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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Algorithm for examination and treatment of eyelid ectropion&#46; It is important to perform a complete examination to determine which treatment is required&#59; this ensures that the best outcomes are attained and reduces relapses&#46; Abbreviations&#58; LCT&#44; lateral canthal tendon&#59; MCT&#44; medial canthal tendon&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with interest the article published recently by Fern&#225;ndez-Canga et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> on eyelid ectropion&#46; Review articles&#44; like that one&#44; given their educational intent&#44; bear an important responsibility&#44; as many readers could take up certain diagnostic and treatment habits based on what they read&#44; and this would have an impact on the care of our patients&#46; For this reason&#44; we would like to add some caveats based on our personal experience of more than 15 years dedicated to oculoplastic surgery and above all based on the scientific evidence&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The review deals with a syndrome of eyelid malposition&#44; which apart from its esthetic impact&#44; also has mainly ophthalmologic consequences&#46; Of note in the article was the limited mention of the ocular surface and lacrimal duct&#46; The eyelid and the eye are intimately related&#44; and so any patient with a problem with the eyelid should undergo full ophthalmologic study&#46; Ectropion can be caused by rubbing watery eyes in cases of obstructions in the lacrimal duct&#44; problems with the ocular surface&#44; or inflammatory processes&#44; to mention some possibillities&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> To summarize study of ectropion merely with reference to eyelid laxity and its different components&#44; without including full ophthalmologic study&#44; would no doubt leave many patients without an appropriate diagnosis of the cause&#44; resulting in a lower rate of therapeutic success&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Regarding the proposed algorithm for prevention of ectropion&#44; it is important to differentiate between ectropion caused by medial or lateral laxity and&#47;or by retractors when we examine our patients&#44; as treatment&#44; and ultimately prevention&#44; would be different &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> We will take a closer look at this concept later&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Regarding treatment&#44; most patients have mixed ectropion&#59; one of the main pathophysiological components underlying involutional ectropion is disinsertion of the lower eyelid retractors&#46; From an educational point of view&#44; the approach to ectropion should necessarily mention treatment of retractors&#59; different techniques and approaches are available for these procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> Z-plasty does not usually achieve satisfactory outcomes if it is not combined with other techniques in the treatment of cicatricial ectropion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The use of synthetic materials in the treatment of cicatricial ectropion is not supported by the evidence&#59; the authors cite a study in which acellular dermis is used as an alternative in the reconstruction of the posterior lamella&#59; however&#44; this approach is not appropriate in cases of ectropion in which we require the anterior but not the posterior lamella&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Finally&#44; as mentioned earlier&#44; in cases of involutional ectropion&#44; in which disinsertion of the retractors plays a key role&#44; we cannot limit the approach to canthopexy or canthoplasty&#44; but should also consider combining these techniques with others that address all pathophysiological causes of the process&#44; particularly surgery of the retractors&#44; and appropriate management of the skin &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We found some conceptual errors that should be clarified so as not to confuse readers&#46; Thus&#44; in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; the authors<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> indicate lower eyelid orbital fat and denote it preaponeurotic fat&#59; in the strict sense&#44; preaponeurotic fat is found in the upper eyelid&#44; which is where we find levator aponeurosis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Additionally&#44; the flap that Tripier described in his original article in 1889 consisted of a bipedicled bridge-shaped musculoskeletal flap&#59; after this first description&#44; different modifications have been introduced&#46; A skin or musculocutaneous flap of the upper eyelid to reconstruct defects of the lower eyelid&#44; with lateral or medial base&#44; as mentioned by Fern&#225;ndez-Canga et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> is without doubt a very versatile and widely used technique in oculoplastic reconstructive surgery&#46; The flap&#44; depending on its size and design&#44; has recently been shown to behave partially as a graft in novel studies with lasers&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Strictly speaking&#44; it should not be called a Tripier flap but a modified Tripier flap&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">At times&#44; partial improvements in this type of case&#44; as those shown in the study by Fern&#225;ndez-Canga et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> comfort the surgeon to a certain degree in view of the esthetic improvements achieved&#44; but it is important to note that the ocular surface is still exposed and therefore homeostasis may be impacted&#46; This is the difficulty that treatment of ectropion entails &#40;particularly in cases with a cicatricial component&#41;&#46; Unless a