Aesth Plast Surg DOI 10.1007/s00266-014-0360-0
CASE REPORT
EXPERIMENTAL/SPECIAL TOPICS
Marginal Ectropion Induced by Conjunctival Ingrowth After Levator Resection Surgery Chang Yeom Kim • Eunji Oh • Cheng-Zhe Wu Jin Sook Yoon • Sang Yeul Lee
•
Received: 4 January 2014 / Accepted: 15 May 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Background Levator resection surgery is commonly performed to correct ptosis, and a large number of postoperative complications are well known. This report presents a previously unreported complication of marginal ectropion after levator resection surgery for congenital ptosis. Methods The three patients with upper eyelid marginal ectropion in this observational case series previously had undergone levator resection surgery for congenital ptosis. The patients’ medical records and clinical photographs were reviewed retrospectively. The patients underwent reoperations for ectropion correction. Unusual tissues identified during the surgery were excised and processed for histopathologic analysis. Results The patients presented with upper eyelid marginal ectropion and had a history of levator resection surgery for congenital ptosis on the same eye. Ingrown tissues were observed during the second operations for ectropion correction in all three patients. Histopathologic analysis
C. Y. Kim J. S. Yoon S. Y. Lee (&) The Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea e-mail: [email protected] E. Oh Department of Diagnostic Pathology, Yonsei University College of Medicine, Seoul, Korea C.-Z. Wu Department of Ophthalmology, Yanbian University Medical College, Jilin, China
was performed for two of the patients, confirming that the tissue consisted of mucosa. The ectropions were corrected after surgical removal of the ingrown tissues. Conclusions Marginal ectropion can occur after levator resection surgery. In this study, the ectropion was attributed to mucosal ingrowth, a complication not previously reported. To improve the surgical outcomes, surgeons should be aware of this complication. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Ptosis
Complication Ectropion Levator resection
Introduction Ptosis is a common eyelid disease [1, 2]. Most ptosis patients have been treated with surgery such as frontalis suspension, levator resection, and conjunctival resection of Mu¨ller’s muscle. Although surgeons thoroughly evaluate patients, decide on appropriate surgical methods, and carefully perform a meticulous technique, postoperative complications may be inevitable. The complications of ptosis surgery include under- or overcorrection; eyelid malposition resulting in lagophthalmos, retraction, entropion, or ectropion; corneal problems including corneal abrasion and exposure keratopathy; nerve or extraocular muscle damage; unsightly cosmetic appearance; and other general postoperative complications such as infection, hemorrhage, wound dehiscence, and unfavorable scarring [3].
123
Aesth Plast Surg Fig. 1 Schematic drawing of the ectropion correction surgery procedures in the reported cases. After the skin incision along the eyelid crease and tissue dissection (a), mucosal tissue was noted on the tarsal plate at the region of ectropion (b). (c) The ingrown tissue was excised, and the detached conjunctiva was repaired with sutures. (d) The levator muscle was reattached at the tarsal plate, and the wound was closed
In this report, we present three previously unreported cases of eyelid marginal ectropion induced by mucosal ingrowth into the inner surface of the upper eyelid after levator resection surgery for congenital ptosis.
analyzed by light microscopic examination with hematoxylin and eosin staining.
