Eleven patients between 39 and 81 years of age (mean, 63.7 years), all with Asian eyelids, were treated between 2000 and 2015. Patients presented with relaxed lower eyelids, dry eye, or excessive lacrimation due to ectropion caused by chronic facial paralysis. The cause of the unilateral facial paralysis was acoustic neuroma in five cases, Bell palsy in two cases, Ramsay-Hunt syndrome in one case, maxillary cancer in one case, parotid gland cancer in one case, and squamous cell carcinoma of the cheek in one case. All patients provided written informed consent for the use of all clinical photographs for publication, which have been archived by the authors. The National Defense Medical College ethical committee approved this study on March 30, 2017 (No. 2707).

The operative procedure was modified and developed over 15 years. The current procedure is presented below.

The degree of relaxation of the lower eyelid was assessed using a lateral traction test, wherein the lateral end of the lower eyelid was pinched by the fingers, pulled laterally, and the distance that the pinched portion moved was measured. The width of the inferior tarsus to be resected (typically 4–8 mm) was calculated as half the length measured with the lateral traction test.

Local anesthesia was performed with 1% lidocaine containing 1:100,000 epinephrine injected into the lower lid and the lateral canthal region. A subciliary incision was made 2-mm inferior to the gray line, extending laterally and slightly downward along a natural crease. The inferior tarsus and palpebral conjunctiva at the lateral angle of the eye were resected, based on the lateral traction test measurement, with a 2- to 3-mm margin remaining to suture the tarsus (Fig. 1A). An orbicularis oculi muscle flap (7-mm wide and 15-mm long) was created medial to the tarsus resection with a superior pedicle attached to the tarsus (Fig. 1B). Superficial fascia was included with the muscle flap in order to maintain its tensile strength. The lateral and medial stumps of the tarsus were sutured together with a single buried stitch, using 5-0 nylon. The conjunctiva was not sutured. The Whitnall tubercle was identified by blunt and blind dissection with mosquito forceps. The inferior tip of the orbicularis oculi muscle flap was turned over, pulled superiorly and laterally, and sutured to the firm tissue on the Whitnall tubercle using 5-0 nylon (Fig. 1B). The tension on the muscle flap was adjusted and slightly overcorrected. The traction of the orbicularis oculi muscle flap raised the tarsus superiorly, laterally, and posteriorly (with a “twisting effect”) (Fig. 2), bringing the tarsus back into contact with the ocular surface. There was sufficient tensile strength in the muscle flap for it not to be torn apart or detached from the lid margin. The residual orbicularis oculi muscle stump (harvesting site) was sutured horizontally with three stitches using a 5-0 absorbable material, although the residual muscle was not sutured in the first four cases. A triangular piece of skin was resected laterally to the tarsus resection (Fig. 1A) and the remaining skin was trimmed as necessary and sutured (Fig. 1B).

A 61-year-old woman was referred to our hospital for paralytic lagophthalmos and scleral show 5 years after developing Bell palsy. The VOTO procedure was performed under local anesthesia, correcting the ectropion. No recurrence of symptoms was observed for 3 years after surgery. The MRD-2 decreased from 8.3 mm (pre-surgery) to 5.8 mm (post-surgery) (Fig. 3).

Another example is given in Fig. 4.