perfect positioning of the eyelid and the lower part of the conjunctival sacs is achieved&#44; with appropriate contact of the eyelid margin and the lacrimal punctum with the eyeball&#44; the ocular surface will continue to be distressed&#44; with symptoms of epiphora&#44; chronic conjunctivitis&#44; or keratitis&#46; Ultimately&#44; these are the most important aspects requiring improvement&#46; We propose a new algorithm for examination and treatment of ectropion taking into account all the points discussed above &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#44; Ectropion with medial predominance&#44; caused by scarring of the anterior lamella&#44; probably associated with retractor laxity due to the age of the patient&#46; B&#44; Treatment by canthoplasty only&#44; without involving either the retractors or anterior lamella&#44; leading to an unsatisfactory outcome&#44; with improvement in ectropion but persistence of an evident eyelid retraction&#46; C&#44; Complete tarsal ectropion&#46; The outcome of an isolated Z-plasty is unsatisfactory&#44; as can be observed comparing with the postoperative image &#40;D&#41; in which ectropion persists with evident inflammation of the ocular surface &#40;taken from Fern&#225;ndez-Canga et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#41;&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Examples of complete treatment taking into account the underlying pathophysiology&#46; Images of severe inferior ectropion&#44; bilateral &#40;A&#41; and right side &#40;B&#41; with involutional components &#40;laxity of the lateral canthal tendon and disinsertion of retractors&#41; and cicatricial components &#40;shortening of the anterior lamella due to chronic actinic damage&#41;&#46; Correct treatment should combine different techniques aimed at correcting the cause of the process&#59; in these cases we performed a heteropalpebral flap in association with anterior lamella &#40;&#42;&#41;&#44; retractor surgery &#40;&#42;&#42;&#41;&#44; and surgery of the lateral canthus &#40;&#42;&#42;&#42;&#41;&#46; A&#8217; and B&#8217;&#44; Images at 4 months after surgery of the same patients&#58; correct positioning of the lower eyelids can be observed&#44; without ectropion or residual retraction&#44; with anatomic and functional restitution of the ocular surface&#46;</p>"
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Letter to the Editor
Comment on "Ectropion in Dermatologic Surgery: Exploration and Reconstruction Techniques"
Réplica a «Ectropión en cirugía dermatológica: exploración y técnicas reconstructivas»
S. Ortiz-Pérez
Unidad de Oculoplástica, Servicio de Oftalmología, Hospital Universitario Virgen de las Nieves, Granada, Spain
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Algorithm for examination and treatment of eyelid ectropion&#46; It is important to perform a complete examination to determine which treatment is required&#59; this ensures that the best outcomes are attained and reduces relapses&#46; Abbreviations&#58; LCT&#44; lateral canthal tendon&#59; MCT&#44; medial canthal tendon&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with interest the article published recently by Fern&#225;ndez-Canga et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> on eyelid ectropion&#46; Review articles&#44; like that one&#44; given their educational intent&#44; bear an important responsibility&#44; as many readers could take up certain diagnostic and treatment habits based on what they read&#44; and this would have an impact on the care of our patients&#46; For this reason&#44; we would like to add some caveats based on our personal experience of more than 15 years dedicated to oculoplastic surgery and above all based on the scientific evidence&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The review deals with a syndrome of eyelid malposition&#44; which apart from its esthetic impact&#44; also has mainly ophthalmologic consequences&#46; Of note in the article was the limited mention of the ocular surface and lacrimal duct&#46; The eyelid and the eye are intimately related&#44; and so any patient with a problem with the eyelid should undergo full ophthalmologic study&#46; Ectropion can be caused by rubbing watery eyes in cases of obstructions in the lacrimal duct&#44; problems with the ocular surface&#44; or inflammatory processes&#44; to mention some possibillities&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> To summarize study of ectropion merely with reference to eyelid laxity and its different components&#44; without including full ophthalmologic study&#44; would no doubt leave many patients without an appropriate diagnosis of the cause&#44; resulting in a lower rate of therapeutic success&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Regarding the proposed algorithm for prevention of ectropion&#44; it is important to differentiate between ectropion caused by medial or lateral laxity and&#47;or by retractors when we examine our patients&#44; as treatment&#44; and ultimately prevention&#44; would be different &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> We will take a closer look at this concept later&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Regarding treatment&#44; most patients have mixed ectropion&#59; one of the main pathophysiological components underlying involutional ectropion is disinsertion of the lower eyelid retractors&#46; From an educational point of view&#44; the approach to ectropion should necessarily mention treatment of retractors&#59; different techniques and approaches are available for these procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> Z-plasty does not usually achieve satisfactory outcomes if it is not combined with other techniques in the treatment of cicatricial ectropion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The use of synthetic materials in the treatment of cicatricial ectropion is not supported by