(Fig. 11.14). Lateral canthal webbing is the result of poor separation of upper and lower blepharoplasty incisions, poor incision design, or improper closure of a canthoplasty incision (Fig. 11.15a). Webbing results primarily with cosmetic concerns, but may, in unusual cases, cause lagophthalmos and functional problems.

11.4.1.1 Medical Management

In addition to the normal postoperative protocol, the patient is instructed to massage the area of webbing gently. Frequency and duration should be set to the maximal tolerance of the patient. Injection of steroids into area may be of value if the mechanism is cicatricial in nature, rather than lack of skin surface area. Triamcinolone acetonide injectable suspension (Kenalog®, Bristol-Myers Squibb, New York, NY), 10 mg per milliliter, is injected directly into the area of webbing. Care should be taken to avoid intravascular injection as rarely, this can precipitate visual loss. The patient continues massage of the area as tolerated. If the webbing does not resolve to functional and cosmetic standards, then surgical intervention is required.

11.4.1.2 Surgical Management

To correct medial canthal webbing, a V–Y plasty, M plasty, or Z plasty can be performed. In cases with significant traction and skin deficiency, an FTSG may be incorporated into

Fig.11.14 Medial canthal webbing of the left upper eyelid. (Photograph courtesy of Kevin Michels, MD)

the repair. The correction of lateral canthal webbing (Fig. 11.15b) is approached in a similar manner.

11.4.2 Scarring

Hypertrophic scarring or suture “tracts” of the incision line can occur after blepharoplasty from inadequate wound closure or reaction to the suture material. Failure to remove suture material within the proper time frame can also promote incision irregularities. Using fast-absorbing gut or Prolene sutures has been shown to decrease the incidence of scar formation [39]. In African-American and Hispanic patients, keloid formation is possible, but very unusual in the eyelids [40]. Keloid formation can often be diminished by reducing skin tension through taping, corticosteroid injections, or immediate placement of silicone elastomer sheeting [41].

11.4.2.1 Medical Management

There are numerous treatment options for scarring and keloid formation; however, no single therapeutic modality has been determined experimentally to be most effective. Treatments include pressure dressing, corticosteroid injections, silicone sheeting, cryotherapy, and laser. Topical vitamin E and zinc oxide may also be of benefit [42].

11.4.2.2 Surgical Management

Surgical management consists of scar excision with appropriate wound reconstruction. If conservative resection of eyelid skin was performed initially, direct scar excision with meticulous closure using a monofilament suture may be attempted. Subcuticular placement of the sutures will help reduce suture tract formation by diminishing the number of puncture sites along the wound edges. Sutures should be removed 5–7 days after placement. Alternatively,