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8.8 Posterior Medial Canthal Thermoplasty 87
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8.8 Posterior Medial Canthal Thermoplasty
8.8.1 Principle and Considerations
Laxity of the medial canthal tendon (MCT) is common. Whether it is due to failure
of the tendon itself or merely a dehiscence of its attachment to the tarsal plate
is unclear. Several techniques have been described to address the problem, but
none are straightforward, and most are not long lasting. Most use non-absorbable
sutures. Although the sutures remain permanently, any useful tension they provide
is soon lost through suture migration. The technique I describe here is what I call
a “cheat operation”. It involves no dissection and works by creating a directed,
posterior lamellar, thermal scar. This simple procedure is surprisingly effective in
about 3/4 of cases.
8.8.2 Case Selection
Significant medial canthal tendon laxity (the punctum can be pulled laterally past
the medial corneal limbus).
8.8.3 Steps
1. Check whether there is significant MCT laxity by observing punctal movement
as you pull the lid laterally (Fig. 8.9a). If it moves as far as the medial limbus
or further the laxity is clinically significant.
2. Before embarking on a thermoplasty check for the presence of a strong medial
canthal fixation point. Do this by grabbing the tissue between the medial
canthus and the caruncle, through the conjunctiva, with toothed forceps and
pulling (Fig. 8.9b). This tissue probably represents the lateral extent of the
medial canthal tendon. If there is firm resistance (no give), then a thermoplasty
can be used.
3. Insert a 6/0 double armed, absorbable suture transconjunctivally behind your
forceps through this firm tissue with a double pass (Fig. 8.9c). Clip the two
ends of the suture together. Confirm firm placement by tugging on the suture.
There should be no give.
4. Place a second suture similarly to the first just below it as a failsafe (optional).
Clip this pair of ends together. If you are unable to obtain strong suture fixation
abandon the procedure.
5. Insert a Bowman’s lacrimal probe into the lower canaliculus until it stops
against the nose and use this probe as a lever to evert the medial lower lid
over a cotton bud held by an assistant (Fig. 8.9d).
6. Mark an inverted triangle of conjunctiva with its base extending from the
caruncle medially to the lacrimal punctum laterally and just avoiding the lower
canaliculus (made visible by the probe). The apex of the triangle is in the
conjunctival fornix, 5 mm proximal to the lid margin (Fig. 8.9e).
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a
b
c
e
d
f
g h
Fig. 8.9 Posterior medial canthal thermoplasty. a Assess medial canthal laxity by observing punc-
tum movement as you pull the lid laterally. b Check for a strong medial canthal fixation point. Grab
the tissue between the medial canthus and the caruncle with toothed forceps and pull. You should
feel firm resistance (no give). c Pre-place two absorbable sutures into firm tissue. d Evert the medial
lid with a lacrimal probe and cotton bud. e Mark a medial triangle, based below the canaliculus
and the apex in the fornix. f Apply strong diathermy to burn the marked conjunctiva. g Insert the
pre-placed sutures into the tarsal plate transconjunctivally, bringing them out through a skin stab
incision. h Tie the sutures firmly and encourage the knots to retract under the skin
8.9 ‘Permanent’ Surgical Correction of Moderate Cicatricial Entropion 89
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7. Burn the whole of this triangle with bipolar diathermy forceps, keeping their
tips slightly apart, until it is white (Fig. 8.9f). Avoid the canalicular area.
8. Rub off any loose necrotic conjunctiva with a cotton bud. Then withdraw the
lacrimal probe.
9. Make a small skin stab incision 4 mm below the lacrimal punctum.
10. Now pass the first of the pre-placed sutures into the tarsal plate, just lateral
to the punctum, from the conjunctival surface, as close to the lid margin as
possible, and bring the needle out through the skin stab incision. If this bite is
too far from the margin a punctal ectropion may result.
11. Pass the second end of the first suture similarly but enter the tarsal plate a
millimetre below the first. Bring the needle out through the same skin stab
incision.
12. Pass the second pair of preplaced sutures similarly, each a millimetre below
the previous one (Fig. 8.9g).
13. Tie each of the two pairs of sutures tightly, allowing their knots to retract into
the skin stab incision and bury themselves (Fig. 8.9h).
8.8.4 Notes
•
This procedure causes temporary distortion and kinking of the canalicular portion of the lid margin medial to the punctum. This will resolve once the sutures
absorb. The purpose of the sutures is to direct the conjunctival scar formation
and contraction medially rather than inferiorly.
•
The sutures may occasionally cut through and cause some discharge and
irritation. Remove any loose sutures.
•
The efficacy of this procedure does not distinguish between the possible aetiologies of the original medial laxity. The thermal scar created could equally
well address a Horner’s muscle failure as a MCT dehiscence.
