Comment on: Upper eyelid levator-recession and anterior lamella repositioning through the gray-line - Avoiding a skin-crease incision.

Sir,

We read with great interest the article by Pandey et al.[1] The authors reported a case series of upper eyelid cicatricial margin entropion with retraction, corrected through a gray-line approach only.

Anterior lamellar recession (ALR) is a well-known conventional surgical method for the correction of the upper eyelid trichiasis and cicatricial entropion. It entails splitting skin and orbicularis oculi muscle from tarsus and conjunctiva, recessing the anterior lamella, and leaving the exposed tarsus bare. Interlamellar separation can be performed through eyelid crease approach [Fig. 1], lid margin approach as performed in this series, or both.[2345]

Figure 1

The anterior lamella (skin and orbicularis) has been dissected off the tarsal plate beyond the lash follicles through upper eyelid crease incision

We believe that the dissection through the upper lid crease incision and down to the lid margin is more effective for the following reasons. First, the lid margin is usually distorted in the upper eyelid cicatricial entropion with no identifiable gray line. Hence, this approach allows for more accurate and meticulous dissection at the lid margin, the site of pathology, without losing the tissue plane, or inadvertently cutting through the tarsal plate which may induce further cicatrization. Second, sometimes dissection continues beyond the lash follicles, peeling the entire anterior lid margin from the tarsus in cases of metaplastic lashes, and keratinization [Fig. 1]. This makes it valid for cases with distichiasis. Third, it allows for addressing concurrent dermatochalasis and other lid malpositions including lid retraction and ptosis though the same incision. Advancing dermatochalasis mechanically may affect the position of the lashes resulting in worsening of the entropion. With the ALR procedure through lid margin, the redundancy of the upper eyelid skin and the underlying orbicularis muscle may be aggravated [Fig. 2]. Hence, excess skin and muscle removal through blepharoplasty have been recommended to prevent downward migration of the anterior lamella and provide a less bulky eyelid.[234] And finally, lid crease formation with bites through the levator helps maintain an upward vector of traction to the anterior lamella and lash eversion.[5]

Figure 2

Recurrent upper lid entropion following anterior lamellar recession of the right upper lid due to anterior lamellar laxity with secondary dermatochalasis causing a rotational inversion of the lid margin

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