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Blepharoplasty, Lower Lid, Canthal Support Treatment & Management

  • Author: David C Cho, MD; Chief Editor: James Neal Long, MD, FACS  more...
 
Updated: Feb 23, 2016
 

Medical Therapy

Some symptoms caused by lower lid laxity can be treated with artificial tears, lower lid taping, or digital massage.

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Intraoperative Details

Pentagonal wedge resection

This procedure corrects excess horizontal length. A pentagon of full-thickness eyelid is excised where the ectropion is most marked. Incisions should be at right angles to the eyelid margin. Appropriate tension upon closure should reappose the eyelid to the eye.

Lateral tarsal strip

A canthotomy is performed. The inferior lateral retinaculum is divided (cantholysis), and the tarsal strip is formed by excision of the surrounding conjunctiva, cilia, and skin. The tarsal strip is suspended to the lateral orbital wall periosteum. This procedure decreases the length of the horizontal palpebral aperture.[10] See the images below.

Preparing the tarsal strip. Preparing the tarsal strip.
The 4-0 Vicryl suture is paced through the tarsal The 4-0 Vicryl suture is paced through the tarsal strip in a horizontal mattress fashion.
The suture is tied to the periosteum of the latera The suture is tied to the periosteum of the lateral orbital rim and tightened.

A study by Baek et al indicated that in patients with involutional lower eyelid entropion, treatment with Quickert suture with modified lateral tarsal strip is associated with a lower recurrence rate (9.1%) than is treatment with Quickert suture alone (25.5%).[11]

Dermal orbiculare pennant

A de-epithelized pennant-shaped flap of skin and pretarsal orbicularis muscle is created from the lower lid. The lateral palpebral commissure is not violated. The lower eyelid becomes mobile with lysis of the inferior retinaculum. The pennant flap is sutured to the lateral orbital wall. This repair is useful in the patient with a large distance from lateral canthus to orbital rim. The dermal orbicular pennant flap provides ample length to reach the lateral orbital wall.[7, 12]

Inferior retinacular lateral canthoplasty or canthopexy

Performed through an upper blepharoplasty incision, the lower lid lateral fat pad is exposed. The fat pad can be removed to better reveal the lateral retinaculum. The lower lid component of the lateral retinaculum can then be plicated (canthopexy) or can be lysed from its bone insertion with reattachment to the lateral orbital rim periosteum (canthoplasty). Suture location to the lateral orbital rim should be at the same level as the superior aspect of the pupil when in primary gaze. The lower lid margin should cover 1-2 mm of the inferior cornea and appear as an overcorrection. This procedure does not disrupt the horizontal palpebral aperture.[12, 13]

Dermal-orbicular pennant with tarsal strip horizontal lid shortening and midface suspension

The dermal orbicular pennant flap is created, followed by a lateral canthotomy. A tarsal strip is created with resection of skin, cilia, and conjunctiva. Access to the mid face is achieved via the lateral incision. Subperiosteal or supraperiosteal dissection is performed. The mid face is suspended to the zygoma bone with suture and screw fixation. This is a powerful technique for the patient with complicated lower eyelid malposition in the setting of multiple prior cosmetic operations.[14]

Vertical spacer graft

Midlamellar cicatricial retraction may be present. An interpositional graft may be required to correct a vertical lid defect. Palatal mucosa or auricular cartilage may be used as graft material. The scarred capsulopalpebral fascia is released, and the graft is sutured in between the tarsus and the released edge of the capsulopalpebral fascia.

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Postoperative Details

The application of a silk suture (Frost suture) to suspend the lower eyelid in a superior direction prevents malposition of the lower eyelid during the acute healing process. This suture can be left in place for 2-5 days, depending on the degree of swelling.

Skin incisions should be aggressively treated with antibiotic ointment to prevent infection and maintain a moist environment for skin healing.

The application of cold packs after surgery may assist with inflammation and edema control.

Oral narcotics are usually sufficient to control the postoperative pain associated with eyelid surgery.

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Complications

Blepharoplasty carries the risk for several complications, including the following:

  • Lower lid malposition: Any procedure in blepharoplasty risks malposition of the lower lid.
  • Chemosis: Swelling or edema of the conjunctiva after surgery is a possible complication.
  • Ectropion: The lower eyelid may turn outward.
  • Corneal abrasion: As with any periorbital surgery, injury to the corneal surface may occur.
  • Pain: Postoperative pain may last from a few days to 1-2 weeks.
  • Wound dehiscence: Meticulous closure is required to prevent dehiscence.
  • Infection: Postoperative infection is uncommon and can frequently be managed with oral antibiotics.
  • Granuloma: Postoperative healing may result in granuloma formation.
  • Hematoma: This is a surgical emergency and requires return to the operating room for decompression. [15]
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Outcome and Prognosis

Outcome from lower lid blepharoplasty and canthal support techniques is quite favorable. Complications are rare with careful patient selection, thoughtful analysis of the deformity, and execution of the correct surgical procedure.

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Contributor Information and Disclosures
Author

David C Cho, MD Plastic Surgeon, Straub Clinic and Hospital

David C Cho, MD is a member of the following medical societies: American Cleft Palate-Craniofacial Association

Disclosure: Nothing to disclose.