8.9 ‘Permanent’ Surgical Correction of Moderate Cicatricial
Entropion
8.9.1 Anterior Lamellar Repositioning
8.9.1.1 Principle and Considerations
Anterior lamellar repositioning corrects mild to moderate lash entropion. It works
by first separating the anterior from the posterior lid lamella as far as the lash roots
and then suturing the lamellae together again with the anterior lamella pulled away
from the margin. This everts the lid margin and lashes and provides a static component to the correction. Suturing the lid retractors to the skin incision during wound
closure adds a long-acting dynamic component to the operation. The procedure is
equally applicable to the upper or the lower lid.
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8.9.2 Case Selection
Cicatricial lid margin entropion with sufficient conjunctival fornix not to require a
mucous membrane graft.
8.9.3 Steps
1. Make a skin crease incision, through the skin and the orbicularis, the length of
the lid. In the upper lid make this at the level of the desired post-operative skin
crease (usually about 7–8 mm from the lid margin in Caucasians). In the lower
lid 4–5 mm from the margin is usually satisfactory (Fig. 8.10a).
2. Dissect down, perpendicularly to the surface, to reach the tarsal plate. If you
cut at an oblique angle, you confuse your orientation.
3. Starting in the middle of the incision, dissect towards the lid margin taking care
to remain on the surface of the tarsal plate throughout (Fig. 8.10b).
4. Continue the dissection towards the lid margin until the lash roots become vis-
ible from behind (Fig. 8.10c). At this point the scissors usually enter a narrow,
channel like, space. Extend the dissection medially and laterally by keeping one
blade of the Westcott scissors within this channel and the other outside it on
the surface of the tarsal plate. This makes extending the dissection very easy.
This dissection separates the anterior lamella from the posterior lamella, but they
remain hinged at the margin.
5. Place five 6/0 absorbable interrupted, everting sutures (Fig. 8.10d). Penetrate
the anterior lamella just proximal to the lash line. Then take a partial thickness,
horizontal, 2 mm long bite of tarsal plate about 2 mm proximal to the skin
entry site i.e., higher up the tarsal plate. Finally exit the anterior lamella just
proximal to the lash line (but distal to the tarsal bite) to complete the ‘box’
type suture. Do not tie this suture but clip its ends together. Now insert and clip
the next suture similarly before tying the first. This delayed tying allows clear
access and visualization for the accurate placement of the subsequent suture
and avoids stressing the previously placed suture. Repeat this sequence for all
the sutures.
Note: As each suture is tied the lashes are seen to evert. Very slight lid margin
eversion may also be seen. If there is significant eversion of the margin, then the
tarsal bite has been placed too proximally. That suture should either be tied less
tightly or replaced.
8.9 ‘Permanent’ Surgical Correction of Moderate Cicatricial Entropion 91
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a b
c d
e f
g
i ii
iii iv
Fig.8.10 Anterior lamellar repositioning (ALR). a Mark and make a skin crease incision. b Dis-
sect down to the tarsal plate. c Dissect on the tarsal plate surface to expose the lash roots. d Insert 5
box type everting sutures from low down on the anterior lamella to higher on the posterior lamella.
e Plicate the levator aponeurosis to the skin incision to reform a skin crease. f Use the plication
sutures to close the skin incision. g i & ii Cross-sectional view of simple ALR. iii & iv ALR
augmentedbygreylinesplit
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If more lash eversion is needed, make a 1–1.5 mm deep grey line incision along
the length of the lid margin (Fig. 8.10g iii and iv). Take care not to detach the whole
anterior lamella from the margin by joining this incision to the deep dissection plane.
6. Bluntly dissect beneath the upper wound edge, proximally upwards (on the
surface of Müller’s muscle in the upper lid) to reveal the ‘white line’ of the
reflected retractor aponeurosis. In patients with strong connective tissue Westcott spring scissors may need to be used for this dissection. Pull Muller’s muscle
downwards to make the white line appear.
7. Suture the white line to the skin with three absorbable 6/0 sutures (Fig. 8.10e).
Note: In this way the retractor pulls on the anterior lamella imparting a lasting
‘dynamic’ component to the operation.
8. When applying the dressing ensure that the lashes are padded in an everted
direction.
Note: Warn the patient that the lashes will initially point unnaturally upwards but
that they will gradually return to a more normal position.
8.10 Mucosal Grafting
If conjunctival scarring has caused significant shrinkage of the fornix, additional
labial or buccal mucosal grafting will be required to deepen the fornices. Details
of this fall outside the scope of this book.
8.11 Take Home Message
•
Aging is the commonest cause of entropion.
•
Cicatricial pemphigoid, though rare, is easily missed if not specifically looked
for.
•
Lasting correction of involutional entropion requires lid margin shortening,
retractor reinsertion and orbicularis stabilization.
References 93
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References
1. Meadows AE, Reck AC, Gaston H, Tyers AG (1999) Everting sutures in involutional entropion.
Orbit 18(3):177–181. https://doi.org/10.1078/orbi.18.3.177.2708.PMID:12045982.
