Lower eyelid retraction, ectropion and entropion

Causes

• The palpebral aperture is shaped by orbital bone anatomy, orbital volume, the integrity of the eyelids, and their muscular and tarsoligamentous support (PMID 2015744).
• Tarsal-plate measurements across age groups: tarsal plates shrink on average with age; entropion eyelids have smaller-than-age-normal tarsal plates, ectropion eyelids larger-than-age-normal plates; entropion is proposed to result from an atrophied plate overcome by normal orbicularis tone, ectropion from a larger plate overcome by reduced tone plus canthal tendon laxity (PMID 10749160).
• A unified pathogenesis theory proposes that involutional change in the two layers of the lower eyelid retractors underlies both tarsal ectropion and involutional entropion as mirror-image malpositions (PMID 32591162).
• Orbital vector: in 167 eyes, a positive orbital vector was present in 87.5% of entropion eyes and a negative orbital vector in 92.3% of ectropion eyes (p<0.001) (PMID 28853964); in 123 normal individuals, retraction and scleral show correlated with greater proptosis and a more negative orbital vector angle (PMID 32549720).
• Blue Mountains Eye Study, 3,654 people aged 49-97: ectropion prevalence 3.9% overall, rising from 0.3% under age 60 to 16.7% at 80 or older; more common in men (5.1%) than women (3.0%), age-adjusted odds ratio 2.1 (PMID 11446446).
• Survey of 24,565 elderly Brazilians: involutional entropion prevalence 2.1% (more in women), involutional ectropion 2.9% (more in men); dry eye and keratopathy tracked with entropion, chronic conjunctivitis with ectropion (PMID 21415800).
• Tehran Geriatric Eye Study, 3,267 adults 60+: entropion prevalence 0.23%, ectropion 0.68%, both far less common than dermatochalasis (55.15%); ectropion was directly associated with age and inversely with diabetes (PMID 42351045).
• Demographic review of 405 involutional entropion patients without prior surgery: incidence rose with age (only 1.7% were 60 or younger), was more common in men, and 30.6% had bilateral disease (PMID 41528965).
• Review of involutional ectropion: age-related periocular tissue degeneration is the underlying cause, and the lateral tarsal strip is the most used and effective surgery for the horizontal laxity component (PMID 36053479).
• Survey of 196 oculoplastic surgeons: the leading cause of lower lid retraction they treat is prior blepharoplasty (31.6%) (PMID 30931685).

Treatments

• Lateral tarsal strip: lateral canthotomy and transection of the lateral canthal tendon crus, splitting the lid into anterior and posterior lamellae; a strip fashioned from the posterior lamella is sutured to periosteum at the lateral orbital wall to restore canthal tension; described for paralytic or senile eyelid laxity, with good results in 51 cases (PMID 508189).
• Quickert entropion operation: rectifies the effect of enophthalmos, restricts upward movement of the preseptal muscle, repairs disinsertion of the lower eyelid retractors, and corrects buckling of the upper tarsal border, with 3.7% recurrence (PMID 418757).
• Canthal anchoring is divided into canthopexy (no cantholysis) for most patients, and canthoplasty (cantholysis with lid shortening) for significant horizontal laxity; anchoring alone cannot compensate for over-resected lid skin or a poorly supported midface (PMID 12832900). Canthoplasty and canthopexy technique is covered in canthoplasty-and-canthopexy.md; a superficial fascial layer usable for suspension, the superficial lateral canthal tendon, is described there in more detail (PMID 11884849), as is a simplified suture canthopexy algorithm, the lateral retinacular suspension (PMID 10359271).
• Canthopexy has been proposed as a routine companion to lower lid blepharoplasty, restoring lid tone and reducing how much skin needs to be resected (PMID 8485945).
• Spacer grafts lengthen the posterior lamella when tightening alone cannot correct retraction. Hard palate mucosa was described as a spacer in 25 eyelids of 18 patients, graft height twice the measured retraction, with predictable results (PMID 2400351). Autogenous ear cartilage combined with canthal tightening was described in 63 patients with dysthyroid, socket or postblepharoplasty retraction (PMID 3940098).

