 |
 |
| Figure
1. Typical apprearance of presenile ectropion. |
Figure
4. Preseptal muscle attached to lateral orbital rim. Arrows show effects
of increased tension. |
 |
 |
| Figure
2. Direction of vector of pull of preseptal part of orbicularis muscle under
lateral canthal ligaments. |
Figure
5. Bowing upward of lateral canthal ligament sa a result of suturing of
preseptal orbicularis muscle under it. |
 |
|
| Figure
3. The goal of surgery - to shift the whole lateral eyelid higher without
shortening it. |
|
Technique
With the patient
under monitored sedation or general anesthesia, both incision lines in the lower
eyelid are marked. Then injection of a mixture of 0.5% lidocaine (Xylocaine(R))
and 0.25% bupivacaine (Marcaine(R)), both with epinephrine, is used for vasoconstriction
and local anesthesia. An incision is made, and the skin flap is first raised
at the pretarsal part of the orbicularis muscle; then at the lower border of
the lower tarsus it is converted to a composite skin/muscle flap. Dissection
is then carried out under the orbicularis mucle to the inside border of the
orbital rim and inside border of the muscle. The exact distance is determined
by how much lift of the check nasolabial fold and correction of the lower lid
and crescent-shaped deformity of the lower eyelid are needed. The herniated
fat pads are removed as required.
The free lateral
edge of the preseptal portion of the orbicularis muscle is then grasped with
a forceps, and the whole lower eyelid structure and cheek attached to it are
shifted upward and slightly laterally to get an idea how high the attachment
of this lateral muscle should be.
 |
| Figure
6. A 46-year-old female patient with early senile changes. Procedure 1 ws
used for suturing, and correction was adequate, with a natural look to the
eyelids. A and C, Preoperative view. B and D, Six-month postoperative view. |
Then, with blunt
dissection, the lateral canthal area is dissected upward, and a pocket is created
under it. Some soft tissue is left in place on top of the periosteum to make
suturing to the anterior aspect of the lateral orbital rim possible. Next, the
free edge of the preseptal portion of the lower eyelid is sutured to a higher
position under the pocket of the lateral canthal ligament (Figure 4). This suturing
causes bowing outward and upward of the lateral canthal structures and ligament
and brings the lid margin laterally up and makes it tighter over the globe (Figure
5).
In some cases,
there are a lot of adhesions that attach the whole lateral eyelid to the orbital
rim. These may need to be released so that the lateral lid angle will be mobile
enough to be shifted to a higher position. During the release of the lower eyelid
structures from the lateral interior border of the orbital rim, some more herniated
fat pad may become evident that could be removed. Usually, suturing of the pretarsal
portion of the orbicularis muscle to the higher position under the lateral canthal
structures is adequate to lift the lateral lower lid upward and tighten it.
In cases where this maneuver is not adequate, or if it creates a triangular
space between the eyeball and the lateral portion of the lower lid, procedure
2 is used- suturing the lateral canthal ligament to the interior medial border
of the lateral orbital rim very close to the lateral angle of the eyelids. Usually,
one suture of 5-0 Vicryl(R) in this area is adequate. This posterior shift of
the lateral canthal angle to a posterior position closes the triangular space
between the lateral part of the lower eyelid and the eyeball. These maneuvers
are all performed without making any incision in the lateral canthal area (the
only incision used would be regular lower eyelid incision).
Once the position
and firmness of the lower eyelid are satisfactory, excess skin and muscle are
trimmed, mostly laterally. Some suturing with 5-0 Vicryl(R) suture is done to
approximate the subcutaneous tissues laterally, and the lower eyelid incision
at the ciliary area is repaired with running subcuticular 6-0 nylon sutures.
Usually, the amount of skin removed from the lower eyelid at the subciliary
area is minimal; in my recent experience there has been approximately 1 to 2
mm of excision. This probably is due to the fact that the lower eyelid margin
is lifted upward, which tightens some of the excess skin, and that the lower
eyelid and its muscle are lifted upward laterally and posteriorly, thereby correcting
the deformity of the lower eyelid from convexity to concavity, permitting minimal
excision of the lower eyelid skin.