Results Materials and Methods
Demographic Data
Institutional Review Board/Ethics Committee approval was obtained for this study. The research adhered to the tenets of the Declaration of Helsinki, and written informed consent was obtained from all the participants (parents or legal guardians). Three patients who experienced the development of marginal ectropion after levator resection surgeries were recruited. The patients’ medical records, clinical photographs, and intraoperative findings were reviewed retrospectively. The patients underwent ectropion correction surgery by one surgeon, and the procedures of ectropion correction surgery are presented in Fig. 1. Unusual tissues identified and excised during ectropion correction were processed for histopathologic analysis. The tissues were
Two boys ages 7 and 19 years and a girl age 18 years presented with upper eyelid marginal ectropion (Table 1). All three patients were Korean, and three eyes with marginal ectropion of all three patients had congenital ptosis with fair to poor levator muscle function (LF) of approximately 5 mm. Levator resection surgeries had been performed by one surgeon respectively 9 months, 12 years, and 15 years previously. Approximately 600 patients had undergone levator resection surgery for congenital ptosis by the same surgeon during the preceding 15 years. The second operations for ectropion correction also were performed by the same surgeon. Although all three patients were children or teenagers, no special measures were required except
123
Aesth Plast Surg Table 1 Demographic data of the three patients with marginal ectropion after levator resection surgery for congenital ptosis Cases
Age (years)
Sex
Eye
F/U time (months)
LF (mm)
Interval (years)a
Ingrown tissue
Histologic analysis
1
7
M
Right
4
5
0.75
Present
NA
2
19
M
Right
6
5
12
Present
Mucosal lining
3
18
F
Right
9
4–5
15
Present
Mucosal lining
F/U follow-up assessment after ectropion correction surgery, LF levator muscle function, M male, F female, NA not applicable a
Time between levator resection and ectropion correction surgery
Fig. 2 Case 1. Clinical photographs of the patient before (a) and after (b, c) levator resection surgery, and after the second surgery for ectropion correction (f). d, e The ingrown tissue (arrows) was observed during the second operation
routine postoperative care with antibiotics and analgesic medications. Case 1 A 7-year-old boy underwent levator resection surgery due to congenital ptosis of the right eye with LF of 5 mm (Fig. 2a). After the usual surgical protocol, the levator and Mu¨ller’s muscles were dissected free from the tarsus and conjunctiva and advanced onto the tarsus [4]. During the procedure, a conjunctival buttonhole occurred inadvertently. The postoperative outcome was positive, and the boy had no eyelid malposition, including ectropion, during the early postoperative periods (Fig. 2b). However, eversion of
the eyelid margin and eyelashes appeared in the right eye 1 month after surgery. Reoperation was performed 9 months after surgery (Fig. 2c) to correct marginal ectropion. After the skin incision, careful dissection of the adhesion on the anterior surface of the levator muscle was performed. In the approach to the anterior surface of the tarsal plate, a pinkish mucosa-like smooth surface tissue was noted on the anterior surface of the tarsal plate (Fig. 2d, e). When the mucosal tissue was removed, the conjunctiva was detached from the tarsal plate. The levator muscle also was detached here and was therefore reattached at the tarsal plate. The conjunctiva was sutured continuously to the upper margin of the tarsal plate using 6-0 absorbable braided
123
Aesth Plast Surg
Fig. 3 Case 2. Photographs before (a) and 6 months after (b) surgery for ectropion correction. The ingrown tissue, excised during the operation, had a mucosal lining and submucosal lymphocytic
infiltration at histopathologic examination. c, d Hematoxylin and eosin staining (original magnification 9100 and 9200, respectively)
polyglactin sutures. The marginal ectropion was corrected, and at this writing, the patient is under regular follow-up care for a slightly large palpebral fissure on the right eye (Fig. 2f).
measurement on the right eye had been approximately 4 mm, and levator resection surgery was performed at that time. Reoperation for ectropion correction was performed. During the operation, a mucosa-like tissue overriding the tarsal plate also was found at the center of the tarsal plate and excised (Fig. 4b). Histopathologic analysis confirmed that the tissue was composed of mucosa (Fig. 4c). After excision of the ingrown tissue, the ectropion was corrected successfully (Fig. 4e, f).
