Cicatricial ectropion is a serious complication of eyelid surgery. Removing too much skin during a lower eyelid blepharoplasty, i.e., surgery to remove bags and wrinkles under the eyes, is the leading cause of this complication. It can also be seen after lower eyelid reconstruction procedures and in patients with severe skin damage from chronic sun exposure. Because skin shortage is the cause of this condition, adequate repair involves adding skin to the eyelid.
A couple of options exist to correct this problem. The first is to recruit skin from the cheek by employing a cheek lift and placing a hard palate graft on the inside of the eyelid. Unfortunately, this is a very sophisticated and expensive surgery. It also requires extended downtime and time off from work.
A second option is to place a skin graft in this area. This alternative is a more straightforward and practical way to treat cicatricial ectropion and assumes a shorter downtime and smaller financial commitment. However, patients are often concerned about the cosmetic outcome of this option.
Can we achieve good results with an eyelid skin graft?
Although skin grafting on the lower eyelids cannot yield the same results as a cheek lift from a cosmetic standpoint, completing the following steps can provide an excellent functional and cosmetic outcome.
- Ensure adequate release of all the scar tissue and scar bands on the lower eyelid where the graft will be placed. This step is crucial as it allows the surgeon to prepare a smooth and uniform “bed” for the graft, preventing its distortion and assuring proper oxygenation.
- Size the graft appropriately. Considering that skin grafts will contract during the healing process, the surgeon creates a template of the defect before harvesting. This step guarantees adequate graft dimensions.
- Carefully select the anatomical area from where the graft will be harvested. Eyelid skin is unlike any other skin in the body. Its only match is more eyelid skin, which is the first place where the surgeon should look. Unfortunately, harvesting skin from the eyelids is rarely feasible, especially in patients who have had previous eyelid surgery. The skin behind the ear is closest to eyelid skin in terms of its thickness and color; this is a more common harvesting site.
- Translate the template created in Step 2 onto the ear and mark the area, making sure to harvest a graft slightly larger than the eyelid defect. Following its harvesting, carefully excise the subcutaneous fat from the undersurface of the skin graft. Neglecting to excise the subcutaneous fat will interrupt the growth of capillaries onto the graft after its placement into the eyelid, thus making the graft more vulnerable.
- Finally, suture the graft into the eyelid defect. The eyelid is left on stretch with a Frost suture to avoid early contraction of the graft, and a patch is placed for 72 hours.
What can patients expect regarding cosmetic outcomes after an eyelid skin graft?
The graft may appear dusky in the beginning stages but will adopt a more pinkish color with time. Grafted skin will then become firm and thick at around week 4. At this time, to help soften the graft, begin eyelid massages that your surgeon will teach you to do. It may also be necessary to inject anti-scarring medications, such as Triamcinolone and 5 FU, into the graft. Your surgeon may apply these medications every two weeks for the first couple of months.
Above all, patience is essential during the postoperative period as the graft will take significant time to look similar to the surrounding skin. Patients will notice changes in graft color and thickness for up to 6 months.
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