Horizontal lower lid tightening
Lateral tarsal strip procedure
(Anderson Arch Ophth 1979) (Figure 7)
- Infiltrate local anesthetic
- Perform lateral canthotomy and inferior cantholysis
- Determine amount of horizontal laxity
- Place lateral traction on lid and mark point where lid crosses lateral rim and commissure
- Create tarsal strip
- Dissect anterior lamella and excise to point where lid crosses lateral commissure
- Excise marginal epithelium
- Detach retractors/conjunctiva from inferior edge
- Remove palpebral conjunctiva with blade, low energy cautery, or radiofrequency ablation
- Trim tarsal strip to point where lid crosses orbital rim
- Suspend strip from periosteum over inner aspect of rim
- 4-0 or 5-0 absorbable or nonabsorbable suture (e.g., polyglactin, polydiaxanone, or polypropylene) on a small half-circle needle (P-2 or OPS-5)
- Horizontal mattress or half-horizontal mattress pattern, ensuring positioning of strim posterior to lateral rim
- Slight overcorrection advisable (about 2–3 mm superior to intended final position of lateral commissure)
- Reform lateral canthal angle (Weber, Ophth Surg 1991)
- Trim redundant skin
- Close skin
Figure 7. Lateral tarsal strip procedure. From Nerad JA, Techniques in Ophthalmic Plastic Surgery, 2010.
Modified Bick procedure
(Barrett, OPRS 2012)
- Lateral canthotomy/inferior cantholysis
- Distract lid laterally and mark point where lid crosses lateral rim
- Excise triangular wedge of lateral canthal tendon and tarsus
- Suspend end of tarsus to periosteum as above
- Reform lateral canthal angle
- Close skin
Closed lateral canthoplasty
(Taban, Georgescu, Rizvi, Lessa) (Figure 8)
- Carry dissection to lateral orbital rim through lateral upper lid crease incision.
- Pass suture internal to external through lateral commissure, then back internally at same point.
- Pass suture through periosteum behind lateral orbital rim and tie.
- Suture can also be passed through drill holes in lateral rim using "Leicester lasso" technique (Kannan OPRS 2014).
- 4-0 silk suture twisted into lasso and passed external to internal through drill holes x2
- LCT suture ends passed through lasso, pulled through drill holes with lasso, and tied
Figure 8. Closed lateral canthoplasty through lateral upper lid crease incision. From Taban M, et al. Ophthal Plast Reconstr Surg. 2010;26:190‑194.
Reinforcement lateral canthoplasty — for complex or recurrent LCT laxity/dehiscence
(Dailey OPRS 2011)
- Superior and inferior crus of LCT approached through supraciliary/subciliary incisions
- LCT plicated and suspended from periosteum behind lateral orbital rim
- Y-shaped graft (e.g., autogenous fascia lata, acellular dermal matix, porcine dermal collagen) sutured to limbs of LCT and periosteum over lateral rim
- Medial spindle procedure (Nowinski, Arch Ophthalmol 1985)
- Excision of diamond-shaped wedge of conjunctiva/retractors inferior to lower punctum
- Double-armed absorbable suture (e.g., 6-0 polyglactin or chromic gut) passed from inferior to superior wound edges, then through inferior fornix and externalized, tied over skin
- Orbitomalar ligament suspension (Korn PRS 2010)
- Dissection carried from lateral canthotomy through orbitomalar ligament under lateral midface, suture passed through deep aspect of SOOF and suspended from lateral orbital rim periosteum
- Alternative fixation technique: LCT suture passed through single drill hole in lateral rim and tied externally to SOOF suture (Oh, OPRS 2013)
- Midface lift
- Preperiosteal (Marshak OPRS 2010) or subperiosteal (Elner, Arch Fac Plast Surg 2003) dissection
- Consider malar augmentation for midface hypoplasia (Steinsapir, PRS 2003; Binder, Fac Plast Surg 2011).
