Horizontal lower lid tightening
Lateral tarsal strip procedure
(Anderson Arch Ophth 1979) (Figure 2)
- 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 2. 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)
- 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
Reinforcement lateral canthoplasty
(Dailey OPRS 2011)
- For complex or recurrent LCT laxity/dehiscence
- 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)
- 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
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.
- 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).
Repair of epicanthal folds
- Create canthoplasty incisions.
- Mustarde "stick man" (Anderson, Arch Ophth 1989)
- 5-flap technique
- Skin redraping method (Sa, Ophthalmology 2012)
- Undermine and transpose myocutaneous flaps.
- Excise excess soft tissue.
- Close skin and soft tissues.
Medial canthal z-plasty for MC dystopia
- Create z-plasty incision incorporating anterior crus of MCT into lower limb of Z.
- 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.
- Bony reconstruction required
- Multidisciplinary craniofacial team approach recommended
Primary repair of NOE fracture
(See Orbital Fractures)
(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 MCTs 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)