelid Cicatrix. After injectionof local anesthetic and placement of two 4-0 silk traction sutures in the margin of the eyelid, an incision was madewith a #15 blade through skin only below the lash line . The blade was then used to sharply dissect in the plane between skinand underlying orbicularis muscle along the horizontal width of theeyelid until all of the white vertical cicatricial bands on the surfaceof the orbicularis muscle were lysed and the eyelid margin was raised
to a normal anatomic position with good apposition to the globe. The horizontal and vertical dimensions of the resultant skindefect were measured.
Harvesting of Skin Graft. After the donor site was selected, site marked according to the shape of the defect with a surgical marking pen and infiltrated with local anesthetic. Theskin was incised with a #15 blade and sharply dissected from the underlyingsubcutaneous tissue with scissors. The underside of the graftwas thinned by removing all subcutaneous tissue. The skin graft wasset aside in wet gauze. The donor site defect was closed with absorbablesutures.
Placement of Skin Graft. The graft was positioned over the lowereyelid skin defect and trimmed to match the size of the defect. The graftwas secured using interrupted 6-0 vicryl anchoring sutures followed byrunning 6-0 plain gut suture along the length of the graft. Thepreviously placed 4-0 silk sutures at the lower eyelid margin were securedto the forehead as Frost sutures.
After applying ophthalmic antibiotic ointment, a pressure patch wasfashioned with nonadherent dressing, eye pads, and tape. The pressuredressing and Frost sutures were left in place for 4–5 days. Upon removal,the patient was instructed to use antibiotic or steroid–antibioticcombination ointment to the graft 4 times per day.
RESULTS
Thirty six patients with cicatricialectropion, who had undergonerepair with full-thickness skin grafting were identified.The causes of cicatricialectropion which were included weretrauma(16,44.44%%), burn(10,27.77%), post Surgical(4,11.11%), chronic blepheritis(2,5.55%), HZO(2,5.55%), insect bite(1,2.77%), chronic dacryocystitis(1,2.77%).
Most common location of ectropion was total lid (11,30.50%), followed by medial 1/3rd (10,27.7%), lateral ½(8,22.20%) , lateral 1/3rd(5,13.80%) ,middle 1/3rd(2,5.50%)and medial ½(2,5.50%).
Out of 36 patients 16(44.4%) were males and 20(55.6%) were females .Mean patient age was 38.15 years ( range 1.5 – 81 years ). The average Delay in Presentation was 40.95 months. Upper lid in 9 patients , lower lid in 25 patients and both lid in 2 patients. 21 right eyelids and 15 left lower eyelids were included.Donor sites for grafts included upper eyelid (2, 5.6%), inner brachial skin (1,2.8%),postauricular skin (33,91.6%). The follow-up period ranged from 1 to 18months, with a mean of 9months.Out of 36 patients primary skin grafting was done in 34 cases and in 2 cases skin grafting was done secondarily.
Thirteen of 36 eyelids (36.11%) in the series underwent one ormore additional procedures at the time of full-thickness skin grafting.Additional procedures included lateral tarsal strip (7 eyelids, 19%),punctoplasty (1 eyelids, 2.77%), canthoplasty (5 eyelids, 13.9%),ipsilateral external dacryocystorhinostomy (1case, 2.77%),
and lesion removal (1 eyelid, 2.77%), Z Plasty (1,2.77%), pentagon excision(2,5.55%) Lateral tarsal strip was themost common additional procedure in 7 eyelids, 2 of which also had concurrent canthoplasties.
The surgical success rate was determined objectively and subjectively. Objective measures were assessed by surgeon – Good correction, Under correction and Over correction. Subjective measures were as told by the patient – Symptomatic relief (such as epiphora, and Patient satisfaction. According to objective measure good correction was observed in 91.70% of cases , under correction in 8.30% of cases and there were no cases of over correction. According to subjective measures both patient satisfaction and symptomatic relief was observed in 89% of cases.
