Anterior Segment and Eyelids: Case 41
The pictures above are taken from two 70 year-old women who complained of  left epiphora and ocular irritation. They both had left lower lid basal cell carcinoma excision six months earlier by the different  general surgeons without skin graft.

a. What is the diagnosis?

Both patients have cicatricial ectropion of the left lower lids.
Defects in the lower lid that are closed horizontally (within the lines of Langer) can occasionally shorten the anterior lamellae and produce postoperative ectropion. This complication occurs when larger defects are being closed in the elderly, in whom there excess horizontal laxity from canthal tendon dehiscence.

A skin defect in the lower lid

Horizontal closure can cause lower 
lid ectropion.

b. How could this problem be prevented?

The following methods can be used to avoid lower lid ectropion:
1. Smaller defects in the lower lid can be closed with a vertical orientation with
    minimal distortion and tension of the lid margin.

A vertical closure is useful in small defect

2. For larger defects, full-thickness skin graft or flap techniques are effective in 
    preventing shortening of the anterior lamellae and ectropion formation.
    The flap techniques include O-Z plasty, sliding flap and transposition flap.

O-Z plasty

Sliding flap

Transposition flap

c. How would you manage this patient?

The surgical treatment of cicatricial ectropion should only begin when the inflammation subsides. 
There are three surgical steps in correcting a cicatricial ectropion resulting from a surgical scar:
1. Excision of the scar and undermine the skin to give a raw area for skin graft
2. Tightening of the lower lid by lateral tarsal strip technique
3. Covering of the raw area with a pre- or post-auricular graft (these grafts are
     preferable to upper lid skin as the former are thicker and therefore cause less 
     postoperative contraction).
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