Surgical Management of Ectropion Following Blepharoplasty

Preoperative Assessment

A comprehensive preoperative evaluation should include a thorough assessment of ectropion severity, horizontal lid laxity, vertical anterior lamella shortage, scarring of the orbital septum, and forced duction testing to assess for restrictive components, as recommended by the American Academy of Ophthalmology 1, 2
A comprehensive visual function assessment, including measuring visual acuity with current correction at distance and near, is recommended by the American Academy of Ophthalmology as part of the preoperative evaluation for lower blepharoplasty 3
A thorough external examination, including assessment of eyelid position, lashes, lacrimal apparatus, tear function, and pertinent facial features, is essential for preoperative planning 3
Ocular alignment and motility should be evaluated using a cover/uncover test to identify pre-existing strabismus, with a strength of evidence level of moderate 3, 2
A slit-lamp examination should be performed to evaluate eyelid margins, tear film, conjunctiva, cornea, and anterior chamber, as recommended by the American Academy of Ophthalmology 3

The lateral tarsal strip procedure is considered a first-line surgical treatment for most cases of post-blepharoplasty ectropion, involving shortening and tightening the lateral canthal tendon, and securing the tarsus to the lateral orbital tubercle, according to the American Society of Ophthalmic Plastic and Reconstructive Surgery 1, 2
For cicatricial ectropion with vertical shortage of skin, skin grafting is required, typically using full-thickness skin from the upper eyelid, retroauricular area, or supraclavicular region, and must be combined with release of scar tissue, as suggested by the American Academy of Ophthalmology 1, 2
Careful dissection and identification of the three fat compartments (medial, central, lateral) during fat management is recommended by the American Society of Ophthalmic Plastic and Reconstructive Surgery, with a high level of evidence 2
Fat transposition, if indicated, should be performed by mobilizing the medial and central fat pads and securing them to the periosteum to fill the tear trough, as described in the literature 2

Conservative management with massage may be effective for up to 6 months postoperatively, but if ectropion has not resolved or shown improvement within 6 months, surgical correction is recommended, as stated by the American Academy of Ophthalmology 1, 2
Aggressive corneal lubrication should be used postoperatively in patients at risk of dry eye, as recommended by the American Academy of Ophthalmology, with a moderate level of evidence 3
The American Society of Ophthalmic Plastic and Reconstructive Surgery recommends keeping the head elevated for the first 48-72 hours and applying cold compresses intermittently for the first 48 hours to reduce swelling and ecchymosis, with a low level of evidence [no citation provided, but recommended by the society]
Postoperative measures including elevation of the head, cold compresses, and avoidance of physical exertion are advised to reduce the risk of bleeding 4, 5

For mild ectropion with predominant horizontal laxity, the lateral tarsal strip procedure alone is recommended, while for moderate to severe ectropion with both horizontal laxity and mild vertical shortage, the lateral tarsal strip procedure with inverting sutures is suggested, according to the American Society of Ophthalmic Plastic and Reconstructive Surgery 1, 2
For severe ectropion with significant vertical shortage, options include the lateral tarsal strip procedure with skin grafting, superotemporal skin transposition, or cheek-midface lift, as recommended by the American Academy of Ophthalmology 1, 2

Failure to identify and address all components contributing to ectropion, inadequate release of scar tissue before grafting, insufficient horizontal tightening, overlooking pre-existing conditions that predispose to ectropion, and delaying surgical intervention beyond 6 months when conservative measures fail, are common pitfalls to avoid, as warned by the American Academy of Ophthalmology 1, 2
Diplopia can occur if the inferior rectus muscle is traumatized during lower lid dissection, with a strength of evidence level of high, according to the American Academy of Ophthalmology 2
Bleeding is a possible complication of blepharoplasty, which can lead to retrobulbar hematoma, subconjunctival bleeding, eyelid hematoma, and prolonged wound healing, with an incidence of vision loss being very rare (about 0.0052% or 1 in 20,000 cases) 2, 4, 5
Scarring and bleeding in the surrounding tissue or adhesion of fatty tissue are among the mechanisms that can lead to complications, including new episodes of diplopia (double vision) 2
If significant bleeding occurs after blepharoplasty, especially retrobulbar hematoma, it is considered a surgical emergency, requiring urgent intervention 4, 5

The American College of Chest Physicians (ACCP) considers blepharoplasty a procedure with a minimal risk of bleeding, but the use of anticoagulants can increase the risk of bleeding during and after the procedure 4, 5
Anticoagulant therapy can be continued for ophthalmic procedures with low risk, such as cataract surgery, as per ACCP guidelines 4
If a patient is already receiving systemic anticoagulant therapy for other medical conditions, it is necessary to individually assess the risks and benefits of discontinuing therapy before the procedure, in accordance with guidelines for perioperative management of antithrombotic therapy, as per ACCP guidelines 4, 5