Postoperative care
consists of elevation and cold compresses during the first 24 hours. Sutures
are removed in 5 to 6 days. Normal activity is permitted as soon as it is tolerated
by the patient.
 |
| Figure
7. A 60-year-old male patient with presenile ectropion and festoons. Procedures
1 and 2 were used in treating this patient. A and C, Preoperative view.
B and D, Four-month postoperative view. |
Results
Overall, satisfactory
results have been the norm. Very rarely have these three techniques failed,
and I have performed no major lower lid reoperations (revisions) for many years.
The rate of ectropions has been almost zero. Preoperative and postoperative
photos of two cases are shown in Figures 6 and 7. Although the tightness of
the lids may be difficult to distinguish in a photograph, the position of the
lower lid in each case could indirectly verify the effectiveness of this technique.
Discussion
Canthopexy has
been used and advocated by many surgeons to prevent or treat postblepharoplasty
ectropion.(2-4) The conventional canthopexy operation usually requires an incision
at the lateral canthal area and the lateral eye-lid angle. This has created
complications such as chemosis, subconjunctival hemorrhage, and an uneven healing
of the interface between the deepithelialized and shortened tarsal plate and
the upper part of this repair. To eliminate these complications, I have used
the techniques described in this article, which basically use only blepharoplasty
incision and suturing of the components that tighten the lower lid laxity. The
first suture is actually a part of the blepharoplasty, in my technique, and
the second suture is used to place the lateral angle of the eyelid in a more
posterior and, if desired, higher position. This will bring the free edge of
the eyelid around the orbit like a belt around a person's waist.
In the first technique
described here, the reason for shortening the lower eyelid is to make the route
of the lateral eyelid structures a curved one instead of straight both superiorly
and anteriorly. This adds to the tension, making the eyelid tighter and bringing
the eyelid angle higher, if needed. As briefly mentioned in the description
of the technique, some dissection to release the lateral border of the lower
eyelid will be required if the angle of the lower lid needs to be lifted upward.
This is desirable in many patients. Actually, the lateral eyelid angle is approximately
2 mm higher than the medial angle. In younger people this difference is greater
and the lateral eyelid is tilted upward. As a person gets older, this tilt decreases
and gradually becomes horizontal. In some people the tilt is actually reversed
so that the lateral angle is below the level of the upper medial angle. With
my technique, the lateral angle is lifted, giving a more youthful look to the
eyelid, as well as tightening the lid margin.
In the second suture
technique, the lateral eyelid angle is positioned more posteriorly and superiorly.
The benefit is obvious, because in some ectropions (or as I call this phenomenon,
"presenile ectropion"), the lid is not short, and actually no scleral
show is visible; however, its laxity prevents it from hugging or grasping the
globe properly so there is always looseness in the lower eyelid. This may actually
become bothersome on windy or cold days, because cold air and wind can get between
the orbit and the lower eyelid, resulting in burning and epiphora. The second
suture would eliminate this problem by bringing the lower eyelid closer to the
orbit. I have used these techniques successfully for many years; residents who
have learned these techniques readily and used them effectively have also achieved
success.
In summary, the
advantage of this approach is that there are no incisions involved in the lateral
canthal area other than the routine blepharoplasty incisions, thus decreasing
the chances of chemosis, contracture, scarring, and deformity at the site of
the incision. This approach is effective as a therapeutic or a preventive measure.
It is basically a part of the lower blepharoplasty operation, and the increase
in the duration of surgery is minor. It should be noted, however, that this
technique may not be effective in severe or unusual deformities of the lower
lid and that muscle attachment may be visible for a few weeks after surgery.
References
1. Massiha H. Combined
skin and skir)-muscle flap technique in lower blepharoplasty: a 10-year experience.
Ann Plast Surg 1990;25:467.
2. Edgerton MT.
Causes and prevention of lower lid ectropion following blepharoplasty. Plast
Reconstr Surg 1972;49:367.
3. Carraway JH,
Mellow CG. The prevention and treatment of lower lid ectropion following blepharoplasty.
Plast Reconstr Surg 1990;85:971-81.
4. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg 1993;20:417-25.
Back |
