Lateral Canthal Support Research Articles

The Use of Fascia Lata Free Graft for Lateral Canthus Reconstruction Following Mohs Lower Lid Surgery

We present a case of a 75-year-old patient who underwent reconstruction of the lower eyelid and lateral canthus following removal of 80% of the lower eyelid due to basal cell carcinoma. A Hughes transconjunctival eyelid-sharing flap was used to form the posterior lamella, and a free skin graft from the ipsilateral upper lid was used to recreate the anterior lamella. The lateral canthal ligament was reconstructed using a free fascia lata graft. A periosteal flap was not used due to local scarring that was the result of previous multiple lateral canthal surgeries. Skin preservation in the lateral canthal area and additional horizontal support for the lower eyelid were achieved by using a local advancement flap. This two-stage surgery produced excellent functional and cosmetic effects. Fascia lata free graft can be an alternative to the periosteal flap for reconstruction of the lateral canthal ligament when use of the lateral orbital periosteum is not feasible.

Changes in Tear Meniscus Height Following Lower Blepharoplasty as Measured by Optical Coherence Tomography.

PurposeThe lower eyelid serves important roles in tear distribution and drainage. The purpose of this study was to measure the tear meniscus height (TMH) with anterior segment optical coherence tomography after lower blepharoplasty.MethodsA total of 52 eyes from 26 patients treated between July 2012 and June 2015 were included in the study. A transcutaneous or transconjunctival approach was performed, depending on whether (1) the supportive lower lid orbicularis oculi muscle was tightened, (2) the middle lamella was elongated, (3) minimal fat was removed or transpositioned, and (4) lateral canthal support was established. Marginal reflex distance 2 and marginal nose distance were analyzed with Image J software. TMH was measured with anterior segment optical coherence tomography. A paired t-test and Wilcoxon signed-rank test were used for statistical comparisons.ResultsMarginal reflex distance 2 decreased and marginal nose distance increased with both surgical techniques. TMH decreased from 337.3 ± 117.9 to 289.3 ± 69.1 µm (p = 0.024) in patients who had transcutaneous lower blepharoplasty, but increased from 186.5 ± 35.5 to 274.8 ± 58.3 µm (p = 0.000) in patients who had transconjunctival lower blepharoplasty. Medial and lateral TMHs decreased significantly from 228.8 ± 80.7 to 152.7 ± 42.1 µm (p = 0.008) in patients with transcutaneous lower blepharoplasty. TMH was significantly restored after lower blepharoplasty with either approach.ConclusionsEnhancing the lower eyelid position combined with orbicularis muscle tightening and lateral canthal support can normalize the TMH following lower eyelid blepharoplasty.

Simplified Muscle-Suspension Lower Blepharoplasty by Orbicularis Hitch.

The suspension of orbicularis oculi during lower blepharoplasty presents a logical surgical addition for further support of the lid, as well as further improvement to its contour profile. It has traditionally been performed as an extension of the skin-muscle flap procedure, but more recently, and aggressively, as a muscle strap-flap separated from the orbicularis sheet by myotomy. Many benefits of suspension, however, can be achieved without incision into muscle (beyond a single stab-wound "button-hole") and without delamination of the lid, as a safe, simple, single-suture suspension of preseptal muscle to lateral orbital rim. The purpose of this report was to evaluate the results of a simplified approach to muscle suspension during lower blepharoplasty. One hundred lower blepharoplasties by orbicularis hitch, performed as two consecutive series of 50, one by a plastic surgeon, the other by an oculoplastic surgeon, were reviewed retrospectively. Skin was resected from all lids, with a mean skin excision of 8 mm and 5 mm, respectively. Average follow-up was 17 and 16 months. Lateral canthal support was added to 2.5% of lids. There was one lid malposition (0.5%), leading to surgical revision, and no other complication or reoperation. Lower blepharoplasty by orbicularis hitch provides the benefits of muscle suspension by way of a simple, single-suture elevation of descended muscle, without the need for significant myotomy or lateral canthal manipulation. Despite its limited surgical invasiveness, it has proven both safe and effective in reversing muscle descent with skin redundancy, while maintaining lid support and lateral canthal integrity. LEVEL OF EVIDENCE 4: Therapeutic.

Lower eyelid blepharoplasty with lateral canthal support

Lower eyelid blepharoplasty with lateral canthal support

Lateral Canthal Support in Prevention of Lower Eyelid Malpositioning in Blepharoplasty: The Tarsal Sling.

