32.1 Patient History Leading to the Specific Problem

The patient we present here is a 72-year-old woman with a complex surgical history, including multiple attempts by multiple surgeons at correcting her bilateral lower eyelid malposition. This problem developed secondary to one of the most common procedures performed today by plastic surgeons, an elective blepharoplasty.

Her first surgery was an elective upper and lower blepharoplasty approximately 30 years prior to presentation. The patient then developed severe bilateral lower eyelid ectropion with significant scleral show requiring correction with a porous polyethylene lower eyelid spacer (Fig. 32-1). She then developed recurrent ectropion on the left lower eyelid (Fig. 32-2). Correction of this problem was performed with a canthoplasty and ear cartilage used as a spacer graft (Fig. 32-3). Months after, the patient presented with exposed ear cartilage, worsening left lower eyelid malposition, significant scleral show, lagophthalmos, persistent eye irritation, and epiphora (Fig. 32-4). The patient then underwent release of the anterior lamella scar, excision of the exposed ear cartilage, and a full-thickness skin graft to compensate for deficient skin in the anterior lamella.

After approximately 30 procedures (minor and major surgeries), the patient presented to us with persistent medial and lateral ectropion of the left lower eyelid (Fig. 32-5).

32.2 Anatomic Description of the Patient’s Current Status

The left lower eyelid is the area of concern. The main anatomic problems are: (1) recurrent left lower eyelid ectropion with an uncommon extension into the medial aspect of the eyelid, (2) inability to reposition the eyelid upward with the one-finger distraction test (Fig. 32-6), (3) deficient anterior lamella skin with contracted skin graft, and (4) persistent scleral exposure causing constant eye irritation and excessive lacrimation.