Case 2 A 19-year-old boy visited our clinic for slightly undercorrected ptosis and upper eyelid eversion of the right eye (Fig. 3a). He had undergone eyelid surgery for bilateral congenital ptosis 12 years previously. The preoperative LF was 5 mm in the right eye and 3 mm in the left eye. Levator resection surgery was performed on the right eye and frontalis suspension using autogenous fascia lata on the left eye. The surgery was performed uneventfully, and the postoperative eyelid height and contour were satisfactory and well-maintained 6 months after surgery. No follow-up care was provided after this period. The operation for correction of marginal ectropion and slight undercorrection of the right eye was performed. During the surgery, a pink-colored smooth tissue was found on the anterior surface of the tarsal plate. The tissue was excised and sent to the pathologist for histologic identification, which showed the presence of mucosal lining and lymphocytic infiltration of the submucosa (Fig. 3c, d). The marginal ectropion was improved postoperatively (Fig. 3b). Case 3 An 18-year-old girl reported marginal ectropion at the center of the upper eyelid on the right eye (Fig. 4a). The patient had visited our clinic for eyelid drooping on the right eye 15 years previously. The preoperative LF
123
Discussion Complications of ptosis surgery have functional and aesthetic consequences. Undercorrection or asymmetric lid level including overcorrection is known to be the most common complication [2, 5]. Less common complications include exposure keratopathy, eyelid malposition, conjunctival prolapse, wound dehiscence, and scarring, among others [3]. The patients in the three reported cases presented with marginal ectropion after levator resection surgery for congenital ptosis. Ectropion after ptosis surgery could result from weakening of the pretarsal orbicularis muscle, thinning or atrophy of eyelid tissues and dehiscence, and elongation or disinsertion of retractor elements such as Mu¨ller’s muscle [6]. In addition, placement of the levator muscle too far inferiorly onto the anterior surface of the tarsus also may result in eversion of the tarsal plate and eyelid ectropion. However, none of the patients in this study had these problems, and the levator muscle was placed at the superior one third of the tarsus during the surgery.
Aesth Plast Surg
Fig. 4 Case 3. Preoperative photograph (a) and the ingrown tissue (arrow) found during ectropion correction (b). Mucosal lining at histopathologic examination. c Hematoxylin and eosin staining (original magnification 9100). Intraoperative appearance before
(d) and after (e) excision of the ingrown tissue. (f) Assessment 9 months later showed improvement in the eversion of the eyelid margin
Instead, all the patients had ingrown tissues. These tissues had a smooth surface and were pink colored like mucosal membranes of the conjunctiva. Histopathologic analysis of two patients confirmed that the tissue consisted of mucosa. It is reasonable to assume that these ingrown tissues originated from palpebral conjunctiva and contributed to marginal ectropion for the following reasons. First, the tissue had the appearance of conjunctival mucosa and
actually had a mucosal lining with stratified cuboidal epithelium characteristic of conjunctiva [7]. Second, the ingrown tissues were located in the region of the ectropion in the upper eyelids on and toward the anterior surface of the tarsal plate. Finally, surgical removal of the ingrown tissues resulted in correction of the eyelid eversions. Epithelial ingrowth-induced tissue contraction is well known in anterior segment ocular surgery. As a
123
Aesth Plast Surg
complication of anterior segment surgery, including cataract surgery and trauma, epithelial ingrowth may occur through the corneal wound, resulting in tissue contraction, or even worse, glaucoma by formation of peripheral anterior synechiae and contraction [8]. In addition, epithelial ingrowth underneath the flap after laser-assisted in situ keratomileusis (LASIK) is reported to occur in 1–15 % of LASIK cases [9, 10]. This condition commonly results from growth of epithelial cells into the interface through a persistent track in an area wherein the peripheral flap does not adequately adhere. Fibrosis also occurs as a result of abnormal extracellular matrix remodeling [11]. Epithelial cyst formation after ptosis repair also has been described [12]. The burying of conjunctival epithelium, obstruction of the gland of Krause, and injury to the lacrimal duct were suggested as probable causes of postsurgical cystic masses after levator resection surgery. The mechanism involving mucosal ingrowth and ectropion after levator resection surgery is not clear. However, a possible explanation is that the conjunctival mucosa grows into the eyelid through a buttonhole formed unintentionally during levator resection surgery and pulls the anterior eyelid margin by contraction. During levator resection surgery for patients with fair to poor LF, both the levator aponeurosis and Mu¨ller’s muscle usually are detached together from the underlying conjunctiva without separation [4]. Conjunctival buttonhole formation may occur when Mu¨ller’s muscle is separated from the conjunctiva because Mu¨ller’s muscle and the conjunctiva are tightly adhered. Although we cannot definitively confirm whether buttonhole formation occurred during levator resection surgery in the reported cases because we were not focused on this point at that time, it is a possible cause of mucosal ingrowth. The conjunctival tissue may migrate into the anterior lamella of the upper eyelid through a buttonhole-like opening on the palpebral conjunctiva. The conjunctiva that lines the inside of the eyelids is a mucous membrane containing fibroblasts, and these cells were found during histopathologic evaluation of the ingrown tissues. Also, histopathologic findings of submucosal lymphocytic infiltration on the ingrown tissues confirmed the presence of inflammation. It is possible that contraction of fibroblasts in ingrown tissue resulted in the marginal ectropion. In this regard, complications of marginal ectropion due to mucosal ingrowth can occur commonly in patients who undergo a posterior approach to ptosis surgery involving a conjunctival incision.