Results and evidence

• Cochrane review of interventions for involutional lower lid entropion found only one eligible randomized trial (63 participants): combined horizontal and vertical tightening (everting sutures plus lateral tarsal strip) beat vertical tightening (everting sutures) alone; the reviewers called the evidence base for entropion surgery thin (PMID 22161369).
• Randomized trial, 45 patients: lateral tarsal strip (LTS) success was 96.2% versus 71.4% for Quickert everting sutures (ES) at 6 months (p=0.025), and 88.5% versus 57.1% at 12 months (p=0.015) (PMID 31127533).
• A separate randomized trial, 52 patients, found no significant difference in 14-month success between LTS plus everting sutures (93%) and the Quickert procedure alone (97%, p=0.46) (PMID 30916886).
• Combined LTS and Quickert sutures, 36 patients (41 eyelids), followed 2 years: recurrence 4.9% at 6 months and 12.2% at 2 years; 9.4% after a primary procedure versus 22.2% after a prior failed one (PMID 16234695).
• Modified LTS suture placement, 88 ectropion and 96 entropion eyelids, mean follow-up 5.4 years: recurrent entropion fell from 17.4% with the conventional technique to 4% with the modified one; recurrent ectropion was 2.3% with the conventional technique (PMID 27817116).
• Largest reported comparison, 641 procedures: LTS achieved 89.1% anatomical success versus 100% for Bick's procedure (p<0.001); reoperation was 9% after LTS versus none after Bick's (p=0.001) (PMID 29463864).
• Multicentric series, 233 patients having LTS with retractor reinsertion for entropion: success 92.1% with an anterior approach versus 85.7% posterior; recurrence 3.7% versus 14.3% (p=0.016), while overcorrection occurred only with the anterior approach (3.1%) (PMID 36760116).
• Largest recent series, 405 patients (612 eyelids), mostly LTS with posterior retractor attachment: 21% of lids had insufficient laxity for a standard LTS; overall recurrence 1.3%; postoperative ectropion was more frequent after an anterior-approach repair and chemosis after a posterior-approach repair (PMID 41528965).

Spacer graft evidence

• Randomized comparison of three spacer materials in 42 lower eyelids: autologous auricular cartilage, bovine acellular dermal matrix (Surgimend) and porcine acellular dermal matrix (Enduragen) showed no significant outcome difference at 6 months, though week-1 swelling was highest with cartilage (PMID 28658181).
• Graft contraction comparison, 19 grafts in 14 patients: acellular dermis contracted a mean 57% versus 16% for hard palate mucosa (p<0.005); acellular dermis did worse specifically in a mildly contracted socket, where over 60% had only partial success or failure from contraction (PMID 12544789).
• 2026 meta-analysis of acellular dermal allografts, 15 studies (413 eyelids): pooled improvement in MRD2 was 2.12 mm and in inferior scleral show 2.21 mm; complication rate 8.97%, reoperation 0.04% (PMID 41628403).
• Primary spacer graft placed at initial cosmetic lower lid blepharoplasty, to prevent rather than treat retraction, in 15 high-risk patients (Hertel over 17): mean MRD2 change was only 0.19 mm; 2 of 15 (13%) still developed retraction, about 2 years later (PMID 37326309).
• Buccal mucosal membrane graft in a four-step protocol (scar release, midface lift, graft, canthal tightening), 12 cicatricial-retraction patients: mean MRD2 improved 2.69 mm (7.73 mm to 5.04 mm), no major complications (PMID 36457092).
• Meta-analysis of cicatricial ectropion treatment, 31 studies (299 patients): surgery gave complete correction in 79% versus 63% for hyaluronic acid filler; filler scored better cosmetically but recurred more (PMID 31584117).
• Systematic review of cicatricial lower eyelid retraction surgery, 29 articles: no single technique is the gold standard; severe cases (scleral show over 2 mm) often need combined reconstruction methods (PMID 37904540).

Postblepharoplasty and midface causes

• In 46 patients referred for postblepharoplasty lower eyelid retraction (PBLER), orbicularis weakness, anterior lamellar shortage, orbital volume deficit and negative-vector topography were all common; a significant middle lamellar scar was found in only 17% of eyelids, challenging the view that scarring alone explains PBLER (PMID 25168805).
• Standard PBLER management combines midface lifting, a posterior lamellar spacer graft and canthal suspension, though results are variable and revision is difficult (PMID 31587762).
• 10-year review of 264 patients having primary transcutaneous lower blepharoplasty with routine lateral canthal support: lid malposition needing surgery occurred in 3.5%, chemosis in 12.1%, orbital hematoma in 0.4% (PMID 18176227).
• Subperiosteal midface lift with or without a hard palate mucosal graft (HPMG), 34 patients, 42% with retraction from prior transcutaneous blepharoplasty: midface lift alone improved lower eyelid height 1.1 mm; adding an HPMG improved it 2.2 mm (p=0.02) (PMID 16884780).
• Temporal MORE (modified orbicularis repositioning) with canthal tightening and fat grafting for lower eyelid displacement after cosmetic blepharoplasty, 117 patients: symptom scores fell from 74.91 to 9.03 out of 100; complications were chemosis (5.13%), hypertrophic scar (2.56%), transient frontal nerve palsy (1.71%) and hematoma (0.85%); 2 patients relapsed (PMID 41364538).
• Comparison of subperiosteal midface lift with four posterior lamellar reconstructions, 120 operations: MRD2 elevation was similar across techniques (0.85-1.59 mm), but reoperation was highest with a hard palate graft (33%) versus the others (p=0.0006), suggesting a no-graft midface lift may be preferable when laxity allows (PMID 38499878).

