171

Medial Canthorraphy

Francesco P. Bernardini

This technique is useful to stabilize the medial canthal tendon and prevent medial migration of the lower punctum when performing a lateral tarsal strip for involutional ectropion with marked medial tendon laxity. It is also useful in the treatment of inferior scleral show/ectropion in case of VII nerve palsy, along with a lateral tarsal strip.

The canalicular system is protected by the insertion of 00 Bowman’s lacrimal probes in the upper and lower canaliculus. A 4-mm-long incision is made parallel to the eye lid margin, 3–4 mm above and below, respectively, the superior and inferior canaliclum (Figure 171.1). The superficial fibers of the orbicularis muscle are bluntly dissected with Wescott scissors in a vertical fashion, perpendicular to the eyelid margin; using a pair of toothed forceps, the deep orbicularis oculi that surrounds and attaches to the inferior and superiror limb if the medial canthal ligament is grasped. A horizontal mattress suture with 7-0 vicryl is passed through the bulk of the deep orbicularis in the upper and lower eyelid

(Figures 171.2–171.4). The skin flaps overlying the muscle flaps are closed with three interrupted 7-0 vicryl sutures. No extra skin is excised, and the canalicular system is checked to verify its patency at the end of the procedure.

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Chapter 171 Medial Canthorraphy 529

Figure 171.1. A 4 mm incision below the inferior canaliculus.

Figure 171.2. Suture passing through the deep medial orbicularis muscle fibers.

530 F.P. Bernardini

Figure 171.3. Mirros image suture of the deep medial orbicularis muscle in the upper lid.

Figure 171.4. Suture knot tied between the opposite orbicularis muscle.

172

Myocutaneous Flaps and Canthopexy

for Repair of Severe Cicatricial

Ectropion

James Leong and Raf Ghabrial

In selected cases, the particular combination of myocutaneous flaps with canthopexy is an effective technique for repair of severe cicatricial ectropion. It incorporates the well-known benefits of myocutaneous aps with a canthopexy suspension suture, thereby avoiding some of the potential complications of full-thickness horizontal shortening procedures.

Local myocutaneous flaps provide good cosmesis as they maintain their original color and texture after their transfer and, if made to follow the relaxed skin tension lines, should result in inconspicuous scars.

The incorporation of a canthopexy suspension suture to correct horizontal laxity has a number of potential advantages over the commonly used lid-shortening procedures such as wedge resection and canthotomy. In particular, canthopexy avoids the possibility of lid notching, lateral displacement of the punctum, phimosis of the lid, and distortion of the canthal angle.

Suitable patients must have sufficient upper eyelid dermatochalasis to allow for an adequate myocutaneous donor flap. Depending on the nature of the ectropion, medial, lateral, or bipedicle myocutaneous flaps may be used.

Bipedicle myocutaneous flaps in particular have the functional advantage of forming a sling supported by the upper lid. The passive inward and upward propensity of the sling and a dynamic mechanical support provided by the orbicularis muscle both work to counteract the downward and outward effect of the ectropion.

One constraint associated with this technique is its dependency on a certain degree of upper lid redundancy. Additionally, unilateral procedures may result in less cosmetically acceptable asymmetrical unilateral blepharoplasty.

Overall, however, this procedure provides excellent results in patients with severe cicatricial ectropion with accompanying upper eyelid dermatochalasis and horizontal lid laxity (Figures 172.1 to 172.3).

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Figure 172.1.

Lateral ectropion.

Figure 172.2.

Myocutaneous flap and canthopexy suture.

Figure 172.3.

Postoperative appearance at 12 months.