The Versatile Lid Crease Approach to Upper Eyelid Margin Rotation.

Lid margin rotational procedures have been used to correct cicatricial trachomatous entropion since the 19(th) century. There are two basic types of surgeries used for lid margin rotation. The first type is based on through-and-through approach combining tarsotomy and the use of sutures on the anterior lamella. The second type of surgery was suggested by Trabut, who proposed a tarsal advancement by posterior approach. We demonstrate that using a lid crease incision combines the basic mechanisms of the anterior and posterior approaches and in addition, addresses a variety of lid problems commonly found in the aged population with cicatricial entropion. After tarsal plate exposure, a tarsotomy through conjunctiva is performed as described by Trabut. Then, instead of using external sutures secured by bolsters, internal absorbable sutures can be used to simultaneously advance the distal tarsal fragment and exert strong tension on the marginal orbicularis muscle. Sixty lids of 40 patients underwent surgery with a lid crease incision. The follow-up ranged from 1 to 12 months (mean 3.0 months ± 2.71). Forty percent of the patients (24 lids) had more than 3 months of follow-up. Adequate margin rotation was achieved in all lids but one that showed a medial eyelash touching the cornea.

INTRODUCTION

Since the 19th century, different types of lid margin rotation have been used to correct the upper eyelid cicatricial entropion.1 Anterior approach procedures are typically performed with a through-and-through incision placed 4 mm from the lash line. External sutures are then used to rotate the lid margin. Variations of this procedure have been described by Green, Pannas, Hotz12 and recently by Wies3 and Ballen.4 The World Health Organization has renamed the Wies/Ballen procedure “bilamellar lid margin rotation” and recommended it as standard modality to correct trachomatous cicatricial entropion.5

Trabut6 in 1949 was, likely, the first to use a different approach to manage cicatricial entropion. A conjunctival incision is used to divide the tarsal plate into two fragments. After creating a plane between the orbicularis and both tarsal fragments, the distal tarsus is advanced over the marginal tarsal fragment with sutures exiting on the lash line. This simple procedure creates a downward vector on the marginal portion of the tarsus, which rotates the margin upward.

Neither of these two basic lid margin rotation procedures addresses other common lid problems such as dermatochalasis, retraction, or ptosis.

In this study, we use a lid crease incision to combine both basic mechanisms of lid margin rotation and if necessary, to concomitantly correct a variety of lid abnormalities.

SURGICAL TECHNIQUE

The main steps of the surgery are shown presented in Figure 1. The surgery is usually performed under local anesthesia. First, the lid crease is located and carefully marked. At this point, if desired, a standard blepharoplasty skin or skin + muscle resection can be outlined the lid is then infiltrated with a local anesthetic solution and a 4-0 silk traction suture is inserted through the tarsal edge of the lid margin. A pretarsal skin muscle flap is raised exposing the whole tarsal plate to the level of the lash roots [Figure 1a]. The lid is everted over a cotton-tipped applicator with care to place the applicator under and not over the skin-muscle flap. Using a number 15 Bard-Parker scalpel blade and Westcott scissors, a curved incision parallel to the lid margin is performed through the full thickness of the tarsus 3 mm posteriorly to the margin [Figure 1b]. The lid is returned to its natural position. Three double-armed 6-0 polyglactin (Vicryl) sutures are then passed through half thickness of the central, medial, and lateral aspects of the distal cut edge of tarsus [Figure 1c] and attached to the orbicularis near the lash line [Figure 1d]. The noncentral sutures should be placed in a radial fashion similar to corneal transplant stitches. As the sutures are tied, the distal portion of the tarsus is advanced over the marginal tarsus [Figure 1e], and the marginal orbicularis is pushed backward rotating outward both lamellae of the lid margin [Figure 1f]. The patient is seated, and the lid position is assessed. If necessary, the levator aponeurosis can be recessed or advanced to correct any retraction or ptosis. The sutures remain within the lid, and no bolsters are used. The lid crease incision is closed with a running 6.0 fast absorbable suture.

Figure 1

Main surgical steps of the lid crease approach to upper lid margin rotation: (a) Using a standard blepharoplasty incision a pretarsal skin-muscle flap is raised exposing the whole tarsal flap until the lash roots are visualized, (b) tarsotomy is performed with a conjunctival incision 3–4 mm from the lid margin, (c) a 6-0 Vycril suture is inserted first through the distal segment of the tarsus, (d) the suture is passed on the orbicularis muscle close to the lash roots, (e) as the suture is tied the distal tarsal fragments is slightly advanced over the marginal tarsus and traction is exerted on the orbicularis, (f) final aspect of the lid rotation

RESULTS

We have used the lid crease approach to manage trachomatous cicatricial entropion at the King Khaled Eye Specialist Hospital on a regular basis. We have treated 60 upper lids of 40 patients (23 females and 17 males) with a mean age of 70.9 ± 13.01 years. The follow-up ranged from 1 to 12 months (mean 3.0 months ± 2.71). Forty percent of the patients (24 lids) had >3 months of follow-up.

There were no major complications such as lid necrosis or significant contour abnormality. Trichiasis was corrected in all but one lid, with two inward lashes touching the cornea medially despite adequate margin position. Patients are satisfied with the surgical outcome. Figure 2 presents a typical example. This patient had cicatricial entropion, trichiasis, and a loose pretarsal anterior lamella with no clear lid crease preoperatively [Figure 2]. Postoperatively the degree of margin and lash rotation and lid crease reformation is evident.

Figure 2

Top: Aged patient with upper dermatochalasis and cicatricial entropion. Lashes are misdirected with a downward direction. Bottom: Postoperative appearance of the rotated margin

DISCUSSION

It should be noted that the lid crease approach is not new but has been largely overlooked. In a pioneering article Sadiq and Pai7 documented their approach of combining the traditional lid margin rotation with a blepharoplasty incision.

We believe that the technique we have described has several advantages compared to the classic Wies/Ballen surgery.34 First, the anterior lamella incision is not on the same level as the tarsotomy. With this approach, the vascularization of the marginal portion of the orbicularis is not compromised, and the chances of ischemia and necrosis of the margin are significantly reduced. Second, as the tarsal plate is completely exposed, it is easy for the surgeon to distribute the forces of the sutures arranging the lateral and medial stitches radially. It is well known that one of the most common complications of lid margin rotation is contour abnormality.8 As recommended in the manual of the so-called bilamellar lid rotation (Wies/Ballen surgery) published by the World Health Organization, the anterior lamella incision follows a straight line.5 In this setting, the external sutures tends to be parallel and not radially distorting the central portion of the margin. Third, the rotational sutures are internal, simplifying the postoperative period. Fourth, the technique incorporates the mechanism suggested by Trabut. As the marginal orbicularis is completely dissected up to the lash follicles and the distal tarsal fragment is advanced over the marginal, a downward vector moves the edge of the marginal tarsus downward, which rotates the margin upward.

Finally, incising the anterior lamella on the lid crease position allows the surgeon to address a variety of common lid problems such as aponeurotic ptosis, lid retraction, laxity of the pretarsal lamella, dermatochalasis, and so on.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.