Oblique views of paralytic ectropion in the right eye. A, Preoperative appearance shows Ectropion Grading Scale grade LIVMIV. Note that the lower eyelid has fallen away from the globe medially and laterally. B, Appearance after lateral transorbital canthopexy and precaruncular medial canthopexy shows Ectropion Grading Scale grade LIMI. Note the return of the medial canthus to the normal position against the lacrimal lake.
The forces of displacement and reconstruction in medial ectropion. A, Anterior, inferior, and lateral displacement of the medial canthus and the inferior canaliculus. B, Eyelid support in medial ectropion. The thick solid arrow demonstrates the net force on the lower eyelid; the horizontal solid line, the support of the medial (MCT) and lateral (LCT) canthal tendons before repositioning; the dashed lines, how the forces of the MCT and LCT can be repositioned superiorly, horizontally, and posteriorly; and the vertical solid line, the condition after reconstruction when the net sum of the forces exerted by the repositioned canthus counteract the force exerted by gravity. C, The white arrow demonstrates the direction of displacement before surgery, and the heavy solid arrow depicts the net counteracting force when the medial canthus has been properly repositioned in a posterior, superior, and lateral position.
Anterior views of ectropion in the right eye. A, Preoperative appearance shows Ectropion Grading Scale grade LtMIV. Note the lateral tarsorrhaphy with blockage of the visual fields. Gold weight is present in the upper eyelid but is not visible. The medial canthus is displaced anteriorly, and the inferior lacrimal punctum does not contact the lacrimal lake. B, Appearance after reversal of the lateral tarsorrhaphy, with lateral transorbital canthopexy to correct lateral laxity, shows Ectropion Grading Scale grade LIMIII. Note the inferior displacement of the medial canthus that occurs after reversal of the tarsorrhaphy, resulting in excessive medial canthal height. C, Appearance after precaruncular medial canthopexy, brow-lift, and upper blepharoplasty shows grade LIMI. The medial canthal position and medial canthal height are now normal. Gold weight in the upper eyelid is now visible.
Oblique view of the medial aspect of the right eye. The lacrimal caruncle and the plica semilunaris are illustrated, along with the position of the tarsal plate and the superior and inferior lacrimal puncta. Reprinted with permission from the Archives of Facial Plastic Surgery.5 Copyright 2003, American Medical Association.
The anterior and posterior limbs of the medial canthal tendon are illustrated, with the caruncle and adjacent conjunctiva reflected laterally. The lacrimal canaliculi are shown entering the lacrimal sac (medial to the canthal tendon). Reprinted with permission from the Archives of Facial Plastic Surgery.5 Copyright 2003, American Medical Association.
Conjunctival incision for the precaruncular approach. Lacrimal probes are placed in the superior and inferior lacrimal puncta. The scissors demonstrate the initial conjunctival incision. The incision may be continued laterally for additional access to the orbital floor (dark dashed line) or anteriorly for full access to the medial canthal tendon and tarsal plate (light dashed line). Reprinted with permission from the Archives of Facial Plastic Surgery.5 Copyright 2003, American Medical Association.
Completed precaruncular approach to the medial orbit. The caruncle and adjacent conjunctiva are retracted laterally. A screw hole is drilled at the posterosuperior lacrimal crest.
A 4-mm screw is in place. A 5-0 permanent suture spans from the medial edge of the tarsal plate (immediately lateral to the lacrimal punctum) to the screw.
Moe KS, Kao C. Precaruncular Medial Canthopexy. Arch Facial Plast Surg. 2005;7(4):244-250. doi:10.1001/archfaci.7.4.244
Author Affiliations: Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of California, San Diego (Dr Moe); and Department of Otolaryngology–Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (Dr Kao).
Correspondence: Kris S. Moe, MD, Division of Otolaryngology–@Head and Neck Surgery, Department of Surgery, University of California, San Diego, 200 W Arbor Dr, Mail Stop 8895, San Diego, CA 92103 (firstname.lastname@example.org).