Coauthor(s)

Allen Gabriel, MD, FACS Assistant Professor, Department of Plastic Surgery, Loma Linda University School of Medicine

Allen Gabriel, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, California Medical Association

Disclosure: Nothing to disclose.

Gordon H Sasaki, MD, FACS Clinical Professor, Department of Plastic Surgery, Loma Linda University School of Medicine

Gordon H Sasaki, MD, FACS is a member of the following medical societies: American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Chief Editor

James Neal Long, MD, FACS Founder of Magnolia Plastic Surgery; Former Associate Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, Children's Hospital and Kirklin Clinics, University of Alabama at Birmingham School of Medicine; Section Chief of Plastic, Reconstructive, Hand, and Microsurgery, Birmingham Veterans Affairs Medical Center

James Neal Long, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, Southeastern Society of Plastic and Reconstructive Surgeons, Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Additional Contributors

Neal R Reisman, MD, JD Chief of Plastic Surgery, St Luke's Episcopal Hospital; Clinical Professor of Plastic Surgery, Baylor College of Medicine

Neal R Reisman, MD, JD is a member of the following medical societies: American Society of Plastic Surgeons, American College of Surgeons, American Society for Aesthetic Plastic Surgery, Lipoplasty Society of North America, Texas Medical Association, Texas Society of Plastic Surgeons

Disclosure: Nothing to disclose.

References
  1. Jelks GW, Jelks EB. Preoperative evaluation and treatment of lower lid ectropion following blepharoplasty. Plast Reconstr Surg. 1990. 85:971.

  2. Garza RM, Lee GK, Press BH. Tarsal ectropion repair and lower blepharoplasty: A case report and review of literature. J Plast Reconstr Aesthet Surg. 2012 Feb. 65(2):249-51. [Medline].

  3. Massry GG. Comprehensive lower eyelid rejuvenation. Facial Plast Surg. 2010 Aug. 26(3):209-21. [Medline].

  4. American Society of Plastic Surgeons (ASPS). 2000/2006/2007 National Plastic Surgery Statistics. ASPS Web site. Available at http://www.plasticsurgery.org/Media/stats/2008-cosmetic-reconstructive-plastic-surgery-minimally-invasive-statistics.pdf. Accessed: June 18, 2009.

  5. McCord CD Jr. The correction of lower lid malposition following lower lid blepharoplasty. Plast Reconstr Surg. 1999 Mar. 103(3):1036-9; discussion 1040. [Medline].

  6. Griffin G, Azizzadeh B, Massry GG. New insights into physical findings associated with postblepharoplasty lower eyelid retraction. Aesthet Surg J. 2014 Sep. 34(7):995-1004. [Medline].

  7. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg. 1993. 20:417.

  8. Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York: Raven Press; 1985.

  9. Spinelli HM, Jelks GW. Periocular reconstruction: a systematic approach. Plast Reconstr Surg. 1993 May. 91(6):1017-24; discussion 1025-6. [Medline].

  10. Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol. 1979 Nov. 97(11):2192-6. [Medline].

  11. Baek JS, Choi SC, Jang SY, Lee JH, Choi HS. Comparison of Surgical Outcome Between Quickert Suture and Quickert Suture With Modified Lateral Tarsal Strip in Involutional Lower Eyelid Entropion. J Craniofac Surg. 2016 Jan. 27 (1):198-200. [Medline].

  12. Jelks GW, Glat PM, Jelk EB, et al. The evolution of the lateral canthoplasty: techniques and indications. Present at the American Association of Plastic Surgeons, 74th annual meeting, San Diego. April 30 to May 3, 1995.

  13. Fagien S. Algorithm for canthoplasty: the lateral retinacular suspension: a simplified suture canthopexy. Plast Reconstr Surg. 1999 Jun. 103(7):2042-53; discussion 2054-8. [Medline].

  14. Hester TR, Codner MA, McCord CD. Subperiosteal malar cheek lift with lower blepharoplasty. McCord DC, Codner MA, Hester TR, eds. Eyelid Surgery: Principles and Techniques. Philadelphia: Lippincott-Raven; 1995.

  15. Kim DY, Lelli GJ Jr. Delayed orbital hematoma after lateral canthoplasty. Ophthal Plast Reconstr Surg. 2010 Nov-Dec. 26(6):481-3. [Medline].

 
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A: The lower eyelid is evaluated for the presence or absence of adequate tone. The snap test is shown. This involves pulling the lower eyelid skin away from the globe with the thumb and index fingers. B: This photograph demonstrates the lid retraction test, which involves displacing the lower eyelid inferiorly in order to evaluate lower eyelid tone. C: This is a preoperative oblique view. Note the brow position in relation to the orbital rim. Note also the excessive eyelid skin and crow's feet in this particular patient. D: Preoperative frontal view of the same patient. Note the lower position of the left brow, the redundancy and asymmetry of the upper eyelid skin, and the crow's feet in the lateral orbital areas.
Eyelid anatomy.
Preparing the tarsal strip.
The 4-0 Vicryl suture is paced through the tarsal strip in a horizontal mattress fashion.
The suture is tied to the periosteum of the lateral orbital rim and tightened.
 
 
 
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