Conclusion Our study demonstrated a previously unreported complication of marginal ectropion induced by conjunctival
123
mucosa ingrowth after levator resection surgery. Considering the number of operations that have been performed, the incidence of this complication is expected to be low. Moreover, this ‘‘mucosal ingrowth’’ theory requires careful interpretation and may not be applicable to patients of different races or ages because of anatomic differences in eyelids, especially between Asian and Caucasian. However, to improve the surgical outcomes, surgeons should be aware of this complication and should carefully separate the levator and Mu¨ller’s muscles from the conjunctiva to prevent a conjunctival buttonhole formation when performing surgery. It also is important to repair the buttonholed conjunctiva carefully to avoid this type of complication. Acknowledgments The authors thank Dong-Su Jang (Medial Illustrator, Medical Research Support Section, Yonsei University College of Medicine, Seoul, Korea) for his support with the medial figure. Conflict of interest The authors declare that they have no conflict of interest and no financial support
References 1. Griepentrog GJ, Diehl NN, Mohney BG (2011) Incidence and demographics of childhood ptosis. Ophthalmology 118: 1180–1183 2. Finsterer J (2003) Ptosis: causes, presentation, and management. Aesthet Plast Surg 27:193–204 3. Barutca SA, Bilgic MI, Askeroglu U, Aksan T, Akan M (2011) An unusual complication following eyelid ptosis surgery: superior rectus paralysis. J Plast Reconstr Aesthet Surg 64:e201–e204 4. Tyers AG, Collin JR (2001) Colour atlas of ophthalmic plastic surgery. Butterworth-Heinemann, Oxford, p 151 5. Collin JR (1979) Complications of ptosis surgery and their management: a review. J R Soc Med 72:25–26 6. Bedran EG, Pereira MV, Bernardes TF (2010) Ectropion. Semin Ophthalmol 25:59–65 7. Mescher AL (2010) Junqueira’s basic histology: text and atlas. McGraw-Hill Medical, New York, p 423 8. Hunyor AP, Belcher CD (2004) Epithelial and fibrous invasion of the eye. In: Steinert RF (ed) Cataract surgery: technique, complications, and management. Saunders, Philadelphia, p 572 9. Stulting RD, Carr JD, Thompson KP, Waring GO III, Wiley WM, Walker JG (1999) Complications of laser in situ keratomileusis for the correction of myopia. Ophthalmology 106:13–20 10. Wang MY, Maloney RK (2000) Epithelial ingrowth after laser in situ keratomileusis. Am J Ophthalmol 129:746–751 11. Fournie´ PR, Gordon GM, Dawson DG, Malecaze FJ, Edelhauser HF, Fini ME (2010) Correlation between epithelial ingrowth and basement membrane remodeling in human corneas after laserassisted in situ keratomileusis. Arch Ophthalmol 128:426–436 12. Gonnering RS, Carroll RP (1986) Cystic lesions of the eyelid following ptosis repair. Ophthalmic Plast Reconstr Surg 2:89–93
CASE REPORT
EXPERIMENTAL/SPECIAL TOPICS
Marginal Ectropion Induced by Conjunctival Ingrowth After Levator Resection Surgery Chang Yeom Kim • Eunji Oh • Cheng-Zhe Wu Jin Sook Yoon • Sang Yeul Lee
•