Objectives To describe a new 3-dimensional technique for medial canthal repositioning, precaruncular medial canthopexy (PMC), and to present an outcome study demonstrating its efficacy.
Methods Data (age, sex, cause, and initial symptoms) were collected prospectively on patients with malposition of the lower eyelid. All patients were photographed before and after surgery in a set protocol. The type and severity of eyelid malposition were documented using the Ectropion Grading Scale (EGS) before and after each procedure. Surgical outcome was evaluated by objective improvement of ectropion grading and subjective resolution of symptoms.
Results Precaruncular medial canthopexy was performed on 30 eyelids of 27 consecutive patients (10 were revisions) for correction of medial eyelid laxity or malposition. Twenty-six patients had ectropion, and 1 had bilateral entropion. The most common cause of eyelid malposition was facial paralysis (n = 21). Ancillary procedures, most commonly lateral transorbital canthopexy (for correction of lateral ectropion), were performed on 60% of the eyelids at the time of PMC. Twenty-eight procedures resulted in complete restoration of the medial canthus to a normal position (EGS grade I). Two patients had minimal residual medial scleral show after surgery (EGS grade II) but experienced symptom relief. There were no wound infections or perioperative complications.
Conclusions Precaruncular medial canthopexy rapidly and safely restores support in all 3 dimensions without blocking the visual field or damaging the lacrimal system, with minimal morbidity and excellent wound healing. In addition to being a primary technique for correcting medial eyelid malposition, PMC should be routinely considered as an adjunct procedure when correcting lateral eyelid malposition.
Ectropion (outward rotation of the lower eyelid) is caused by laxity or retraction of the lower eyelid; paralysis of the orbicularis oculi muscle may contribute to the pathologic condition (Figure 1A). The resulting symptoms include epiphora, photophobia, and visual impairment. It is generally recognized that the lateral canthal tendon is the weakest aspect of the lower eyelid support system and thus that it is usually at least partially responsible for most cases of lower eyelid laxity. The contribution of the medial canthal tendon to this pathologic condition is commonly overlooked, however, partly because of the lack of understanding that it may cause eyelid laxity and partly owing to the fact that the presence of the lacrimal drainage system makes surgical correction of the area technically complex. Few procedures circumvent this anatomic impediment.
A successful outcome in correcting ectropion depends on the surgeon understanding that ectropion is not a single type of eyelid malposition but rather a group of disorders that may affect the lateral, central, or medial eyelid, alone or in combination. To demonstrate this, we modified the original Ectropion Grading Scale (EGS) described in 20001 to evaluate malposition of the medial and lateral lower eyelids individually (Table 1). Use of the EGS thus assists in the first priority of treating lower eyelid malposition: correct characterization of the underlying malposition.
In the medial eyelid, loss of support from the medial and lateral canthi leads to inferior, anterior, and lateral displacement (Figure 2A). The resting position of the eyelid depends on the vector summation of the residual eyelid support against the force of gravity (Figure 2B). The net force necessary to restore proper eyelid position and function must be equal in magnitude and opposite in direction to the displacing forces on the eyelid. Anatomic correction of lower eyelid malposition thus requires adding support to the eyelid in 3 vectors: horizontal, vertical, and anteroposterior (Figure 2C). This is true for the lateral and medial canthal tendons, and we previously reported a procedure for 3-vector tightening of the lateral canthus.1 Malposition of the medial canthal tendon, however, is more difficult to correct in all 3 vectors because of the presence of the superior and inferior canaliculi and the lacrimal sac and the proximity of the orbital contents. Most procedures currently used to reposition the medial canthus are ineffective in this regard.