Lower blepharoplasty is a cornerstone in facial rejuvenation and improvement. Despite its popularity, several adverse effects have been described; of these, postsurgical eyelid displacement, with its aesthetic and functional consequences, is one of the more frequent complications. The tarsal sling procedure is a simplified canthopexy consisting in the fixation of the lateral portion of the septum--the canthal ligament--to the orbital wall periosteum. The aim of the current research is to demonstrate how the tarsal sling technique is effective in the prevention of lower lid malpositioning. A retrospective analysis of 40 consecutive healthy individuals was carried out. In group 1, 20 patients underwent standard blepharoplasty; in group 2, blepharoplasty was associated to the tarsal sling canthopexy. Pre- and postsurgical position of the lower eyelid margin was compared through photographic measurements at 5 time points and statistical analysis performed. Group 1 patients evidenced an increased distance between the interpupillary line and the lateral aspect of the lower lid margin. A progressive spontaneous improvement (reduction in scleral exposition) was detected. Patients who underwent the tarsal sling procedure (group 2) reported a postoperative overcorrection of scleral appearance. Two years postsurgery, progressive relapse occurred, but the lower eyelid did not reach presurgical values and maintained a slight degree of overcorrection. Tarsal sling is an easy, fast, and efficacious procedure to prevent eyelid displacement in lower blepharoplasty. Its routine use is a tool to assure further support to lower lids in the younger patients or when lid laxity is absent during presurgical examination.

Blefaroplastia inferior: poderia a cirurgia proporcionar satisfação aos pacientes?

The purpose of this study was to analyze prospectively fifty patients submitted to lower eyelid blepharoplasty at the Federal University of São Paulo, between April 2005 and May 2007. Fifty patients were assigned to interventions into two surgical groups by using random allocation. The Surgical Group1 (control group) was composed of 25 patients who were submitted to conservatively standard fat-resection lower eyelid blepharoplasty, and routine lateral canthal support. The Surgical Group 2 (experimental group) was represented by 25 patients submitted to lower eyelid blepharoplasty with periorbital fat mobilization and arcus marginalis redrape, and routine lateral canthal support. The self-esteem of all patients was compared with those in 25 age-matched volunteers from the general population. The parameters of the Rosenberg Self-Esteem Scale were determined preoperatively and at 6-month interval postoperatively. Standardized photographs obtained before and after surgery were evaluated by three independent observers. The median follow-up was 395 days (range 364 to 547 days). The mean age was 48.8 years, the population's gender was predominantly female (96%). Analysis of preoperative and postoperative photographs showed that 96% patients achieved significant improvement. Self-esteem scores improved from baseline preoperative mean levels of 5.1 (Standard Deviation = 4.1) to a mean level of 3.6 (Standard Deviation = 3.5) at 6 months post-surgery (p=0.001). No patients had orbital hematoma, blepharitis, lagophthalmos or ectropion. The authors concluded that both procedures are safe and effective with low complication rates, and marked improvement in self-esteem was observed in patients at 6-month follow-up.

The Five-Step Lower Blepharoplasty

Lower lid blepharoplasty has potential for significant long-lasting complications and marginal aesthetic outcomes if not performed correctly, or if one disregards the anatomical aspects of the orbicularis oculi muscle. This has detracted surgeons from performing the technical maneuvers necessary for optimal periorbital rejuvenation. A simplified, "five-step" clinical approach based on sound anatomical principles is presented. A review of 50 lower lid blepharoplasty patients (each bilateral) using the five-step technique was conducted to delineate the efficacy in improving lower eyelid aesthetics. Digital images from 50 consecutive primary lower blepharoplasty patients (100 lower lids: 37 women and 13 men) were measured using a computer program with standardized data points that were later converted to ratios. Of the 100 lower eyelid five-step blepharoplasties analyzed, complication rates were low and data points measured demonstrated improvements in all aesthetic parameters. The width and position of the tear trough, position of the lower lid relative to the pupil, and the intercanthal angle were all improved. There were no cases of lower lid malposition. Aesthetic outcomes in lower lid blepharoplasty can be improved using a five-step technical sequence that addresses all of the anatomical findings. Lower lid blepharoplasty results are improved when (1) the supportive deep malar fat compartment is augmented; (2) lower lid orbicularis oculi muscle is preserved with minimal fat removal (if at all); (3) the main retaining structure (orbicularis retaining ligament) is selectively released; (4) lateral canthal support is established or strengthened (lateral retinacular suspension); and (5) minimal skin is removed. Therapeutic, IV.

Comparison between two surgical techniques for lower eyelid rejuvenation: safety analysis and outcomes

The purpose of this study was to analyze prospectively 50 patients submitted to lower blepharoplasty allocated to two surgical groups at Federal University of São Paulo, between April 2005 and May 2007. Fifty patients were assigned for interventions into two surgical groups by using random allocation. The SG1 (control group) was composed of 25 patients who were submitted to conservatively standard fat-resection lower blepharoplasty, and routine lateral canthal support. The SG2 (experimental group) was represented by 25 patients submitted to lower blepharoplasty with periorbital fat mobilization and arcus marginalis redrape, and routine lateral canthal support. Preoperative demographic and morphological data from patient charts and standardized photographs obtained before and after surgery were evaluated by an independent observer. Surgical techniques and management of complications were determined from operative reports and clinical notes. The median follow-up was 395 days (range 364 to 547 days). The mean age was 48.8 years; the population's gender was predominantly female (96%). Analysis of preoperative and postoperative photographs showed that all patients achieved significant improvement. Lateral canthal support was performed in all patients with statistically significant results. The authors concluded that both procedures are safe and effective, with low complication rates.