Received: 4 January 2014 / Accepted: 15 May 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Background Levator resection surgery is commonly performed to correct ptosis, and a large number of postoperative complications are well known. This report presents a previously unreported complication of marginal ectropion after levator resection surgery for congenital ptosis. Methods The three patients with upper eyelid marginal ectropion in this observational case series previously had undergone levator resection surgery for congenital ptosis. The patients’ medical records and clinical photographs were reviewed retrospectively. The patients underwent reoperations for ectropion correction. Unusual tissues identified during the surgery were excised and processed for histopathologic analysis. Results The patients presented with upper eyelid marginal ectropion and had a history of levator resection surgery for congenital ptosis on the same eye. Ingrown tissues were observed during the second operations for ectropion correction in all three patients. Histopathologic analysis
C. Y. Kim J. S. Yoon S. Y. Lee (&) The Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea e-mail: [email protected] E. Oh Department of Diagnostic Pathology, Yonsei University College of Medicine, Seoul, Korea C.-Z. Wu Department of Ophthalmology, Yanbian University Medical College, Jilin, China
was performed for two of the patients, confirming that the tissue consisted of mucosa. The ectropions were corrected after surgical removal of the ingrown tissues. Conclusions Marginal ectropion can occur after levator resection surgery. In this study, the ectropion was attributed to mucosal ingrowth, a complication not previously reported. To improve the surgical outcomes, surgeons should be aware of this complication. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Ptosis
Complication Ectropion Levator resection
Introduction Ptosis is a common eyelid disease [1, 2]. Most ptosis patients have been treated with surgery such as frontalis suspension, levator resection, and conjunctival resection of Mu¨ller’s muscle. Although surgeons thoroughly evaluate patients, decide on appropriate surgical methods, and carefully perform a meticulous technique, postoperative complications may be inevitable. The complications of ptosis surgery include under- or overcorrection; eyelid malposition resulting in lagophthalmos, retraction, entropion, or ectropion; corneal problems including corneal abrasion and exposure keratopathy; nerve or extraocular muscle damage; unsightly cosmetic appearance; and other general postoperative complications such as infection, hemorrhage, wound dehiscence, and unfavorable scarring [3].
123
Aesth Plast Surg Fig. 1 Schematic drawing of the ectropion correction surgery procedures in the reported cases. After the skin incision along the eyelid crease and tissue dissection (a), mucosal tissue was noted on the tarsal plate at the region of ectropion (b). (c) The ingrown tissue was excised, and the detached conjunctiva was repaired with sutures. (d) The levator muscle was reattached at the tarsal plate, and the wound was closed
In this report, we present three previously unreported cases of eyelid marginal ectropion induced by mucosal ingrowth into the inner surface of the upper eyelid after levator resection surgery for congenital ptosis.
analyzed by light microscopic examination with hematoxylin and eosin staining.
