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A Comparison of Surgical Outcomes of Two Combination Surgeries for Involutional Entropion

Fixing 3 vs 2 Pathologic Components

Yang, Sungwon MD; Kim, Seungheon MD; Baek, Sehyun MD, PhD

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doi: 10.1097/SCS.0000000000005677


Entropion is one of the most frequently observed eyelid malformation diseases in the clinical practice of ophthalmologists. There are 4 types of entropion: congenital, involutional, cicatricial, and spastic. The most common type is involutional for the lower eyelids, while cicatricial is found most frequently in the upper eyelids. The frequency of entropion in Asians seems somewhat higher than in non-Asians, although age differences should be considered for a direct comparison between these groups.1–3

Knowledge of lid anatomy and its degenerative changes is essential to successfully correct the major pathogenic components of involutional entropion.4 It is caused by horizontal lid laxity, preseptal orbicularis oculi muscle overriding, and inferior retractor dehiscence or weakening. In addition, orbital fat protrusion, enophthalmos, small axial globe projection, and positive orbital vectors are related to involutional entropion.1,5–7

Lateral tarsal strip (LTS), skim-muscle excision (SME), and inferior retractor tightening (IRT) are some of the most prevalent treatment methods to correct involutional entropion. Simply, these techniques are designed to address one of the three main factors involved in involutional entropion: LTS for horizontal laxity, SME for orbicularis oculi overriding, and IRT for vertical eyelid laxity. Although the short-term outcomes of those single techniques seemed promising, they were found to be prone to recurrence in long-term follow-ups. Consequently, a variety of combinational techniques were developed to lower recurrence rate.8–15 We previously reported on a surgery combining the IRT + LTS + SME procedures in 80 Korean patients with horizontal and vertical laxities. Our combination surgery, which corrected the three major pathologic components of involutional entropion, also exhibited effective surgical outcomes (98.8% success rate during 26.5 ± 4.6 months).16

So far, there have been many reports comparing the success and recurrence rates of combinational surgery to a single surgery technique for involutional entropion correction.17–21 However, there have been few studies comparing the 2 combinational surgeries fixating 3 and 2 pathologic components of involutional entropion, respectively. We herein represent the comparative surgical outcomes of IRT + LTS + SME and LTS + SME for involutional entropion correction in the Korean population.


This study was a retrospective review of involutional entropion patients who were divided into 2 groups (Group A and Group B) according to their surgery methods. In Group A, 85 eyelids of 80 patients underwent the IRT + LTS + SME procedure between April 2004 and February 2014. In Group B, 63 eyelids of 58 patients were treated with the LTS + SME procedure between March 2014 and February 2018 (Figs. 1 and 2).

Photographs of the lateral tarsal strip operation with skin muscle excision surgery. (A) The lower canthal tendon was separated from the lateral lower lid through trimming. (B) The lateral canthal tendon was fixated to Whitnall tubercle and a subciliary line was drawn 2 mm below the lower eyelid margin. (C-D) The amount of excess skin was measured by pinching with forceps. A crescent-like design was subsequently drawn. (E) Skin excision was performed with Westcott scissors, and the overriding orbiculi muscle was removed with a cautery. (F) Skin was sutured.
Pre-operative and post-operative photographs in LTS + SME surgery. (A) Pre-operative photograph showing corneociliary interaction in involutional entropion patients. (B) Post-operative photograph showing normal eyelid position after LTS + SME surgery.

All subjects in both groups were clinically diagnosed with involutional entropion. They exhibited corneociliary touching upon slit-lamp examination and their lower eyelids showed delayed spring-back to their normal position with intentional blinking in the snap back test. Lid distractions greater than 6 mm from the globe were considered abnormal in the lower lid distraction test. We also observed orbicularis oculi muscle overriding in patients when they blinked hard as instructed by clinicians even though the evaluation was subjective. The exclusion criteria for the 2 groups included different types of entropion except for involutional, any type of previous lower lid surgery, a follow-up period of less than 6 months, and other surgical techniques for involutional entropion treatment.

Medical records of the 2 groups were reviewed and the demographic data were analyzed together (Supplemental Digital Content, Table 1, Surgical success rate, recurrence rate, and intraoperative and postoperative complications were compared with statistical analysis (Supplemental Digital Content, Table 2, Success was defined as no corneociliary interaction during rest through the entire follow-up period. Recurrence was noted if ciliary interaction was seen during the follow-up.

