What is ectropion surgery?
Ectropion is a condition where the lower eyelid droops or turns away from the eye itself. The eyelid can appear as if it is turned “inside out”, where the delicate, pink inner lining called the conjunctiva is exposed. The lower lid not touching the eye can create symptoms that can be mild or severe and may even cause loss of vision. With ectropion, the lower eyelid is loose and floppy, and you may not be able to close your eye. This can cause eye irritation, dry eyes, redness, tearing, crusting, and eventually permanent eye damage with decreased vision. Ectropion can be caused by multiple causes including aging, facial muscle paralysis, eyelid trauma, prior eyelid surgery or eyelid lesions. Ectropion can be diagnosed by physical examination and treatments vary depending on how much the drooping eyelid bothers you. Conservative treatment like ointments and taping the eye closed at night may improve symptoms.
Surgery is only treatment that can be used to tighten the eyelid. Ectropion surgery will depend on the cause and location of the ectropion. Loose tendons can be tightened and repositioned to restore normal eyelid shape and function. Surgeries include the lateral tarsal strip procedure, medial canthal plication, horizontal eyelid shortening, canthopexy and canthoplasty. If tendons cannot be tightened, another tendon can be borrowed from a different location in the body to recreate eyelid support (tendon transfer procedures). Age-related correction may need to lift the middle third of the face that sagged due to aging or facial paralysis if it is contributing to the problem (midface lift). If scar tissue from prior injury or surgery is contributing to ectropion, grafting of either skin, cartilage or the inner lining of the mouth may be necessary to restore proper eyelid function. After surgery, the eyelid will feel and look tighter to the eye and symptoms should improve or resolve as the eyelid heals completely.
When do I need ectropion surgery?
As the eyelid sags and turns inside out, you can lose the ability to close your eye. This leads to burning, dry eye, tearing and visible asymmetry. Patient’s will dislike the bright pink inner lining of the conjunctiva they can see while looking in the mirror. The eye may tear uncontrollably. At the same time, the eye experiences dryness, a sensation there is something in the eye (foreign body sensation), or a burning sensation because the tears are not able to moisturize and lubricate the eye. Severe eye irritation can lead to inflammation and corneal (outer surface of the eye) scratches. Repeat corneal trauma can result in ulcerations, infections and eventually, decreased vision. Conservative medical treatment like eye lubricating drops and ointments may improve symptoms but will not correct the droopy eyelid. When the irritating symptoms of ectropion bother you enough, then it is time to go for a surgical evaluation for ectropion repair. Likewise, when the appearance of the eyelid hanging away from the eye is bothering you, then a surgical evaluation can be performed. If you are bothered by puffy eyes or loose skin under the eyes, then this is a good time to bring this up with the surgeon as they can be addressed at the same time as the ectropion.
How do I prepare for ectropion surgery?
An eye exam will document the condition of the eyes before surgery. You will need a full vision check from your Opthalmologist prior to any eyelid surgery. Our doctor will discuss the procedure with you including risks, benefits and alternative treatments. They will review your medications including herbal and over-the-counter drugs and supplements. Many herbal products and pain relievers make it harder for you blood to clot and should be discontinued before surgery. You will sign informed consents and get your instructions for before and after surgery.
You will see your own personal physician for a medical clearance to make sure they feel it is safe for you to have surgery. Your physician may order laboratory blood tests, an EKG or a chest X-ray. You need to stop smoking as this delays healing. You should have nothing to eat or drink after midnight before your procedure. You will be told when to arrive at the surgery center before your surgery. You are signed in, change into a gown, given an IV, and talk to the nurse and anesthesiologist. You will then talk to your surgeon before you get any medication at the hospital so you can ask questions.
What happens during ectropion surgery?
You are taken in to the operating room, lie down on your back, and the anesthesiologist will put you to sleep with a breathing tube to make sure your airway is safe. The area to be operated on is sterilely prepared with a cleaning solution and drapes. A local anesthetic is injected to decrease bleeding and discomfort. Both eyes are usually protected with special lubricating ointment and a special contact lens during surgery. Protection of both eyes is necessary because we use the unaffected eye to create symmetry. Most commonly, the lower eyelid is tightened by tightening the tendon support and re-creating eyelid shape and angle of the eye (lateral tarsal strip, canthopexy and canthoplasty). If performed, midface lifting is approached from the inside of the eyelid. The tendon is purposely repositioned a little higher and always tighter than before surgery to keep the eyelid against the eye which will age naturally. This restores proper function and a healthy appearance. After eyelid repositioning, the skin is closed and special tapes are placed around the incision to support the eyelids.
You are taken to the waiting room and watched to make sure you are recovering from anesthesia. Because ectropion surgery is considered a minimally invasive procedure, you usually go home the same day. You need someone to bring you home from the surgery center to make sure you get home safely.
In more complex situations and revision surgery, repair requires borrowing of the materials from other sites in the body (donor sites), shortening the eyelid or tightening the tendon the inner corner of the eye, which is more complex as tear drainage system needs to be repositioned. If the tear system is repositioned, special soft tubes (Crawford stents) will be placed in the tear drainage system and the eye will experience temporary increase in tearing. These tubes are removed in the office in 4-6 weeks after surgery.
Borrowing materials from donor sites does not affect their long-term function significantly and should not add to the recovery time, because each donor site heals while the eyelid heals. Common donor sites are the roof of the mouth or the inside of the cheek or skin. If they are needed, skin grafts are usually taken from upper eyelid (upper blepharoplasty) or either in front or behind the ear with a hidden scar.
Tendons to substitute eyelid support can be borrowed from non-dominant hand (palmaris longus), outer thigh (tensor fascia lata) or rarely leg (plantaris longus) and transplanted to support the eyelid. Donor site care instructions will be given and usually involve wearing a special wrap around the arm, thigh or leg for 7-10 days.
What is the follow-up for ectropion surgery?
The procedure is not very painful, but you may take oral pain medicine the doctor has given you or acetaminophen (Tylenol). If you need a narcotic pain medicine you should take them with food in your stomach and start on a mild stool softener like Senna. You will be often given antibiotic eyedrop and moisturizing eyedrops for use during the day and an ointment to place between your eyelids at night. Occasionally, your doctor will prescribe antibiotics especially if complex repair with borrowing tissues was undertaking. Keeping your head elevated will decrease pressure on the incision. You should take it easy for at least one week and your doctor will let you know what level of activity you can resume. Call your doctor if you have increasing redness of the incision, fever, bleeding, pus, drainage, the incision opens or you have worsening pain. Also, let your doctor know if you have any other concerns. You will see your doctor the week after surgery and sutures will be removed. You usually can be performing normal activities within two weeks of surgery.
What are the risks of ectropion surgery?
The risks of your ectropion surgery will vary depending on how severe your condition is and what other medical conditions you have. The general risks of any lower lid surgery include bleeding, infection, dry eyes, eye irritation, difficulty with eye closure, visible scarring or skin discoloration, eye muscle injury, the need for additional surgery, chronic pain, numbness, temporary blurry vision or rare vision loss and risks of general anesthesia. Preparing for surgery and following your doctor’s instructions are useful to help minimize risks.
The Surgeons of Norelle Health are highly trained and skilled in the diagnosis, management, and treatment of ectropion. Dr. Araslanova can provide the optimal treatment for ectropion. Moderate to severe ectropion causing symptoms may be covered by your insurance although most insurances consider milder ectropion to be cosmetic . As out-of-network providers, we will check your benefits for you and let you know if there are costs are so there are no surprises. We use an individualized treatment plan for your concerns to provide a personalized holistic plan of care. If you would like assistance, please feel free to contact us.