Results Materials and Methods
Demographic Data
Institutional Review Board/Ethics Committee approval was obtained for this study. The research adhered to the tenets of the Declaration of Helsinki, and written informed consent was obtained from all the participants (parents or legal guardians). Three patients who experienced the development of marginal ectropion after levator resection surgeries were recruited. The patients’ medical records, clinical photographs, and intraoperative findings were reviewed retrospectively. The patients underwent ectropion correction surgery by one surgeon, and the procedures of ectropion correction surgery are presented in Fig. 1. Unusual tissues identified and excised during ectropion correction were processed for histopathologic analysis. The tissues were
Two boys ages 7 and 19 years and a girl age 18 years presented with upper eyelid marginal ectropion (Table 1). All three patients were Korean, and three eyes with marginal ectropion of all three patients had congenital ptosis with fair to poor levator muscle function (LF) of approximately 5 mm. Levator resection surgeries had been performed by one surgeon respectively 9 months, 12 years, and 15 years previously. Approximately 600 patients had undergone levator resection surgery for congenital ptosis by the same surgeon during the preceding 15 years. The second operations for ectropion correction also were performed by the same surgeon. Although all three patients were children or teenagers, no special measures were required except
123
Aesth Plast Surg Table 1 Demographic data of the three patients with marginal ectropion after levator resection surgery for congenital ptosis Cases
Age (years)
Sex
Eye
F/U time (months)
LF (mm)
Interval (years)a
Ingrown tissue
Histologic analysis
1
7
M
Right
4
5
0.75
Present
NA
2
19
M
Right
6
5
12
Present
Mucosal lining
3
18
F
Right
9
4–5
15
Present
Mucosal lining
F/U follow-up assessment after ectropion correction surgery, LF levator muscle function, M male, F female, NA not applicable a
Time between levator resection and ectropion correction surgery
Fig. 2 Case 1. Clinical photographs of the patient before (a) and after (b, c) levator resection surgery, and after the second surgery for ectropion correction (f). d, e The ingrown tissue (arrows) was observed during the second operation
routine postoperative care with antibiotics and analgesic medications. Case 1 A 7-year-old boy underwent levator resection surgery due to congenital ptosis of the right eye with LF of 5 mm (Fig. 2a). After the usual surgical protocol, the levator and Mu¨ller’s muscles were dissected free from the tarsus and conjunctiva and advanced onto the tarsus [4]. During the procedure, a conjunctival buttonhole occurred inadvertently. The postoperative outcome was positive, and the boy had no eyelid malposition, including ectropion, during the early postoperative periods (Fig. 2b). However, eversion of
the eyelid margin and eyelashes appeared in the right eye 1 month after surgery. Reoperation was performed 9 months after surgery (Fig. 2c) to correct marginal ectropion. After the skin incision, careful dissection of the adhesion on the anterior surface of the levator muscle was performed. In the approach to the anterior surface of the tarsal plate, a pinkish mucosa-like smooth surface tissue was noted on the anterior surface of the tarsal plate (Fig. 2d, e). When the mucosal tissue was removed, the conjunctiva was detached from the tarsal plate. The levator muscle also was detached here and was therefore reattached at the tarsal plate. The conjunctiva was sutured continuously to the upper margin of the tarsal plate using 6-0 absorbable braided
123
Aesth Plast Surg
Fig. 3 Case 2. Photographs before (a) and 6 months after (b) surgery for ectropion correction. The ingrown tissue, excised during the operation, had a mucosal lining and submucosal lymphocytic
infiltration at histopathologic examination. c, d Hematoxylin and eosin staining (original magnification 9100 and 9200, respectively)
polyglactin sutures. The marginal ectropion was corrected, and at this writing, the patient is under regular follow-up care for a slightly large palpebral fissure on the right eye (Fig. 2f).
measurement on the right eye had been approximately 4 mm, and levator resection surgery was performed at that time. Reoperation for ectropion correction was performed. During the operation, a mucosa-like tissue overriding the tarsal plate also was found at the center of the tarsal plate and excised (Fig. 4b). Histopathologic analysis confirmed that the tissue was composed of mucosa (Fig. 4c). After excision of the ingrown tissue, the ectropion was corrected successfully (Fig. 4e, f).