the evidence&#59; the authors cite a study in which acellular dermis is used as an alternative in the reconstruction of the posterior lamella&#59; however&#44; this approach is not appropriate in cases of ectropion in which we require the anterior but not the posterior lamella&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Finally&#44; as mentioned earlier&#44; in cases of involutional ectropion&#44; in which disinsertion of the retractors plays a key role&#44; we cannot limit the approach to canthopexy or canthoplasty&#44; but should also consider combining these techniques with others that address all pathophysiological causes of the process&#44; particularly surgery of the retractors&#44; and appropriate management of the skin &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We found some conceptual errors that should be clarified so as not to confuse readers&#46; Thus&#44; in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; the authors<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> indicate lower eyelid orbital fat and denote it preaponeurotic fat&#59; in the strict sense&#44; preaponeurotic fat is found in the upper eyelid&#44; which is where we find levator aponeurosis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Additionally&#44; the flap that Tripier described in his original article in 1889 consisted of a bipedicled bridge-shaped musculoskeletal flap&#59; after this first description&#44; different modifications have been introduced&#46; A skin or musculocutaneous flap of the upper eyelid to reconstruct defects of the lower eyelid&#44; with lateral or medial base&#44; as mentioned by Fern&#225;ndez-Canga et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> is without doubt a very versatile and widely used technique in oculoplastic reconstructive surgery&#46; The flap&#44; depending on its size and design&#44; has recently been shown to behave partially as a graft in novel studies with lasers&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Strictly speaking&#44; it should not be called a Tripier flap but a modified Tripier flap&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">At times&#44; partial improvements in this type of case&#44; as those shown in the study by Fern&#225;ndez-Canga et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> comfort the surgeon to a certain degree in view of the esthetic improvements achieved&#44; but it is important to note that the ocular surface is still exposed and therefore homeostasis may be impacted&#46; This is the difficulty that treatment of ectropion entails &#40;particularly in cases with a cicatricial component&#41;&#46; Unless a perfect positioning of the eyelid and the lower part of the conjunctival sacs is achieved&#44; with appropriate contact of the eyelid margin and the lacrimal punctum with the eyeball&#44; the ocular surface will continue to be distressed&#44; with symptoms of epiphora&#44; chronic conjunctivitis&#44; or keratitis&#46; Ultimately&#44; these are the most important aspects requiring improvement&#46; We propose a new algorithm for examination and treatment of ectropion taking into account all the points discussed above &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ortiz-P&#233;rez S&#46; R&#233;plica a &#171;Ectropi&#243;n en cirug&#237;a dermatol&#243;gica&#58; exploraci&#243;n y t&#233;cnicas reconstructivas&#187;&#46; Actas Dermosifiliogr&#46; 2021&#59;112&#58;385&#8211;388&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#44; Ectropion with medial predominance&#44; caused by scarring of the anterior lamella&#44; probably associated with retractor laxity due to the age of the patient&#46; B&#44; Treatment by canthoplasty only&#44; without involving either the retractors or anterior lamella&#44; leading to an unsatisfactory outcome&#44; with improvement in ectropion but persistence of an evident eyelid retraction&#46; C&#44; Complete tarsal ectropion&#46; The outcome of an isolated Z-plasty is unsatisfactory&#44; as can be observed comparing with the postoperative image &#40;D&#41; in which ectropion persists with evident inflammation of the ocular surface &#40;taken from Fern&#225;ndez-Canga et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#41;&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Examples of complete treatment taking into account the underlying pathophysiology&#46; Images of severe inferior ectropion&#44; bilateral &#40;A&#41; and right side &#40;B&#41; with involutional components &#40;laxity of the lateral canthal tendon and disinsertion of retractors&#41; and cicatricial components &#40;shortening of the anterior lamella due to chronic actinic damage&#41;&#46; Correct treatment should combine different techniques aimed at correcting the cause of the process&#59; in these cases we performed a heteropalpebral flap in association with anterior lamella &#40;&#42;&#41;&#44; retractor surgery &#40;&#42;&#42;&#41;&#44; and surgery of the lateral canthus &#40;&#42;&#42;&#42;&#41;&#46; A&#8217; and B&#8217;&#44; Images at 4 months after surgery of the same patients&#58; correct positioning of the lower eyelids can be observed&#44; without ectropion or residual retraction&#44; with anatomic and functional restitution of the ocular surface&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Algorithm for examination and treatment of eyelid ectropion&#46; It is important to perform a complete examination to determine which treatment is required&#59; this ensures that the best outcomes are attained and reduces relapses&#46; Abbreviations&#58; LCT&#44; lateral canthal tendon&#59; MCT&#44; medial canthal tendon&#46;</p>"
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                      "titulo" => "Surgical microanatomy of lower eyelid tarsal ectropion repair with a putterman ptosis clamp"
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ISSN: 15782190
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