Commonly used techniques for medial canthal repositioning include full-thickness wedge excision of the lower eyelid, canthal resection, medial tarsal strip tightening,2 and medial or lateral tarsorrhaphy. Some of these techniques can actually worsen the position of the medial canthus, cause asymmetry of the palpebral fissure, and block the visual field. Furthermore, although these procedures increase eyelid tension in a single horizontal or vertical vector, they do not address the anteroposterior vector; these procedures can actually pull the eyelid away from the globe. Frueh and Su3 suspend the medial tarsal plate to the superior orbital rim periosteum, which may tighten the horizontal and vertical vectors, but this fails in the anteroposterior vector. Fante and Elner4 recently described a transcaruncular approach for medial canthal tendon plication. This procedure tightens the canthus in all 3 vectors but can fail to correct eversion of the inferior canaliculus. In addition, the transcaruncular approach offers poor landmarks for dissection, and the researchers noted delayed wound healing and long-term postoperative edema in some cases.
We developed a precaruncular approach to the medial orbital wall that is more efficacious than approaches directly through or lateral to the caruncle and that results in excellent postoperative wound healing.5 By using precaruncular medial canthopexy (PMC), we have been able to tighten the medial eyelid in all 3 vectors and effectively reposition the inferior punctum without damaging the lacrimal system. This article demonstrates the surgical technique and presents an outcome evaluation of 30 consecutive procedures.
Twenty-seven adults who underwent correction of ectropion of the medial eyelid were entered into this study of 30 consecutive procedures. Data collected on all patients included initial diagnosis, age, sex, preoperative symptoms, previous attempts at surgical correction, preoperative and postoperative EGS grade, and whether adjunct procedures were performed.
The primary indications for performing PMC were symptomatic malposition or laxity of the medial lower eyelid. In addition, patients who had EGS grade LIV or higher lateral ectropion underwent PMC as an adjunct procedure. Precaruncular medial canthopexy was also used to increase lower eyelid support to correct cicatricial ectropion, to correct entropion caused by lower eyelid laxity, and to restore eyelid position and support for reconstruction after tumor resection.
Patients with EGS grade MII or higher were candidates for surgical correction. The EGS was used to describe the lower eyelid position from grade 0 to grade V in the medial (M) and lateral (L) aspects (Table 1). The subscript “t” indicates that the patient had undergone previous medial or lateral tarsorrhaphy (Figure 3A). This is important to note specifically because tarsorrhaphy severely distorts the patient’s anatomy. The position of the eyelid in its native state can no longer be determined, and, thus, the severity of the underlying laxity cannot be accurately assessed preoperatively. All the patients were photographed using a 105-mm macro lens before and after surgery in a standard protocol that included views of the full face (1:7), both eyes open and closed (1:4), and each eye individually (1:2; anterior, oblique, and lateral views). For patients who also had lateral canthal laxity, lateral transorbital canthopexy (LTC) was performed as described previously.1 For patients with facial paralysis, correction of lagophthalmos was usually undertaken at the same time using retrograde upper eyelid loading,6 brow-lifting, and blepharoplasty.
Lower eyelid strength was assessed using the snap test (the lower eyelid is pulled forward, and it should retract rapidly back into position without requiring a blink). Medial and lateral distraction tests were used to assess the tension of the medial and lateral canthal tendons.7-9 Preoperative photographic analysis was performed for all patients to rule out other abnormalities of eyelid position and as an aid in explaining the expected outcome to patients. The photographic analysis included measurement of the horizontal and vertical palpebral fissures, the pupil diameter, the distance from the lower eyelid margin to the inferior limbus (margin-limbus distance [MLD-2]), the distance from the lower eyelid to the globe (margin-globe distance [MGD-2]), the height of the medial canthal tendon (medial canthal height [MCH], the vertical distance from the interpupillary line to the medial canthus), the lateral canthal height (LCH) (the distance from the interpupillary line to the lateral canthus), and the distance from the lateral canthus to the globe (LCGD). The EGS was used to describe the eyelid position in 26 patients with ectropion. The EGS is not applicable for entropion and therefore was not used in patient 27.