For statistical analysis of the data, SPSS statistics 20.0 for Windows (IBM Corp.) was used. The association between the success rate and surgery method was analyzed with the Fisher exact test. The comparability of the groups with respect to age, gender, and length of follow-up was analyzed using the Student's t, chi-square, and Wilcoxon rank tests, respectively.

This study was approved by the Institutional Review Board of Korea University Medical Center and adhered to the tenets of the Declaration of Helsinki. For photographs that identified the patient, a consent form was obtained from each patient.


All surgeries were performed under local anesthesia, which included alcaine eye drops and subcutaneous infiltration of the lower eyelid and lateral canthus with half-and-half by volume of lidocaine 2% with 1:100,000 epinephrine and bupivacaine 0.5%.

Inferior Retractor Tightening (IRT)

After skin marking and subcutaneous local anesthetic infiltration, an infraciliary incision was created with a 15th Bard-Parker blade along the marking line. A 4–0 silk suture was placed at the superior edge of the incision and pulled slightly for superior retraction. The orbicularis oculi muscle was dissected from the orbital septum layer with Westcott scissors to the inferior orbital rim. The orbital septum was opened, and the fat pad was dissected from the underlying capsulopalpebral fascia. The disinserted inferior retractor was identified as a white band. The disinserted retractor was reattached to the inferior edge of the tarsal plate with 6–0 prolene in the center of each third of the lower lid.

Lateral Tarsal Strip (LTS)

First, a lateral canthotomy and inferior cantholysis were performed. The lower canthal tendon was dissected from the lateral lower lid by trimming the mucocutaneous junction with Westcott scissors, dissecting the anterior lamella, and then separating the inferior palpebral conjunctiva from the tarsal plate. The dissected canthal tendon was stretched to the orbital rim so that the surgeon could estimate the amount of shortening required for proper lid tension. The tendon was tailored and suspended to the periosteum over Whitnall's tubercle with 4–0 vicryl. After performing minimal skin muscle excision of the lower eyelid with cauterization, the skin of the lateral canthus was then re-approximated and sutured with 7–0 silk.

Skin Muscle Excision (SME)

The patient was asked to look upward and open his/her mouth to prevent over-correction. By pinching the excess skin at the center of the lower lid with tooth forceps, the proper removal amount of the skin-muscle was measured and marked to rotate the cilia away from the cornea. A skin incision was then performed with a needle tip monopolar cautery (Ellman International, Inc., 3-Button Fingerswitch Handpiece with Locking Chuck) along the marking. Redundant skin was removed with Westcott scissors. Then, with the hand cautery, a strip of overriding orbicularis oculi muscle was excised with simultaneous cauterization of the excision bed (Medtronic Inc, Accu-Temp High Temperature Cautery). Finally, a skin suture was performed with 7–0 black silk.


Group A included 85 eyelids of 80 patients while Group B included 63 eyelids of 58 patients. Both the IRT + LTS + SME and LTS + SME groups were similar with respect to age. Females accounted for the majority within both groups even though there was a higher proportion of them in Group A (Group A: 56.3%, Group B: 87.9%). The mean follow-up period was 26.5 months in Group A and 21.0 months in Group B (Supplemental Digital Content, Table 1, Six patients in Group B were followed for more than 32 months and their average follow-up was 48.7 months. There were no recurrent cases among them.

In Group A, the success rate was 98.8% with one case of recurrence at 6 months postoperatively. In Group B, the success rate was 98.2% with one case of recurrence 7 months during follow-up. There was no significant difference in surgical success or recurrence between the 2 groups (Supplemental Digital Content, Table 2, No intraoperative complications were noted in both groups and 2 postoperative complications were identified only in Group A. Two patients had lateral canthal deformities. They subsequently underwent lateral tarsal strip surgery with satisfactory results.

Surgery time was 26.4 ± 2.4 minutes in Group A and 20.6 ± 3.9 minutes in Group B. The surgery time of the LTS + SME procedure was significantly shorter than the IRT + LTS + SME procedure (Supplemental Digital Content, Table 2,


The lateral tarsal strip procedure is very simple to perform and clinical series of LTS have reported good results with few complications (5–8%).11,17,18,22–25 The LTS procedure performed in the 2 groups did not differ. There were 2 cases of canthal deformities only in Group A with a statistically nonsignificant difference (P = 0.509). Two patients with canthal deformities underwent lateral tarsal strip reoperations and recovered well.

