Instrumentation:
- Wescott and Stevens scissors
- Cautery
- Forceps
- Sutures
- Periosteal elevator
Anesthesia:
- Most can be performed with local anesthesia
- Sedation if needed
Technique:
Lower-eyelid canthoplasty:
- Perform lateral canthotomy and inferior cantholysis with Stevens or Wescott scissors.
- Determine amount of horizontal tightening of lower lid by redraping to the lateral canthal crus.
- Excise full thickness wedge resection of the lateral aspect of lower lid.
- Secure lower lid to intact superior lateral canthal tendon (Figure 1).
- Close skin.
Lateral tarsal strip (Figure 2):
- Perform lateral canthotomy and inferior cantholysis with Stevens or Wescott scissors.
- Determine amount of horizontal tightening of lower lid by redraping to the lateral canthal crus.
- Score lid margin at medial extent of potential lateral tarsal strip.
- Release septum and inferior retractors from inferior aspect of lower lid.
- Divide anterior and posterior lamellae lateral to scored lid margin.
- Remove mucocutaneous junction of eyelid laterally.
- Scrape conjunctiva from the posterior aspect of strip.
- Fixate to periosteum of internal lateral orbital rim at approximate site of Whitnall's tubercle with sutures—for example, horizontal mattress suture.
- Place gray line suture.
- Close skin.
Figure 1. Fixation of the lower lid to the intact superior lateral canthal tendon.
Figure 2. Formation of the lateral tarsal strip (from Anderson and Gordy 1979).
Lateral canthopexy:
- Entire canthus is moved by changing its attachment from the eyelid to the lateral orbital wall.
- To elevate or depress the canthus en bloc:
- Make a Z-plasty incision at lateral canthus (Figure 3).
- Dissect to periosteum where it is incised and perform a subperiosteal dissection to release the canthus en bloc (Figure 4).
- Mark the lateral orbital rim at the desired canthal position at the intended site of the canthus.
- Insert a malleable retractor to protect the globe.
- Use a drill to pass from interior to exterior of the lateral orbital rim.
- Use a permanent suture or metal wire to engage the body of the canthus, and then pass it through the hole(s).
- If you made 2 drill holes, tie the suture or wire to itself over the bridging bone.
- If you made 1 drill hole, pass the suture into the temporalis tissue and tie.
- Rotate the arms of Z-plasty with layered closure.
Figure 3. Marking of the Z-plasty.
Figure 4. En bloc elevation of lateral canthus via subperiosteal dissection and placement of permanent suture through the canthal body.
- To secure either the upper or lower lid to bone
- Perform a lateral canthotomy and inferior cantholysis with Stevens or Wescott scissors.
- Determine the amount of horizontal tightening of the lower lid by redraping to the lateral canthal crus.
- Score lid margin at medial extent of potential lateral tarsal strip.
- Release septum and inferior retractors from inferior aspect of lower lid.
- Divide anterior and posterior lamellae lateral to scored lid margin.
- Remove mucocutaneous junction of eyelid laterally.
- Scrape conjunctiva from posterior aspect of strip.
- Incise periosteum and elevate it over the internal and external lateral orbital rim at the site of fixation.
- Insert a malleable retractor to protect the globe.
- Use a drill to pass from interior to exterior of the lateral orbital rim.
- Use a permanent suture or metal wire to engage the body of the canthus, and then pass it through the hole(s).
- If you made 2 drill holes, tie the suture or wire to itself over the bridging bone.
- If you made 1 drill hole, pass the suture into the temporalis tissue and tie.
Special circumstances:
- Tissue augmentation might be needed in cicatricial disease.
- Partial/split-thickness skin grafting for anterior lamellar deficiencies
- Hard palate or acellular dermal matrix graft for posterior lamellar deficiencies
- Lazy "T" for lower-lid laxity and punctal ectropion
- Traction suture to lower lid is initially placed
- Insert a lacrimal probe in lower punctum and canaliculus.
- Excise conjunctiva/retractors/septum to orbicularis in form of medial spindle of 7 mm x 10 mm.
- A vertical incision is made through lid margin about 5 mm lateral to inferior punctum
- Redrape lid medially to determine amount of excess
- Perform a full-thickness wedge resection of lower lid
- Bury the closure of conjunctiva.
- Closure of full thickness margin using usual techniques
- Upper-eyelid horizontal tightening
- Upper eyelid canthoplasty
- Perform a lateral canthotomy and superior cantholysis with Stevens or Wescott scissors.
- Determine amount of horizontal tightening of upper lid by redraping to the lateral canthal crus.
- Excise full-thickness wedge resection of the lateral aspect of upper lid.
- Secure lower lid to intact inferior lateral canthal tendon.
- Close skin.
- Pentagonal wedge resection of upper eyelid
- Mark medially on lid margin to lid crease about 5 mm lateral to punctum and about 10 mm lateral the initial site depending on laxity.
- If concurrent upper-lid blepharoplasty will be performed, construct the apex of the pentagonal wedge to assimilate to the blepharoplasty incision.
- Use Stevens scissors to excise the previously marked full-thickness portion of the eyelid; incision must extend through entire vertical dimension of tarsus.
- Close as full thickness eyelid laceration.