Case 2 A 19-year-old boy visited our clinic for slightly undercorrected ptosis and upper eyelid eversion of the right eye (Fig. 3a). He had undergone eyelid surgery for bilateral congenital ptosis 12 years previously. The preoperative LF was 5 mm in the right eye and 3 mm in the left eye. Levator resection surgery was performed on the right eye and frontalis suspension using autogenous fascia lata on the left eye. The surgery was performed uneventfully, and the postoperative eyelid height and contour were satisfactory and well-maintained 6 months after surgery. No follow-up care was provided after this period. The operation for correction of marginal ectropion and slight undercorrection of the right eye was performed. During the surgery, a pink-colored smooth tissue was found on the anterior surface of the tarsal plate. The tissue was excised and sent to the pathologist for histologic identification, which showed the presence of mucosal lining and lymphocytic infiltration of the submucosa (Fig. 3c, d). The marginal ectropion was improved postoperatively (Fig. 3b). Case 3 An 18-year-old girl reported marginal ectropion at the center of the upper eyelid on the right eye (Fig. 4a). The patient had visited our clinic for eyelid drooping on the right eye 15 years previously. The preoperative LF
123
Discussion Complications of ptosis surgery have functional and aesthetic consequences. Undercorrection or asymmetric lid level including overcorrection is known to be the most common complication [2, 5]. Less common complications include exposure keratopathy, eyelid malposition, conjunctival prolapse, wound dehiscence, and scarring, among others [3]. The patients in the three reported cases presented with marginal ectropion after levator resection surgery for congenital ptosis. Ectropion after ptosis surgery could result from weakening of the pretarsal orbicularis muscle, thinning or atrophy of eyelid tissues and dehiscence, and elongation or disinsertion of retractor elements such as Mu¨ller’s muscle [6]. In addition, placement of the levator muscle too far inferiorly onto the anterior surface of the tarsus also may result in eversion of the tarsal plate and eyelid ectropion. However, none of the patients in this study had these problems, and the levator muscle was placed at the superior one third of the tarsus during the surgery.
Aesth Plast Surg
Fig. 4 Case 3. Preoperative photograph (a) and the ingrown tissue (arrow) found during ectropion correction (b). Mucosal lining at histopathologic examination. c Hematoxylin and eosin staining (original magnification 9100). Intraoperative appearance before
(d) and after (e) excision of the ingrown tissue. (f) Assessment 9 months later showed improvement in the eversion of the eyelid margin
Instead, all the patients had ingrown tissues. These tissues had a smooth surface and were pink colored like mucosal membranes of the conjunctiva. Histopathologic analysis of two patients confirmed that the tissue consisted of mucosa. It is reasonable to assume that these ingrown tissues originated from palpebral conjunctiva and contributed to marginal ectropion for the following reasons. First, the tissue had the appearance of conjunctival mucosa and
actually had a mucosal lining with stratified cuboidal epithelium characteristic of conjunctiva [7]. Second, the ingrown tissues were located in the region of the ectropion in the upper eyelids on and toward the anterior surface of the tarsal plate. Finally, surgical removal of the ingrown tissues resulted in correction of the eyelid eversions. Epithelial ingrowth-induced tissue contraction is well known in anterior segment ocular surgery. As a
123
Aesth Plast Surg
complication of anterior segment surgery, including cataract surgery and trauma, epithelial ingrowth may occur through the corneal wound, resulting in tissue contraction, or even worse, glaucoma by formation of peripheral anterior synechiae and contraction [8]. In addition, epithelial ingrowth underneath the flap after laser-assisted in situ keratomileusis (LASIK) is reported to occur in 1–15 % of LASIK cases [9, 10]. This condition commonly results from growth of epithelial cells into the interface through a persistent track in an area wherein the peripheral flap does not adequately adhere. Fibrosis also occurs as a result of abnormal extracellular matrix remodeling [11]. Epithelial cyst formation after ptosis repair also has been described [12]. The burying of conjunctival epithelium, obstruction of the gland of Krause, and injury to the lacrimal duct were suggested as probable causes of postsurgical cystic masses after levator resection surgery. The mechanism involving mucosal ingrowth and ectropion after levator resection surgery is not clear. However, a possible explanation is that the conjunctival mucosa grows into the eyelid through a buttonhole formed unintentionally during levator resection surgery and pulls the anterior eyelid margin by contraction. During levator resection surgery for patients with fair to poor LF, both the levator aponeurosis and Mu¨ller’s muscle usually are detached together from the underlying conjunctiva without separation [4]. Conjunctival buttonhole formation may occur when Mu¨ller’s muscle is separated from the conjunctiva because Mu¨ller’s muscle and the conjunctiva are tightly adhered. Although we cannot definitively confirm whether buttonhole formation occurred during levator resection surgery in the reported cases because we were not focused on this point at that time, it is a possible cause of mucosal ingrowth. The conjunctival tissue may migrate into the anterior lamella of the upper eyelid through a buttonhole-like opening on the palpebral conjunctiva. The conjunctiva that lines the inside of the eyelids is a mucous membrane containing fibroblasts, and these cells were found during histopathologic evaluation of the ingrown tissues. Also, histopathologic findings of submucosal lymphocytic infiltration on the ingrown tissues confirmed the presence of inflammation. It is possible that contraction of fibroblasts in ingrown tissue resulted in the marginal ectropion. In this regard, complications of marginal ectropion due to mucosal ingrowth can occur commonly in patients who undergo a posterior approach to ptosis surgery involving a conjunctival incision.
