7.1 Goals

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  To correct the outward turning of the eyelid.

  
  
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  To tighten and stabilize the eyelid.

  
  
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  To shorten the eyelid, which may become lengthened and lax with age.

  
  
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  To help correct mild lid retraction and tearing due to poor lacrimal pump function. ¹

7.2 Advantages

The lateral tarsal strip procedure that was originally described by Anderson and Gordy has become the accepted gold standard for ectropion repair. ² The lateral tarsal strip has the advantage of directly addressing the ectropion at the root cause: a lax lateral canthal tendon. Unlike approaches addressing ectropion via the central eyelid such as a tarsal wedge excision, it causes less rounding and medial displacement of the lateral canthal angle. It also has less risk of causing abnormal contour of the lid margin. ²

7.3 Expectations

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  Tightens and repositions a lax lower eyelid.

  
  
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  Corrects ectropion, mild lid retraction, and decreased lacrimal pump function.

  
  
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  With the improvement in eyelid position, it is common to note improved eyelid margin redness, irritation, and tearing.

7.4 Key Principles

Re-creating the appropriate curvature of the lower eyelid is required for successful ectropion repair. The normal lower eyelid wraps around the globe, and the lateral canthal tendon attaches to the periosteum on the inside of the lateral orbital rim at Whitnall’s tubercle (Fig. 7‑1). Improper reattachment of the lower lid during ectropion repair may cause loss of lid/globe apposition, an abnormally rotated tarsal plate, or lateral canthal dystopia.

Reinsertion of the lower lid retractors is sometimes performed concurrently with the lateral tarsal strip if there is evidence of lower lid retractor disinsertion. Signs of lower lid retractor disinsertion include deepening of the inferior fornix, a higher lower eyelid resting position, reduced excursion in down gaze, and loss of the lower eyelid skin crease. Sometimes a white line may be visible on the conjunctival aspect of the eyelid representing the edge of the disinserted retractors. ^{3 ,​ 4} Reinsertion of the lower lid retractors further stabilizes the eyelid by restoring the vector pull of the eyelid retractors.

Punctal ectropion may occur concurrently with general ectropion. Mild punctal ectropion will often be corrected by simple ectropion repair, but more severe punctal ectropion may require a medial spindle procedure to specifically address this issue. ⁵ This can be evaluated pre-operatively by applying lateral traction to the lower eyelid and evaluating how much correction of the punctal position is achieved.

Medial canthal laxity may be concomitantly found with lateral canthal laxity and it is important to evaluate for and address this if present. Medial canthal laxity can be diagnosed by applying lateral traction to the lower eyelid. If this results in displacement of the punctum past the medial limbus with the eye in primary gaze, significant medial canthal laxity is present and care must be taken to avoid excessively tightening the lower eyelid as this may displace the punctum into an abnormal position. Medial canthal plication to secure the medial canthal tendon can be performed concurrently when laxity is noted.

Any cicatricial or gravitational forces pulling the eyelid downward and contributing to the ectropion should be identified and addressed. Failure to do so will result in unsatisfactory results and risks early failure of the ectropion surgery. Be aware of any prior lid or facial surgeries (lower blepharoplasty, skin cancer resection and reconstruction, etc.) and note skin conditions like rosacea or actinic keratosis, which cause chronic inflammation and contraction of the anterior lamella. Evaluate the patient for involutional mid-face descent, which gravitationally pulls down the lower lid and contributes weight that the lateral canthal tendon must support. If present, it is recommended to address them concurrent to ectropion repair as well.

7.5 Indications

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  Ectropion due to involutional changes, facial nerve paralysis, congenital abnormalities, and cicatricial changes.

  
  
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  Excessive tearing that is felt to be due to loss of eyelid pump function.

  
  
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  Chronic irritation from floppy eyelids. In severe cases of floppy eyelids, the lateral tarsal strip procedure may also be performed on the upper eyelids and is not limited to the lower eyelids.