Cicatricial Ectropion

Definition and Mechanism

Fig. 2.55B - Cicatricial ectropion. (Kanski's Clinical Ophthalmology, 10th ed., Courtesy A. Pearson)

Causes

Symptoms

• Tearing (epiphora) - from punctal malposition and lacrimal pump failure
• Irritation and redness
• Mucous discharge
• May be asymptomatic in mild cases

Signs

• Outward turning of the eyelid margin

• Eyelid skin scarring (key distinguishing feature from involutional ectropion)
• Superficial punctate keratopathy (SPK) from corneal exposure
• Conjunctival injection, thickening, and eventual keratinization from chronic dryness
• Exposed, inflamed palpebral conjunctiva

Workup

1. History - prior surgery, trauma, chemical burns, skin disease
2. External examination - assess orbicularis oculi function, horizontal eyelid laxity, punctal location; look for scarring, eyelid tumors
3. Slit lamp examination - evaluate for exposure keratopathy and conjunctival inflammation

Treatment

Medical (temporizing)

• Lubricating drops and ointments to address exposure keratopathy
• Warm compresses + antibiotic ointment (e.g., bacitracin or erythromycin q.i.d.) for inflamed exposed eyelid margin
• Short course of antibiotic-steroid combination ointment if closely monitored
• Eyelid taping as a temporizing measure

Surgical (definitive)

Comparison with Other Ectropion Types

Key Points

• The hallmark is scarring of the anterior lamella pulling the lid outward - treatment must always address the vertical skin deficit.
• Z-plasty is the workhorse for mild localized cases; it lengthens the scar while redirecting tension vectors.
• Full-thickness skin grafts are preferred over split-thickness grafts for reconstruction because split-thickness grafts are more prone to secondary contracture, which risks recurrence of the ectropion.
• Reconstruction after tumor excision (subciliary approach) is a recognized surgical cause.

Sources: Kanski's Clinical Ophthalmology: A Systematic Approach, 10th ed., p. 84; Wills Eye Manual, 7th ed., p. 384-386

Surgical Treatment of Cicatricial Ectropion - In Detail

Surgical Options by Severity

1. Z-Plasty (Mild Localized Cases)

Principle

Mechanism

• The scar forms the central limb of the "Z"
• Two triangular flaps are raised from each end of the scar at equal angles
• The two flaps are then "flip-flopped" - transposed into each other's original positions
• This borrows tissue from the width of the scar to gain length in its longitudinal axis

Geometry

• Classic 60-degree Z-plasty = the limbs are cut at 60° to the central scar
• Gain in length = 75% of the original scar length
• The scar is redirected 90 degrees from its original axis
• Angles can range from 30° to 90°: wider angles give greater length gain but more tension on closure
• All three limbs (central + two arms) must be of equal length

Z-plasty variants for scar revision and contracture release. (Mulholland & Greenfield's Surgery, 7th ed.)

Steps

1. Mark the contracted scar as the central limb
2. Mark two limbs of equal length at 60° from each end of the central limb (in opposite directions, creating the "Z" shape)
3. Incise along all three lines
4. Elevate the two triangular subcutaneous flaps
5. Transpose them: flap A goes into flap B's bed and vice versa
6. Close with fine absorbable sutures

Variants for larger areas

• Multiple serial Z-plasties: designed end-to-end along a long contracted scar - each unit provides incremental lengthening
• Double Z / Double opposing Z ("Butterfly"): used when more lengthening is needed without a single large transposition
• 4-flap Z-plasty (90°-90°) and 5-flap ("Jumping Man"): for extensive contractures, provide greater length gain with lower individual flap tension

Advantages

• Uses local tissue (best color and texture match)
• No donor site scar elsewhere on the face
• Single-stage procedure

Disadvantage

• Increases total incision length (the new zigzag lines can be harder to camouflage than a linear scar)

2. Local Transposition / Rotation Flaps (Moderate Cases)

Rhombic (Limberg) Transposition Flap

• A rhomboid-shaped flap is designed adjacent to the scar defect
• The flap is elevated and transposed over the intervening tissue into the primary defect
• The key suture closes the secondary defect; the flap is then inset into the primary defect
• Useful for moderate-sized localized defects near the lower lid

Cheek Rotation-Advancement Flap

• For larger periorbital defects following tumor excision
• Tissue is recruited from the cheek, which has good color and contour match to the lower eyelid skin
• Incisions are camouflaged along the nasolabial fold and infraorbital rim
• Risk: if flap is too small or contracts, it may itself cause recurrent ectropion - careful vector planning is essential

V-Y Advancement Flap

• Useful when healthy tissue surrounds the scar and can be advanced into the contracture release area
• Lengthens in the direction of the V-Y conversion without the added incisions of a Z-plasty

3. Free Skin Grafts (Severe or Generalized Cases)

Full-Thickness Skin Graft (FTSG) - Preferred

• FTSG contracts significantly less than split-thickness grafts (STSGs)
• Less secondary contracture = lower risk of recurrent ectropion
• Better color, texture, and thickness match for the thin eyelid skin
• Particularly important near free margins (eyelid, lip) where contracture causes functional problems

1. Release the cicatricial scar completely (excise or widely undermine) until the eyelid returns to its natural position against the globe
2. Measure the resulting skin deficit carefully with the eyelid held in correct position
3. Harvest the full-thickness graft from the donor site (including dermis, excluding subcutaneous fat)
4. Defat the graft, trim to size
5. Suture into the defect under slight tension to account for some primary contraction
6. Apply a firm bolster dressing to maximize graft-bed contact and prevent seroma/hematoma
7. Leave bolster for 5-7 days

Split-Thickness Skin Graft (STSG) - Less Preferred

• Technically easier to harvest (dermatome)
• Larger surface areas possible
• However, STSGs contract more, risking recurrent ectropion
• Some authors accept STSG for the upper lid (where thin pliable skin can be better matched) but FTSG is still preferred for the lower lid
• The high rate of graft contracture following STSG reconstruction is a well-documented complication of eyelid burns reconstruction

4. Cicatrix Release + Spacer Grafts (Middle Lamellar Involvement)

• The cicatricial adhesions are lysed (released)
• A spacer graft is placed to prevent re-adhesion: hard palate mucosal graft or acellular dermal allograft substitute
• This corrects lower eyelid retraction with ectropion where the septum is the contracted structure

Key Surgical Principles (Summary)

1. Always correct the vertical deficit - horizontal tightening will fail and may worsen things
2. FTSG > STSG for eyelids due to lower contracture risk
3. Contralateral upper lid and retroauricular skin are the gold-standard donor sites for periocular FTSG
4. Bolster dressing is mandatory after skin grafting to the eyelid
5. Z-plasty is first-line for mild localized scars - it uses local tissue and avoids a donor site
6. Serial Z-plasties extend the technique to longer contracted scars
7. If posterior lamellar or middle lamellar scarring coexists, mucosal or dermal spacer grafts address that layer separately
8. Allow 3-6 months for scar maturation before definitive reconstruction in post-surgical or post-burn cases (unless corneal exposure demands earlier intervention)

Sources: Kanski's Clinical Ophthalmology, 10th ed., p. 84; Andrews' Diseases of the Skin, p. 1030; Mulholland & Greenfield's Surgery, 7th ed., p. 762-765; Cummings Otolaryngology, pp. 385, 532-534; Scott-Brown's Otorhinolaryngology, p. 1323