Primary Transcutaneous Lower Blepharoplasty with Routine Lateral Canthal Support: A Comprehensive 10-Year Review

Rejuvenation of the lower eyelid often requires tightening of excess skin and muscle and removal or transposition of orbital fat. Although transcutaneous lower blepharoplasty can accomplish these aesthetic demands, it has been associated with an increased risk of lower lid malposition. Routine lateral canthal support during lower blepharoplasty has recently been advocated to minimize this risk. This study reviewed the outcome of a surgeon's 10-year experience with primary lower transcutaneous blepharoplasty and lateral canthal support consisting of canthopexy, canthoplasty, and orbicularis suspension. A retrospective chart review of a primary lower transcutaneous blepharoplasty series over a 10-year period was performed. Patients with a history of prior eyelid surgery for blepharoplasty or midface lift were excluded. Preoperative demographic and morphological data from patient charts and standardized photographs obtained before and after surgery were evaluated by an independent observer. Surgical technique and management of complications were determined from operative reports and clinical notes. There were 264 patients with a median follow-up of 264 days (range, 60 to 2410 days). Lid malposition requiring operative correction occurred in nine patients (3.5 percent). Additional complications included orbital hematoma in one patient (0.4 percent), chemosis in 32 patients (12.1 percent), and blepharitis in 10 patients (3.8 percent). Minor surgical revisions unrelated to lid malposition were performed on 31 patients (11.7 percent) for correction of subciliary incision cysts or granulomas, canthal suture inflammation, and canthal webbing. Lateral canthal support should be considered a routine component of lower transcutaneous blepharoplasty to obtain the desired aesthetic result and maintain the natural appearance of the eyelid shape. The associated complication rate is acceptable.

Lateral Canthal Support System in Japanese

The present study aimed to elucidate microscopically the precise structure of the generally termed 'lateral canthal tendon' (LCT). Specimens from 9 post-mortem lower eyelids of 6 Japanese aged from 72 to 91 years old at death were fixed in 10% buffered formalin, and microscopically examined. Specimens were excised as exenterated samples including an area 5 mm wider than the orbital aperture. The removed contents were further incised longitudinally on the central eyelid and also incised parallel to the upper eyelid margin on the site 3 mm from its margin. After the preparation of microscopical examination, sections of all 9 eyelids were stained with Hematoxylin and Eosin. We found that the structure generally termed LCT consisted of two definitive different layers microscopically. The superficial layer was only an orbital septum (septal band). It was mainly constituted of thick fibers between adipose-rich tissues. The deep layer continued from the tarsus and projected posteriorly; which was a ligament (tarsoligamentous band). This tissue was constituted by thin, minute fibers with little adipose tissues. The structure generally termed LCT is not a tendon but a complex constitution of an orbital septum and a ligament; which we named, in a mass, 'lateral canthal bands', cooperatively supporting the lateral canthus.

Septal-myocutaneous flap technique for lower lid blepharoplasty.

Lower lid blepharoplasty can present a significant challenge to the facial plastic surgeon. Routine findings of periorbital fat herniation and dermatochalasia of the lower lid are often associated with the presence of more occult findings, e.g., tarsoligamentous laxity and ectropion. Traditional surgical approaches to the aging lower eyelid utilize the skin flap, the skin-muscle flap, and the transconjunctival technique. The limitation of any one of these procedures alone is that of not addressing the multiple problems of the aging eyelid; this may lead to common postoperative problems of lower lid blepharoplasty, including lid retraction, lagopthalmos, scleral show, rounding of the lateral canthus, and ectropion. We present an integrated surgical solution to the functional and anatomical defects of both the anterior and posterior lamellae, and, when indicated, lateral canthal support. The procedure incorporates a small lateral subciliary and lateral canthal incision with a myocutaneous advancement flap developed in a plane deep to the orbital septum, combined with transconjunctival blepharoplasty for removal of herniated orbital fat. It allows for simultaneous management of the multiple defects of the aging lower eyelid and complete restoration of the relevant anatomy, while avoiding the common pitfalls of lower lid blepharoplasty. We present our experience of 64 patients who underwent bilateral combined septal-myocutaneous advancement flap and transconjunctival blepharoplasty. Indications and postoperative results are reviewed. No complications, including scleral show or ectropion, have been noted over the 4-year postoperative period.

Use of Temporalis Fascia in Eyelid Reconstruction

Full-thickness eyelid defects, as a result of trauma, continue to present a dilemma to the reconstructive surgeon. The authors present a technique of utilizing a temporalis fascia graft to hammock and support a nasal septal cartilage graft as part of reconstruction of the lower eyelid and the lateral canthus after traumatic avulsion. The static suspension afforded by the fascia helps produce proper apposition of the lower eyelid to the globe and provides lateral canthal support. This tissue implant is well tolerated in the eyelid and is readily available in the ophthalmic surgical field.