Long-term clinical experience with a 3-step combined technique for involutional lower eyelid entropion and ectropion based on common pathophysiologic mechanisms

Background Involutional lower eyelid malpositions, including ectropion and entropion, are common age-related conditions resulting from horizontal eyelid laxity, imbalance between the anterior and posterior lamellae, and orbicularis oculi muscle dysfunction. Although numerous surgical techniques have been described, no single approach has proven universally superior. At our institution, two previously described condition-specific 3-step procedures are used to address the specific pathophysiologic mechanisms underlying involutional ectropion and entropion. Methods A retrospective analysis was conducted on patients treated between 2012 and 2025 using condition-specific 3-step surgical techniques. For involutional ectropion, the procedure combined lower eyelid skin release, lateral eyelid shortening through a base-up full-thickness triangular resection, and transposition of a laterally based upper eyelid myocutaneous flap. For involutional entropion, the technique consisted of partial orbicularis oculi muscle myectomy, lateral eyelid shortening through a base-down triangular resection, and excision of a lower eyelid skin strip. Functional and aesthetic outcomes, postoperative complications, and recurrence rates were evaluated throughout follow-up. Results Forty-five patients (57 eyelids) underwent ectropion correction, with a mean follow-up of 22 months. The overall success rate was 94.7%, with one case of undercorrection and two late recurrences, all successfully managed with secondary procedures. Complications were minimal and limited to one early wound dehiscence. Thirty-five patients (40 eyelids) underwent entropion correction, with a median follow-up of 12 months. No recurrences were observed, while one case of undercorrection and one early wound dehiscence were reported. Conclusions Involutional ectropion and entropion share a common pathophysiologic substrate characterized by horizontal eyelid laxity, lamellar imbalance, and orbicularis oculi dysfunction. Despite technical differences, both procedures are based on the same reconstructive principles: restoration of horizontal eyelid tension, rebalancing of the anterior and posterior lamellae, and normalization of orbicularis muscle forces. The favorable long-term outcomes and low recurrence rates observed in both groups support a pathophysiology-driven, vector-based reconstructive approach for the management of involutional lower eyelid malpositions.