At the medial angle of each eye are 2 specialized structures formed in part by the conjunctiva: the semilunar fold and the lacrimal caruncle (Figure 4). The semilunar fold (plica semilunaris) consists of a delicate vertical crescent of conjunctiva, the free edge of which is concave and concentric with the corneal margin. It is separated from the bulbar conjunctiva by a 2-mm-deep cul-de-sac. The lacrimal caruncle is a segment of modified skin located medial to the semilunar fold. It is covered by stratified, nonkeratinized squamous epithelium. It contains large sebaceous glands similar to meibomian glands and has delicate hairs with sebaceous glands similar to the glands of Zeis.9
The medial canthal tendon has 2 heads: 1 deep and 1 superficial. The deep portion is thinner and runs behind the lacrimal fossa to attach to the posterior lacrimal crest. The superficial portion lies anterior to the lacrimal fossa. It is formed by fusion of the superior and inferior crura of the medial aspect of the orbicularis muscle. The posterior attachment of the medial canthal tendon and the orbicularis muscle create the essential posteriorly directed force on the medial eyelid, which maintains the eyelid against the globe and the punctum in the lacrimal lake (Figure 5).
The posteroinferior limb of the medial canthal tendon (Horner muscle) can be followed medially from the tarsus to its insertion on the posterior lacrimal crest. By dissecting immediately posterior to the Horner muscle, the preseptal plane is entered, which prevents herniation of the orbital fat and allows a direct avascular path to the medial orbital wall and orbital floor.5
After placement of a corneal protector, 1 to 2 mL of 1% lidocaine with epinephrine (1:100 000) is injected into the region of the medial canthus medial to the caruncle. Lacrimal probes are placed superiorly and inferiorly to protect the canaliculi from inadvertent transection and to provide retraction of the upper and lower eyelids. A precaruncular incision is made between the skin and the lacrimal caruncle using Westcott scissors. The conjunctiva is incised as shown in Figure 6. Dissection continues medially along the posterior limb of the medial canthal tendon (the Horner muscle), using it as a guide to the posterior lacrimal crest. The periorbita is lifted off the medial orbital wall, and a screw hole is drilled at the posterosuperior lacrimal crest, superior to the lacrimal sac (Figure 7). A 4-mm titanium or resorbable screw (Macropore Inc, San Diego) is then placed. A CV-5 Gore-Tex suture on a TTc-13 needle (WL Gore & Associates Inc, Flagstaff, Ariz) is passed around the screw head. The lacrimal probes and corneal shield are then removed, and the suture is anchored deeply to the medial end of the tarsal plate as close to the eyelid margin as possible, immediately lateral to the lacrimal punctum (Figure 8). If the suture is placed too low, the punctum will remain everted, causing epiphora. The suture is then tied on itself, providing the appropriate tension to raise, medialize, and posteriorly tighten the medial canthus as desired. Slight overcorrection (1 mm) is desirable. The inferior punctum should be checked for proper inversion and elevation. The incision is closed using a 5-0 absorbable suture placed between the apex of the caruncle and the medial eyelid. Postoperatively, the patient is instructed to place frozen peas over the wound as tolerated for the first 24 hours after surgery and is asked to avoid rubbing the eyelid for 2 weeks.
For younger patients and those with grade MII-IV ectropion, it may not be necessary to place a screw through the medial orbital wall. Instead, the suture can be passed through the full thickness of the periorbita. Tension should be applied to the suture before placing the knot to be certain that the strength of fixation is adequate. Furthermore, for patients with MII-III ectropion, it may not be necessary to place the suture as high on the medial tarsus because there is less tendency for the punctum to evert.
