Purpose

To present complex cases of severe involutional lower eyelid ectropion that persisted despite correctly performed standard surgical techniques, requiring a modified and more extensive surgical approach.

---

Methods

This retrospective study included patients treated for severe involutional lower eyelid ectropion between January 2024 and December 2025. Only cases with complete or near-complete lower eyelid eversion were analysed. Horizontal shortening was performed using the lateral tarsal strip (LTS) technique or wedge excision, while vertical instability was managed with either retractor tightening/reattachment or complete retractor release in cases with fibrosis and shortening. Additional procedures were performed according to intraoperative findings.

---

Results

Nine patients with severe unilateral involutional ectropion were included. Symptom duration ranged from 6 to 22 months. LTS was performed in all patients. Three patients underwent complete retractor release, while six had retractor tightening or reattachment. Additional procedures included medial conjunctival diamond excision, anterior lamella reconstruction with a transposition skin flap, and Frost suture placement. During a mean follow-up of 10.5 months, no recurrence occurred in patients treated with complete retractor release. In contrast, recurrence developed in five of six patients treated with retractor tightening or reattachment. Stable eyelid position was achieved only after retractor release.

---

Conclusion

Severe involutional ectropion with complete lower eyelid eversion represents an advanced cicatricial and biomechanical disorder in which standard procedures may be insufficient. Fibrotic shortening and pathological traction of the lower eyelid retractors appear to play a key role in recurrence. Complete retractor release may therefore be essential for eliminating vertical traction and achieving long-term anatomical correction in advanced cases.

---

Additional Authors

First name	Last name	Base Hospital / Institution
Biljana	Kuzmanović Elabjer	Sveti Duh University Hospital, Zagreb; Faculty of Dental Medicine and Health Osijek, University Josip Juraj Strossmayer in Osijek, Croatia
Iva	Bulat	Faculty of Dental Medicine and Health Osijek, University Josip Juraj Strossmayer in Osijek, Croatia
Dora	Marinčić	Sveti Duh University Hospital, Zagreb; Faculty of Dental Medicine and Health Osijek, University Josip Juraj Strossmayer in Osijek, Croatia
Mladen	Bušić	Sveti Duh University Hospital, Zagreb; Faculty of Dental Medicine and Health Osijek, University Josip Juraj Strossmayer in Osijek, Croatia

↑ Back to top