Graft was viable in 94.4%(34) of cases and was rejected in 5.6%(2) of cases. Graft apposition was not good in 3 cases in which secondary bolster placement was done. Ectropion was undercorrected in 3 cases which resulted in mild residual ectropion which was managed by Lazy T in 2 cases and repeat skin grafting in 1 case . Overall surgical success rate was 89.00%. There were 2 cases of graft contracture seen in followup. There were no cases of bleeding or hematoma formation, or graft hypertrophy.All cases were noted to have satisfactory cosmetic outcomes (as told by the patient) in terms of matching skin type and tone between the graft and the host sites.
DISCUSSION
There are reports in the literature on the surgical managementofcicatricialeyelid ectropion with skin grafting incases of burns1,congenital and acquired skin abnormalities2,3,prior blepharoplasties4,postradiation scarring5,and excision
of eyelid tumors6,7.Ehrlich et al4 included 65 patients (45%) were labelled as “unknown pathogenesis”while Bush et al.8included 9 cases of unspecified “cicatricialectropion.”
Graft survival is uniformly high in studies to date,with graft failure rate (including partial and complete failure)ranging from 0% to 27..Recurrence rate, on the other hand,is more variable depending on the underlying etiology. Kim etal.5 reported residual ectropion in 11 of 25 patients (44%) withneed for surgical revision in 12% in postradiation lower eyelidectropion. Rathoreet al.6 reported graft contracture leading tolower eyelid ectropion in 5 patients (8% of lower eyelid cases ofall etiologies), 3 of whom needed additional corrective surgery.
In this series, the most common graft donor sites was post auricular skin and, followed by upper eye lid skin and inner brachial skin . This order of preference for graft donor sites is different from that which is reported in previously published series5-8 in which the most common site was upper eyelid skin followed by supra clavicular skin .
Post auricular skin has least sun exposure and it is convinient as it is located where scar is least visible , the only drawback is slight discomfort on wearing glasses.Upper eyelid skin graft harvesting has least scarring but there are chances of lagophthalmos on already compromised lower eyelidInner brachial skin graft is used when large graft is needed.
In this study out of 36 eyes in 2 eyes graft was rejected. The cause of rejection was poor vascularity, in both the cases graft apposition was not good. In one more case graft apposition was not good but the graft was accepted but there was mild residual ectropion in this case graft was taken from upper eyelid.In two cases on follow up graft contracture was present. The most common complication was graft rejection in two cases and mild residual ectropion in three cases.
Lateral tarsal strip isa useful adjunct in patients with lower eyelid laxity, whichplaces eyelids at risk for ectropion in addition to the verticallyshortened anterior lamella. Any downward traction thatoccurs during graft healing, for instance, could result in exacerbationof ectropion caused by horizontal eyelid laxity. Thiscombination of full-thickness skin grafting and lateral tarsalstrip achieves concurrent vertical lengthening and horizontalshortening of the lower eyelid. Canthoplasty was performedin patients who did not have enough lower eyelid laxity fora lateral tarsal strip but in whom canthal repositioning wasthought to be beneficial. While canthal surgery constituted themost commonly performed concurrent procedure, it was notroutinely included with every full-thickness skin graft. Theappropriate surgical approach was selected on a case-by-case basis. Patients with epiphora who were found to have punctalstenosis or nasolacrimal obstruction in addition to ectropionunderwent other procedures, such as snip punctoplasty and external dacryocystorhinostomy. In 1 case Z plasty was done and in one case pentagon excision was done to correct the horizontal laxity.The contribution of each of these concurrent procedures to the final outcome of the full-thickness skin graft is likely variable. While concurrent punctoplasty and dacryocystorhinostomy are not expected to directly alter the nature and configuration of the lower eyelid ectropion, appropriate addition of lateral tarsal strip, Z plasty , pentagon excision and canthoplasty clearly can.
This article describes the surgical technique of full-thicknessskin grafting and shows that with appropriate adjunctive procedures,this technique is an effective method for treatmentof cicatricialectropion as demonstrated by 94.4%% graft viability.
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