Natural History of Asymptomatic Clinical Retinal Detachments - letters

the cutaneous approach, whether it is for blepharoplasty, orbital surgery, or eyelid rotation, relates to the orbicularis septal complex. Hematoma, inflammation, and scarring in this middle lamellar plane can result in eyelid retraction or volume deflation. Lower eyelid entropion surgeries accomplish their anatomic goal by creating a scar between the lower eyelid retractors and the anterior tarsal fibrous tissue. This scar both transfers the force of the retractors to the anterior lamella and creates a mechanical stiffness that inhibits inward rotation of the margin. Trying to get the right amount of scar tissue is a delicate balancing act, subject to the inconsistencies of the biology of wound healing. Too little scar, and the entropion will recur. Too much scar, and overcorrection or eyelid retraction will result. Understanding the anatomy, physiology, and wound healing biology of the various available surgical manipulations provides the surgeon with an artist’s palate. The accomplished surgeon individualizes each surgery based on subtle differences in anatomy, trying to accomplish just the right amount of intervention (and recognizing that undercorrection is more easily managed than overcorrection.) Drs Erb and Dresner are likely correct that surgery to the orbicularis septal complex increases the success rate of transconjunctival entropion surgery (although comparison of the retrospective studies that they reference is not scientifically valid, and a randomized prospective study would be required to prove their point). On the other hand, aggressive treatment of the orbicularis septal complex increases the complication rate and, indeed, turns the conjunctival approach into essentially a full thickness approach, which is what we started out trying to avoid. Unnecessary surgical reduction of eyelid volume also has negative aesthetic consequences. The orbicularis septal complex is always manipulated to some extent in the process of exposing the anterior tarsus, but we suggest that debulking of orbicularis should be individualized and graded based on the degree of scar tissue needed to stabilize the margin and on the aesthetic goal of the surgery.