- Midface tissues suspended and fixated with sutures to drill holes, screws, malar implants, or elevated with fixation devices (e.g., Endotine™ midface (Berkowitz, Aesth Surg J 2005)
- Full-thickness wedge resection (traditional)
- Lateral tarsal strip procedure or modified Bick procedure can be performed on upper lid in similar manner as lower lid (Dutton, AJO 1985; Perlman, OPRS 2002)
- 4-lid lateral tarsal strip-periosteal flap technique (Burkat, OPRS 2005)
- 5-mm lateral canthus incision to expose lateral rim
- 6-mm periosteal flap created and reflected medially
- Lateral tarsal strips fashioned in standard fashion and fixated to periosteal flaps with 5-0 polyglactin suture
Anterior medial canthal tendon plication
- Create skin incisions (single horizontal or double vertical) over anterior crus of MCT and medial end of tarsus
- Pass suture sequentially through MCT near bony insertion, subcutaneous tunnel, and medial end of tarsus, taking care to avoid canaliculus (placement of lacrimal probe helpful)
- Tie under appropriate tension
- Close skin incisions(s)
Transcaruncular (posterior) medial canthal tendon plication
(Fante OPRS 2001) (Figure 9)
- Incise conjunctiva below medial end of lower tarsus
- Create transcaruncular incision between caruncle and plica semilunaris, dissect bluntly to medial orbital wall
- Engage medial end of tarsus with suture (4-0 polypropylene on P-2 needle), avoiding canaliculus, and pass suture subconjunctivally to transcaruncular incision
- Pass same suture through periosteum at or above posterior lacrimal crest, then back through subconjunctival space to exit incision beneath tarsus
- If medial lower lid retraction is present, suture can be fixated more superiorly on medial rim Moe
- Adjust suture tension and tie
- Rotate knot to bury it in medial orbit
Figure 9. Transcaruncular medial canthal tendon plication. From Fante RG, Elner VM. Ophthal Plast Reconstr Surg. 2001:17;16‑27. (A) Horizontal conjunctival incision is made at the base of the medial tarsus. (B) A second conjunctival incision is made in the medial fornix just posterior to the caruncle. Blunt dissection proceeds to the medial periorbita. (C) The medial end of the tarsus is engaged by 4‑0 polypropylene suture, which is then passed subconjunctivally from the lower-eyelid incision to the medial fornix incision. (D) Periorbita at or above the posterior lacrimal crest is secured with the suture under direct headlamp observation while an assistant provides exposure. (E) The needle is passed subconjunctivally from the medial fornix incision to the lower eyelid incision. At this point, both ends of the suture exit from the lower-eyelid incision. (F) A fisherman's knot is tied to achieve appropriate tension. Once permanently tied, the ends are cut and the knot is rotated into the medial orbit.
Medial tarsal suspension — for medial lower lid retraction
(Frueh OPRS 2002)
- Create horizontal skin incisions from medial commissure to within 2 mm medial to each punctum (Figure 10).
- Dissect pockets in suborbicularis plane medial to lower punctum (avoiding canaliculi) and in superomedial upper lid.
- Pass suture (5-0 or 4-0 nonabsorbable) through periosteum over superomedial rim.
- Pass same suture through medial end of lower tarsus and tie under appropriate tension, rotate knot to bury next to superomedial rim.
- Sew edges of upper and lower lid skin incisions together (medial tarsorrhaphy).
Figure 10. Medial tarsal suspension. From Frueh BR, Su CS. Ophthal Plast Reconstr Surg. 2002:18;133‑137.
Repair of epicanthal folds
- Create canthoplasty incisions
- Mustarde "stick man" (Anderson, Arch Ophth 1989) (Figure 11A)
- 5-flap technique (Figure 11C)
- Skin redraping method (Sa, Ophthalmology 2012)
- Undermine and transpose myocutaneous flaps, excise excess soft tissue
- Close skin and soft tissues
Figure 11. (A)
Mustarde medial canthoplasty. (B)
Johnson modification of Blair technique (historical). (C)
Anderson 5‑flap technique (double Z‑plasty and V‑to‑Y advancement). From Anderson RL, Nowinski TS. Arch Ophthalmol.
Medial canthal z-plasty — for MC dystopia
- Create z-plasty incision, incorporating anterior crus of MCT into lower limb of Z (Figure 12).
- Dissect MCT from lacrimal sac, undermine flaps
- Transpose flaps and resuspend MCT in higher position with suture to periosteum over frontal process of maxilla
- Close incisions
Figure 12. (A) Traumatic right medial canthal dystopia with planned Z‑plasty incisions. (B) Postoperative result following medial canthus Z‑plasty.
- Bony reconstruction required, multidisciplinary craniofacial team approach recommended
Primary repair of NOE fracture
(Smith 1992; Dutton, AJO 1985)
- Bilateral telecanthus (e.g., blepharophimosis (Sebastia, Aesth Plast Surg 2011) bilateral NOE fractures)
- MCTs are wired to each other through drill holes across the nasal cavity
- Wire can aid in reduction/fixation of bony abnormalities, or in setting of normal bony anatomy can be passed through drill holes to engage MCT's and reduce telecanthus
- Surgical approaches include bicoronal, Lynch incision, or incision directly over MCT (Nunery incision) (Timoney, OPRS 2012)
- Unilateral telecanthus (traumatic)
- MCT is wired across the nasal cavity to stable bone (frontal process of maxilla or frontal bone) on the opposite side (Kelly, OPRS 2004; Markowitz, PRS 1991)
- Titanium wire with barb and needle (Synthes®) can be used transnasally or anchored directly to frontal process (Engelstad Int J Oral Maxillofac Surg 2012)
Fixation of MCT to bone anchors
- Titanium microplates/screws (Shore, Ophthalmology 1992; Howard, Arch Ophth 1992)
- Mitek bone anchor (Antonyshyn, PRS 1996; Goldenberg, Ann Plast Surg 2008)
- Lactosorb anchor (Sharma, Arch Ophth 2006)