Risks and complications

• Intraoperative canthopexy significantly increased the risk of postoperative chemosis (p=0.009) in an 892-case blepharoplasty series; dry eye symptoms and chemosis occurred overall in 26.5% and 26.3% of cases, more often with combined upper-and-lower blepharoplasty and the skin-muscle flap technique (PMID 23329270).
• Trichiasis was the most frequent minor complication after lateral tarsal strip with retractor reinsertion (6%), and overcorrection occurred only with the anterior-approach technique (3.1%) (PMID 36760116).
• Granuloma, pain, tearing and discharge were the complications behind the 8.97% overall rate in the acellular dermal allograft meta-analysis (PMID 41628403).
• Reoperation was highest when a hard palate graft was added to a midface lift, in two separate series (PMID 38499878), (PMID 16884780).

Recovery

Direct recovery-time data for lateral tarsal strip or spacer-graft surgery were not found in this review. For early postblepharoplasty retraction, a surgeon survey found 54.1% wait at least 6 months before operating, since many early cases improve with massage (51.3% use it first-line) or steroid injection (PMID 30931685).

Current questions

• Lateral tarsal strip versus Bick's procedure: the largest comparison favored Bick's procedure on success and reoperation rate (PMID 29463864), yet lateral tarsal strip remains the technique most surgeons use for horizontal laxity (PMID 36053479).
• Lateral tarsal strip plus everting sutures versus Quickert sutures alone for entropion: one randomized trial favored the combined approach (PMID 31127533), a second randomized trial found no difference (PMID 30916886), and the Cochrane review that predates both trials called the evidence base thin (PMID 22161369).
• Best spacer material: a randomized trial found no significant difference between auricular cartilage, bovine and porcine acellular dermal matrix (PMID 28658181), while a separate series found hard palate grafts carried a higher reoperation rate than a no-graft midface lift (PMID 38499878).
• Anterior versus posterior retractor reinsertion with the lateral tarsal strip: the anterior approach had fewer recurrences but more overcorrection in one multicentric series (PMID 36760116).
• Whether a primary spacer graft at the time of initial cosmetic lower blepharoplasty prevents later retraction in high-risk patients: a small series found it did not fully prevent retraction developing years later (PMID 37326309).
• What causes postblepharoplasty retraction: orbicularis weakness, lamellar shortage and negative-vector topography were more common than scarring in one referral series, against the traditional teaching that middle lamellar scar is the main cause (PMID 25168805).

Terms

• Ectropion: outward turning of the eyelid margin, away from the eye (PMID 11446446).
• Entropion: inward turning of the eyelid margin, against the eye (PMID 418757).
• Lower eyelid retraction: a lower lid margin positioned too low, exposing sclera below the cornea (PMID 16884780).
• Involutional: age-related, from loosening or atrophy of the supporting tissues, as opposed to scarring or paralysis (PMID 10749160).
• Cicatricial: caused by scar tissue shortening the front layer of the eyelid, commonly after surgery, trauma or sun damage (PMID 31584117).
• MRD2: margin reflex distance 2, measured from the corneal light reflex to the lower lid margin, used to quantify retraction (PMID 16884780).
• Scleral show: visible white sclera below the cornea from a low lower lid (PMID 37904540).
• Orbital vector: the relationship between the front of the cornea and the front of the cheekbone in profile; a negative vector (eye more forward than cheekbone) is associated with ectropion and retraction (PMID 28853964).
• Lateral tarsal strip: a strip fashioned from the lateral eyelid and reattached to the orbital rim to tighten and support the lid (PMID 508189).
• Spacer graft: tissue (hard palate mucosa, ear cartilage, acellular dermis or buccal mucosa) placed in the back layer of the eyelid to lengthen it and correct retraction (PMID 2400351).
• Canthopexy and canthoplasty: suture suspension versus surgical shortening of the outer corner of the eyelids, covered in canthoplasty-and-canthopexy.md.

Papers