A Backflip Flap: A New Surgical Correction for Severe Cicatricial Entropion

Sir: Patients with severe cicatricial entropion represent one of the most challenging oculoplastic problems. Surgical treatment is directed at restoring the natural position of the mucocutaneous junction. This objective is frequently managed by interpositioning a “spacer graft,” with buccal mucosa, tarsal plate, hard palate, and ear cartilage used as a graft.1–4 However, survival of the graft is uncertain and there is a risk of recurrence caused by atrophy of the graft. To prevent recurrence by atrophy, the harvest of a slightly larger graft causes a transformation of the donor site. In this article, we report a new means of surgical correction for severe cicatricial entropion to fill a conjunctival deficit with the inferior eyelid skin as a hinge flap made from a pedicled orbicularis oculi muscle, termed a “backflip flap.” An incision is made in the skin 3 to 4 mm below the eyelashes, parallel to the lid margin. Also, another incision is made 4 to 5 mm below the incision line, to form a spindle-shaped area. The upper incision is extended underneath the orbicularis oculi muscle, and the skin is peeled off to the lower margin of the tarsal plate to open the conjunctiva. The lower incision is extended immediately above the orbicularis oculi muscle and subcutaneously undermined by a few millimeters, forming an orbicularis oculi muscle flap on the lower margin of the tarsal plate. This skin flap is reversed and sutured to the tarsus superiorly and to the retractors and conjunctiva inferiorly as a hinge flap (Fig. 1). To strengthen the entropion correction, the eyelash-side skin is fixed onto the tarsal plate with three sutures.Fig. 1.: Sagittal schematic view of the operative procedure. The flap was reversed as a hinge flap and sutured to the conjunctiva.We performed this technique on three patients, and all patients reported symptomatic improvement, with no complications, and were satisfied with the results (Fig. 2).Fig. 2.: A 20-year-old woman presented with exophthalmos and entropion accompanied by Basedow disease. (Above) Preoperative view showing that the lower eyelashes stand in front of the eyeball. (Center) Photograph demonstrating the appearance 1 year postoperatively. (Below) Photograph demonstrating the condition of the skin flap 1 year postoperatively.No one has challenged using skin as a “spacer,” because it is suspected of leading to corneal injury, infection, increased mucus, and obturation of the lacrimal canaliculus with dirt. However, the skin of the inferior eyelid is among the thinnest on the body and the hair is silky,5 so it is thought that there are few complications resulting from use of this skin. Also, it is useful for reconstruction because it is originally removed surgically in almost all procedures. We decided to use not the skin graft but an orbicularis oculi mucocutaneous flap to stabilize the blood circulation. Furthermore, this procedure does not require harvesting grafts from other areas. The disadvantage of this procedure is that, because of the amount of handling in the same region, the patients developed postoperative edema and required approximately 1 month to recover. Because cases of severe entropion are rare, we only have experience with three cases. In the future, we will increase the number of cases and would like to evaluate the usefulness of this technique. We believe that the technique described here is one of the choices for use in severe cicatricial entropion for the following reasons: ease of handling, few complications, and good results. DISCLOSURE None of the authors has a financial interest to declare in relation to the content of this article. Yoshiaki Sakamoto, M.D. Hideo Nakajima, M.D. Department of Plastic and Reconstructive Surgery Keio University School of Medicine Ikkei Tamada, M.D. Department of Plastic and Reconstructive Surgery Tokyo Metropolitan Kiyose Children's Hospital Yumiko Uchikawa, M.D. Kazuo Kishi, M.D.