Anterior Lamellar Recession with Eyelid Crease Incision

Treatment of cicatricial entropion depends upon the amount of the entropion and the process that caused the entropion.  For moderate to severe entropion from a cicatrizing process of the conjunctiva, I try to make no incisions in the conjunctiva for fear of reactivating the cicatrizing process.  My preference for these cases is an anterior lamellar recession.  However, there is often a component of “anterior lamellar slide”, in which the anterior lamella has become dissociated from the posterior lamella and migrates over the eyelid margin.  In these cases, I believe there needs to be additional superior traction to the anterior lamella through the addition of a lid crease incision and establishment of a strong eyelid crease. 

This is Richard Allen at oculosurg.com.  This video demonstrates repair of cicatricial entropion of the upper eyelid with an anterior lamella recession, eyelash follicle excision, and a lid crease incision with eyelid crease formation.  The 15 blade is used to make an incision at the grey line at the eyelid margin along the length of the upper eyelid.  The blade is then used to make an eyelid crease incision.  If there were redundant skin, a small blepharoplasty would also be performed.  The needle tip cautery is used to dissect through the orbicularis muscle to the underlying orbital septum.  The thermal cautery is used to dissect to the anterior surface of the tarsus.  The thermal cautery is then used to disinsert the confluence of the orbital septum and levator aponeurosis from the anterior surface of the tarsus.  Dissection is carried out between the levator aponeurosis and the underlying Muller muscle.  The Westcott scissors are then used to dissect between the anterior and posterior lamella from the eyelid margin incision.  This is connected to the dissection plane from the eyelid crease incision, resulting in full mobilization of the anterior lamella between the eyelid margin and eyelid crease.  Residual lash follicles are excised along the length of the inferior boarder of the anterior lamella.  The anterior lamella is the recessed relative to the posterior lamella with a 5-0 Vicryl suture that is placed 1 mm from the inferior edge of the anterior lamella.  The suture then engages the anterior surface of the tarsus 2-3 mm superior to the eyelid margin.  The suture is then placed through the anterior lamella.  Tying the suture results in a 1-2 mm recession of the anterior lamella.  This is performed along the length of the eyelid.  I usually place 5-6 sutures.  Attention is then directed to the eyelid crease formation.  The confluence of the levator aponeurosis and the orbital septum is identified.  The eyelid crease incision is then closed with a 5-0 fast absorbing suture which engages the skin, followed by the confluence of the orbital septum and levator aponeurosis, followed by the skin.  Interrupted sutures are placed in the same fashion along the length of the eyelid.  Antibiotic ointment will be placed over the repair, and the patient will follow up in approximately one week for suture removal.