2. Quickert MH. In: Sorsby A (ed) Modern ophthalmology, vol 4, 2nd edn. Butterworth, London,
p 940
3. Danks JJ, Rose GE (1998) Involutional lower lid entropion: to shorten or not to shorten? Oph-
thalmology 105(11):2085–2087. ISSN 0181–8420. https://doi.org/10.1018/S0181-8420(98)911
28-5
Ectropion
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9.1 Overview
•
Types
•
Assessment
•
Surgical management:
– Lid margin wedge resection & Bick repair
– Medial lower lid retractor plication
– Central lower lid retractor posterior plication
– Free skin graft
– Upper to lower lid skin pedicle flap
– Permanent (overlap) lateral tarsorrhaphy
– Medial canthoplasty.
9
Lid margin ectropion (outward turning) can affect both the upper and the lower
lids. The commonest cause of lower lid ectropion is aging (involutional ectropion).
Upper lid ectropion is the result of anterior lamellar scarring (cicatricial ectropion).
Iatrogenic upper and lower lid cicatricial ectropion sometimes follow periocular or
mid face surgery. They can be avoided by following simple rules (see Chap.14).
9.2 Symptoms
Watering is the commonest symptom of ectropion. It occurs with as little as a millimetre of punctal ectropion. An ectropic punctum dries and closes spontaneously.
Lower lid margin ectropion allows tears to collect in the trough formed between the
everted lid and the eye. They overflow when the patient leans forwards, particularly
when reading.
Constant wetting from tear overflow causes an eczematous skin reaction which
adds a cicatricial component to the ectropion. Manage this by waterproofing the
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Th a l l e r, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_9
95
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skin with a thin smear of hydrocortisone 1% skin ointment. This also settles the
inflammation. Instruct the patient to massage the ointment gently towards the lid
margin two or three times a day.
The second commonest complaint is of redness and crusting of the of the
exposed lower lid conjunctiva. Even when the patient is not bothered about these,
it bothers those who see them.
Ectropion may cause minimal symptoms in the elderly whose tear production
is naturally reduced. It is not a threat to vision and is safe to leave untreated if the
patient prefers.
9.3 Types
9.3.1 Congenital
Congenital ectropion is rare, associated with anterior lamellar shortage and it may
be part of a syndrome such as Down’s.
9.3.2 Involutional
Aging is the commonest cause of lower lid ectropion. Enophthalmos caused by
orbital fat atrophy results in a relative laxity of the lid (lid-globe disparity) making
it unstable. ‘Facial deflation’ through fat atrophy, together with stretching of the
facial suspensory ligaments by relentless gravity, leads to mid face descent, which
in turn pulls downward on the lower lid, stretching it. A lifetime of eye rubbing,
and relative loss of orbicularis tone are further causative factors.
The posterior attachment of the lower lid retractors to the inferior edge of the
tarsal plate stabilizes it. Laxity of the retractors permits an unstable lid to flip
outwards by 180
Gravity prevents upper lid involutional ectropion by holding the lid against the
eye.
o
(tarsal ectropion).
9.3.3 Eye Rubbing
Constant eye rubbing stretches the lid margin and weakens the canthal tendons.
Nocturnal stretching of the lids by head movement against the bedclothes is a
possible explanation for the floppy eyelid syndrome.
9.4 Assessment 97
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a
Fig. 9.1 Paralytic ectropion. a Paralytic ectropion tends to recur. b Combine lid shortening (pas-
sive) with medial canthoplasty and lateral tarsorrhaphy to transfer active lift from the upper to the
lower lid
b
9.3.4 Cicatricial
Any condition that causes skin shrinkage will pull the lid margin outwards.
Chronic eczema, and the eczematous reaction caused by constant skin wetting
through tearing, cause ectropion. Rare conditions such as Icthyosis have a similar effect. However, the commonest cause is sun damage related skin shrinkage.
Iatrogenic skin deficit can occur following periocular tumour surgery, cosmetic
blepharoplasty and chemical or laser ‘skin resurfacing’.
9.3.5 Paralytic
Loss of orbicularis muscle tone, whether age related or due to denervation, as
in facial palsy or botulinum toxin treatment, can give rise to a paralytic lower
lid ectropion. This type of ectropion has a strong tendency to recur following
simple lid margin tightening unless an additional active ‘lift’ from the upper lid
is introduced by performing a small lateral tarsorrhaphy and medial canthoplasty
(Fig. 9.1).
9.4 Assessment
9.4.1 Relative Lid/Globe Laxity (Invariably Present)
Geometry dictates that for a lid margin to hang away from the eye it must have
become lax relative to the eye. It is irrelevant whether this is due to enophthalmos
or actual lid margin lengthening through a combination of aging, frequent eye
rubbing and/or the chronic pull from tight skin.
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