Introduction:

Eyelid burns comprise about 15 percent of burn injuries and represent about 67 percent of patients with facial burns. The most common ocular complication of facial burns is cicatricial ectropion. The ectropion occurs when burn scar contracture gradually causes retraction and subsequent eversion of the eyelids. As a result, corneal exposure can occur and with time, the normal protection of the ocular surface is compromised, leading to infectious keratitis, corneal perforation, or blindness.

The lower eyelid ectropion is more common and difficult to treat than the upper eyelid as both gravity and scar contracture share the same vector directed inferiorly. Therefore, simply releasing the scar and covering with skin grafting or local flaps is often inadequate in preventing recurrence.

Various surgical approaches have been described to treat cicatricial ectropion including tarsorraphies, burn scar excision with skin grafting, and various local flaps. Unfortunately, no consensus in surgical treatment has been available, and recurrence is high, often requiring multiple reoperations. We propose a combined approach to the surgical treatment of lower eyelid burn ectropion in order to correct the deformity and prevent the need for future operative interventions.

Methods:

All patients who presented to the University of Michigan Burn Reconstruction Clinic with lower eyelid burn ectropions were included in this study for evaluation. All patients had previously undergone acute burn care at a comprehensive burn treatment center and now presented for late reconstruction of scar contractures and aesthetic deformities. All patients underwent a series of operations designed to correct both the intrinsic and extrinsic burn scar contractures related to the deep lower eyelid burns.

The initial step of the reconstruction is to release all extrinsic contractures, particularly malar contractures, which can significantly contribute to the lower eyelid burn ectropion. Once released, we then perform a suborbicularis oculi fat (SOOF) suspension to the orbital rim with a lateral orbicularis oculi sling, to reduce the downward traction on the eyelid and improve the support for the eyelid. A postseptal, middle lamellar, cartilage or hard palatal graft is then placed to improve the support of the lower eyelid further. Medial and lateral canthoplasties are then performed to elevate the level of the eyelid and correct eyelid eversion due to the burn ectropion. The canthoplasties are designed to elevate the lower eyelid and approximate the punctum to the globe which will help to re-establish the lacrimal pump mechanism and reduce tearing. Z-plasties are then performed as needed to correct any burn webbings around the eyes. Lastly, a full-thickness skin graft (FTSG) is placed in the final wound to reconstruct the defect. Their pre and postoperative evaluations and long-term results are presented with photographs.

Results:

Ten patients with severe lower eyelid burn ectropions are presented in this case series. The patients underwent an average of 2.4 previous operations on their lower eyelid burns to address their open wounds and lower eyelid burn ectropion prior to their presentation to the Burn Reconstruction Clinic. On average, patients experienced burns involving 44% of their face. A total of 11 lower eyelids in 10 patients have been surgically treated. One patient with bilateral lower eyelid ectropions has experienced a recurrence of his lower eyelid ectropion due to postoperative infection. This patient required one additional operation to correct the ectropion. All other patients have experienced a significant improvement in their lower eyelid position with resolution of conjunctival injection, keratitis, and dramatic reduction in tearing, with no need for additional operative interventions.

Conclusion:

In conclusion, a complex reconstructive approach that addresses both the intrinsic and extrinsic burn contractures and structural components of the lower eyelid and the adjacent aesthetic subunits is highly effective in treating the postburn ectropion of the lower eyelid.