Skin-muscle excision techniques with pinching used in this study exhibited some unique and advantageous features compared to other similar techniques. Firstly, our surgery did not involve the creation of skin-muscle flaps. In LTS + SME, an incision was performed with a needle tip monopolar cautery and a skin-muscle layer was resected with Westcott scissors at the time. This technique differs from other classical skin-muscle flap excision techniques which require a dissection between the orbicularis oculi muscle and orbital septum.26,27 Secondly, we used a hand cautery to remove a strip of the orbicularis muscle. The hand cautery not only excised the orbicularis muscle with bleeding control, but also cauterized the excised bed leading to scarring, which prevented orbicularis muscle overriding. Ziegler and others reported on the successful correction of involutional entropion through anterior lamellar cauterization.28–30 Compared to our method, the skin cauterization of these techniques results in temporary skin burns and cosmetically undesirable eschars.

Theoretically, it is ideal to treat involutional entropion by correcting all 3 main pathologic degenerations. However, scrupulous reconstruction inevitably results in surgical complexities that add to the difficulty of the procedure. As a result, the surgery requires significantly more time and increases the possibility of complications. This may explain why lateral canthal deformities happened only in the A group despite the same LTS surgery in both groups. LTS + SME corrects 2 pathologic components of involutional entropion: LTS for horizontal laxity and SME for orbicularis muscle overriding. Without vertical laxity correction by IRT, LTS + SME still achieved statistically high success rates compared to IRT + LTS + SME. Cauterization with the hand cautery under the inferior tarsal border may contract the lower lid and contribute to the correction of anterior lamellar vertical laxity.30

Our technique required significantly shorter surgery time than IRT + LTS + SME. Surgery time was also shorter than other various techniques including non-combinational surgeries.19,31–33 Given the old age of involutional entropion patients, expeditious surgery techniques have definite merit. Perhaps it is time for clinicians to begin placing more value on surgical efficiency vs efficacy.

There were no cases of secondary ectropion in both groups in our study even though secondary ectropion was reported in nearly all of the techniques that involved an anterior approach through the skin.12,18,34,35 Surgical techniques invading the middle lamellar such as IRT were associated with a risk of secondary ectropion. LTS + SME surgery does not interrupt the orbital septum and this desirable feature of our technique may help avoid potential complications.

There have been some studies on different orbital anatomy and involutional entropion based on racial difference. Koreans appeared to have narrower orbital opening and longer interorbital distance compared to Caucacians.36 In CT scans, there was 40% of negative orbital vector among 50 Koreans (Mean age 60.6 year-old), while 71% among 14 Americans (Mean age 53.9 year-old).37,38 Carter et al. reported that Asians may be more predisposed to the development of involutional entropion due to more anteriorly protruded orbital fat.1 In our study, 138 Korean patients with involutional entropion were included. None of them had orbital fracture history or enophthalmos or facial dysmorphology. Considering the characteristics of orbital anatomy in Korean race, surgical outcomes of our technique may vary in other races, but we guess that LTS + SME technique may not be influenced significantly by different race factor because operator can tailor the amount of surgical correction in each patient for tendon shortening in LTS surgery and for excess lower eyelid removal in SME surgery.

There are some limitations of our study. Firstly, time-lines of Group A and Group B who underwent different surgeries were not contemporary. Perhaps the surgeon's skill has improved over time and affected the surgical outcomes of 2 groups. Nonetheless, we believe that surgeon's skill difference over time did not make significant difference in the surgical outcomes between 2 groups because the surgeon had long been experienced in involutional entropion surgeries before our study. Secondly, relative short follow-up of group B may weaken the argument of our study. Despite of that, follow-up period of 2 groups is not relatively short compared to previous studies. Moreover, it is not likely that recurrence rate in Group B would abruptly increase after the follow-up period more than 21 months. Finally, subjects in this study were all Koreans and the result might need to be interpreted in consideration of race difference, especially in anatomical feature. In the future, our technique may be studied in broader populations and even in wider spectrum of entropion including cicatricial and spastic.

In conclusion, we found that the success rate of the LTS + SME technique was statistically comparable to the IRT + LTS + SME procedure. LTS + SME resulted in significantly less surgery time than IRT + LTS + SME, thus being advantageous for older patients. Our method exhibited a tendency for decreased complications. Finally, LTS + SME is an effective and efficient treatment for involutional entropion.


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Combinational surgery; involutional entropion; lateral tarsal strip; skin-muscle excision

Supplemental Digital Content

© 2019 by Mutaz B. Habal, MD.