Outcomes were evaluated for 30 consecutive procedures performed to correct malposition of the medial lower eyelid on 27 consecutive patients (3 patients had bilateral malposition). There were 18 men and 9 women, and the mean age was 62 years (range, 28-85 years). Mean follow-up was 24 months (range, 6-51 months). Ten procedures (33%) were revisions after failed correction of the eyelid malposition. Three of these patients (10%), had undergone previous tarsorrhaphy (2 lateral and 1 medial), which was reversed as part of the procedure to restore the visual field to normal.
The most common cause of ectropion in this series was facial paralysis due to tumor resection (n = 21; 70%). Other operative indications included lower eyelid reconstruction after tumor resection, cicatricial ectropion, and entropion (due to lower eyelid laxity and dehiscence of the retractors). Individual patient data are given in Table 2.
All the patients experienced significant improvement in their symptoms. Malposition of the lower eyelid was corrected to EGS grade MI on 28 eyelids (93%); 2 patients (patients 3 and 17) demonstrated minimal residual medial scleral show (grade MII). These 2 patients were satisfied with the relief of symptoms and the cosmetic improvement without further revision surgery. All the procedures that involved reversing a tarsorrhaphy were successful functionally and cosmetically. There were no infections or perioperative complications. Postoperatively, patient 27 complained of bilateral diffuse itching and erythema of the conjunctiva that was believed to have been due to a reaction to the resorbable sutures; these symptoms rapidly responded to the instillation of 0.5% loteprednol etabonate drops. The wounds healed rapidly without visible scarring. There were no instances of interruption of the lacrimal system or evidence that the function of the lacrimal system was altered.
The EGS was used on 28 lower eyelids of 26 patients before and after PMC. Patient 27 had bilateral entropion, which is not graded using the EGS. The preoperative EGS grades for patients with medial malposition of the lower eyelid were Mt (n = 1; 4%), MII (n = 9; 32%), MIII (n = 7; 25%), MIV (n = 7; 25%), and MV (n = 4; 14%). Overall, grade MI was achieved in 28 (93%) of 30 eyes, and grade MII was achieved in 2 eyes (7%) (patients 3 and 17).
The most common ancillary procedures performed at the time of PMC were LTC (n = 18; 60%) and retrograde upper eyelid weight implantation (n = 14; 47%). Three patients underwent lysis of cicatricial scarring with placement of a full-thickness skin graft to raise the lower eyelid, and 1 patient received a skin/orbicularis muscle rotational flap to repair a defect after tumor excision and to correct a coincidental cicatricial ectropion. The other ancillary procedures included brow-lift, facial suspension, blepharoplasty, hypoglossal-facial neurorrhaphy, and cross-facial nerve grafting (Table 2).
Numerous procedures have been described in the literature to reposition the medial canthus. Most of these procedures provide an element of horizontal or vertical support, but few provide an anteroposterior component. Unless the canthal complex is tightened superiorly and posteriorly, in addition to the standard medial tightening, the inferior lacrimal punctum will not be repositioned in contact with the lacrimal lake, and the outcome will not be optimal.
Another drawback to procedures that tighten the canthus in a predominantly medial vector is that they may also create an “accordion effect” on the inferior lacrimal canaliculus and compromise its function. None of the patients in this series complained of increased epiphora after surgery, and we found no evidence of impaired lacrimal function. This is most likely because the repositioning suture is placed lateral to the inferior punctum and the canthus is restored to its original position by repositioning in all 3 vectors, so that the length of the canaliculus is unchanged.
Another disadvantage of most procedures used to reposition the medial canthus is that they are transcutaneous; access to the posterior aspect of the medial canthal tendon is poor from this approach. The precaruncular method described in this article circumvents this difficulty by approaching the tendon from behind the lacrimal drainage system. In doing so, the superior aspect of the posterior lacrimal crest is readily accessible, and a direct route is provided for suturing the medial canthus into the proper position. Kakizaki et al10 recently reported that 2 ligaments that support the lower eyelid, in addition to the Lockwood ligament, all originate on the posterior lacrimal crest; this underscores the importance of accessing this key area for lower eyelid repositioning.