Conclusion Our study demonstrated a previously unreported complication of marginal ectropion induced by conjunctival
123
mucosa ingrowth after levator resection surgery. Considering the number of operations that have been performed, the incidence of this complication is expected to be low. Moreover, this ‘‘mucosal ingrowth’’ theory requires careful interpretation and may not be applicable to patients of different races or ages because of anatomic differences in eyelids, especially between Asian and Caucasian. However, to improve the surgical outcomes, surgeons should be aware of this complication and should carefully separate the levator and Mu¨ller’s muscles from the conjunctiva to prevent a conjunctival buttonhole formation when performing surgery. It also is important to repair the buttonholed conjunctiva carefully to avoid this type of complication. Acknowledgments The authors thank Dong-Su Jang (Medial Illustrator, Medical Research Support Section, Yonsei University College of Medicine, Seoul, Korea) for his support with the medial figure. Conflict of interest The authors declare that they have no conflict of interest and no financial support
References 1. Griepentrog GJ, Diehl NN, Mohney BG (2011) Incidence and demographics of childhood ptosis. Ophthalmology 118: 1180–1183 2. Finsterer J (2003) Ptosis: causes, presentation, and management. Aesthet Plast Surg 27:193–204 3. Barutca SA, Bilgic MI, Askeroglu U, Aksan T, Akan M (2011) An unusual complication following eyelid ptosis surgery: superior rectus paralysis. J Plast Reconstr Aesthet Surg 64:e201–e204 4. Tyers AG, Collin JR (2001) Colour atlas of ophthalmic plastic surgery. Butterworth-Heinemann, Oxford, p 151 5. Collin JR (1979) Complications of ptosis surgery and their management: a review. J R Soc Med 72:25–26 6. Bedran EG, Pereira MV, Bernardes TF (2010) Ectropion. Semin Ophthalmol 25:59–65 7. Mescher AL (2010) Junqueira’s basic histology: text and atlas. McGraw-Hill Medical, New York, p 423 8. Hunyor AP, Belcher CD (2004) Epithelial and fibrous invasion of the eye. In: Steinert RF (ed) Cataract surgery: technique, complications, and management. Saunders, Philadelphia, p 572 9. Stulting RD, Carr JD, Thompson KP, Waring GO III, Wiley WM, Walker JG (1999) Complications of laser in situ keratomileusis for the correction of myopia. Ophthalmology 106:13–20 10. Wang MY, Maloney RK (2000) Epithelial ingrowth after laser in situ keratomileusis. Am J Ophthalmol 129:746–751 11. Fournie´ PR, Gordon GM, Dawson DG, Malecaze FJ, Edelhauser HF, Fini ME (2010) Correlation between epithelial ingrowth and basement membrane remodeling in human corneas after laserassisted in situ keratomileusis. Arch Ophthalmol 128:426–436 12. Gonnering RS, Carroll RP (1986) Cystic lesions of the eyelid following ptosis repair. Ophthalmic Plast Reconstr Surg 2:89–93
