Oculoplastic Procedure Addresses Upper Eyelid Ectropion

Close-up anesthesia before blepharoplasty and lipofilling plastic surgery operation for modifying the eye region of the face in medical clinic. Surgeon sutures the eyelid
Researchers explore a surgical technique for the anatomical correction of upper eyelid ectropion, including tarsal scoring incision.

With a partial-thickness tarsal plate scoring and lower flap redraping surgical technique, surgeons were able to resolve upper eyelid ectropion, a study published in Anesthetic Surgery Journal shows. The investigation also demonstrates the procedure  reduces dry eye symptoms.

While upper eyelid ectropion is similar to lower eyelid ectropion, it is both much less common and often undiagnosed following aesthetic blepharoplasties or involutional change. Dry eye symptoms commonly follow postsurgical ectropion and, if not treated, it can impact the functional surgical outcome.

The retrospective review looked at cases of consecutive patients who underwent a new surgical protocol for upper eyelid ectropion correction. Patients with severe symblepharon or severe ocular surface disease were excluded.

Surgical correction of upper eyelid ectropion included adhesiolysis and undermining and redraping the pretarsal flap. If the ectropion had not resolved at this point in surgery, the pretarsal flap was dissected in the pretarsal plane toward the inferior edge of the tarsal plate until the eyelashes were exposed and then the tarsal plate was scored. Finally, sutures between the inferior pretarsal flap and the tarsal plate were placed. If the downward repositioning of the inferior pretarsal flap led to multiple fold formation, the orbital septum and preaponeurotic fat were advanced down to the tarsal plate.

Of the 54 patients who underwent surgery (48 with prior upper blepharoplasty and 6 with senile changes), 53 complained of dry eye symptoms and 51 showed successful postoperative results, with lashes normally directed downward and well-positioned eyelid margin without gray line exposure. Tarsal scoring was performed in 28 patients. 

All patients had “good” cosmetic results without significant complications. Three patients experienced subtle inversion of the eyelid margin without trichiasis.

Two of 32 patients assessed with the 7-point Patient Global Impression of Improvement (PGI-I) scale reported symptoms to be “very much better,” 20 “much better,” 7 “a little better,” 2 no change and 1 patient “a little worse.” The mean Ocular Surface Disease Index (OSDI) score decreased from approximately 43.2 at baseline to approximately 29. at the final visit (P =.006 by Wilcoxon signed rank test). Mean difference was significantly higher in the patients who underwent tarsal scoring than in those who underwent just redraping (15.5 ± 18.5 vs 12.7 ± 25.9, P <.05 by Mann Whitney U test).

The mean preoperative score in the 13 patients with severe dry eye (OSDI ≥33) improved significantly after surgery (from 59.4 ± 16.6 to 42.1 ± 21.4, P =.034).

The number of patients in the severe category dropped from 13 before surgery to 10 after surgery. Patients in the normal category increased from 2 to 6 after surgery. Change in mean score for patients with mild to moderate dry eye and difference in overall postoperative severity were not significant.

The investigators recommend ophthalmologists carefully examine patients to rule out ectropion and dry eye before they perform ptosis correction, which can worsen the ectropion and aggravate dry eye symptoms.

Limitations of the study included limited assessment of dry eye and limited, varying length of follow-up (mean of 6 months, range: 2 months to 6 years).


Cho IC, Kim B, You HJ, Tark WH. Surgical correction of upper eyelid ectropion presenting dry eye symptoms. Anesth Surgery J. Published online June 1, 2020. doi:10.1093/asj/sjaa143