With no complications or treatment failures in this series of 30 procedures, the PMC technique seems to be highly effective. In addition, PMC is rapid and relatively simple to perform. There are several important points to remember, however, to ensure the best possible outcome. Detailed preoperative photographs should be taken, and the surgeon should study these before surgery to rule out other abnormalities of eyelid position that were not appreciated at the time of physical examination. The grade of medial and lateral ectropion should be used to determine whether adjunct procedures, such as LTC, should be undertaken. We recommend performing LTC for EGS grade MIV or greater. Depending on the degree of abnormality, it may not be necessary to fix the suture to the medial orbital wall with a screw; for grades MII to MIV, it is usually adequate to place the suture through the periosteum of the superior aspect of the posterior lacrimal crest if the tissue is sufficiently strong. For patients with facial paralysis, positioning of the suture immediately lateral to the inferior lacrimal punctum is also essential. The suture should be placed in the tarsus, approximately 1 mm lateral to the punctum and within 1 mm of the superior margin of the eyelid. This placement will avoid trauma to the inferior canaliculus while rotating the punctum superiorly and posteriorly to coapt with the lacrimal lake. The corneal protector should be removed before tightening this suture. When the suture is tied, it should slightly overcorrect the height of the canthus with respect to that of the contralateral side. Finally, postoperative photographs should be taken several months after surgery, and the degree of ectropion should again be graded for self-assessment of surgical results.
In this series, LTC was performed at the same time as PMC in 18 eyes (60%). This is similar to the experience of Frueh and Su,3 who also performed lateral eyelid repositioning procedures at the time of medial eyelid tightening in 66% of their patients, yielding an overall success rate of 82% in their series. The patients who most often require additional procedures are those with facial paralysis. For these patients, it is necessary to also consider placement of an upper eyelid weight or spring, a bilateral browlift, and possibly upper eyelid blepharoplasty.
Patients 4, 10, and 15 were referred to us after having undergone tarsorrhaphies for paralytic eyelid malposition. The situation of patients who have had previous tarsorrhaphy needs special mention. These patients typically have facial paralysis and adynamic eyelids; if the patient also has an anesthetic cornea, the tarsorrhaphy should probably not be reversed because these patients are at very high risk for exposure keratitis. Tarsorrhaphy prevents evaluation of the native position of the lower eyelid (hence, the EGS designation of “t,” eg, LtMIII), making it difficult to determine whether tightening of 1 canthus alone will be sufficient or whether lateral and medial canthopexy will both be required. Figure 3 shows a patient who has had reversal of the lateral tarsorrhaphy with concomitant LTC. When the tarsorrhaphy has been reversed, the increased laxity of the medial canthus becomes apparent (Figure 3B). After PMC has been performed, normal eyelid position has been restored (Figure 3C). Our general approach is to perform LTC and PMC at the time of tarsorrhaphy reversal, and we have had good cosmetic and functional results with this protocol. Patients 4, 10, and 15 underwent reversal of the tarsorrhaphies to improve the visual field and enhance their appearance and were restored to grade MI.
In conclusion, PMC is an effective method of 3-vector repositioning of the medial canthus. In this study of 30 consecutive procedures (33% performed after ≥1 previous attempts at correction), we returned the medial canthal tendon to a normal position in a reliable manner, with rapid wound healing and reproducible results. The procedure does not decrease the visual field, interfere with the lacrimal system, or create visible scars. Use of PMC should also be routinely considered when planning lateral canthal repositioning for EGS grade LIV or LV ectropion. Similarly, in addition to performing PMC, a procedure to address lateral eyelid laxity should be considered for EGS grade MIV or MV ectropion.
Correspondence: Kris S. Moe, MD, Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of California, San Diego, 200 W Arbor Dr, Mail Stop 8895, San Diego, CA 92103 (email@example.com).
Accepted for Publication: April 7, 2005.