Dual Canthoplasty

Overview

A canthoplasty is a cosmetic operation that includes altering the corner of the eye. The phrase derives from the Greek words "kanthos," which means "corner of the eye," and "plasty," which means "to shape."

A canthoplasty is a reconstructive surgical treatment performed to repair drooping or sagging of the outer corner of the eye by raising the canthal angle to produce a larger and brighter appearing eye.

Dual canthoplasty alters the vertical dimension of the eyes, whereas epicanthoplasty and lateral canthoplasty alter the horizontal dimension of the eyes. Epicanthoplasty is a surgical treatment that enlarges the eye horizontally at the inner corner, whereas lateral canthoplasty enlarges the eye at the outside border. Adjusting the slant of the palpebral fissure by lateral canthoplasty can accomplish an enlargement of eye width and smoother characteristics, especially if the slant of the palpebral fissure is elevated and the horizontal dimension of the palpebral fissure is short. 

Depending on the patient's condition, this treatment can be combined with additional surgeries such as double eyelidplasty, eye roll creation surgery, fat transplant, and brow or facial bone contouring surgery to get even better results.

 

Anatomy of the Lateral Canthal Area

The lateral canthal region under the skin is made up of three parts: the lateral palpebral raphe (LPR), the superficial lateral palpebral ligament (SLPL), and the deep lateral palpebral ligament  (DLPL). The LPR is formed when the lateral ends of the superior and inferior orbicularis oculi muscles interlace at the lateral commissure.

The lateral palpebral ligament is divided into the SLPL and the DLPL. The SLPL extends from the lateral ends of tarsal plate to the periosteum of lateral orbital rim. The DLPL extends from the lateral ends of tarsal plate deep into the origin of the SLPL to Whitnall's tubercle on the zygomatic bone inside the orbital margin. It is located deeper than the SLPL. The DLPL is attached to the lateral orbital tubercle (Whitnall's tubercle). Whitnall's tubercle was located 2.9–0.8 mm inside of the orbital rim of the zygoma.

The SLPL must be incised and dissected to release the lateral canthus and allow for an efficient operation while doing lateral canthoplasty. There is no need to waste effort detaching or incising the DLPL because it is deeply situated and difficult to discover.

 

Dual Canthoplasty Vs. Blepharoplasty

Dual canthoplasty procedure should not be confused with lower lid blepharoplasty, which is a different form of eyelid surgery. A blepharoplasty removes extra skin, muscle, and perhaps fat from the lower or upper eyelid to make the eye seem younger, although surgery does not change the shape or size of the eye. In short, a blepharoplasty removes "baggage." 

A dual canthoplasty, on the other hand, is a cosmetic surgery technique that lifts the eye's outer corner (the lateral canthus), reshapes the eye to a more almond shape, and enlarges the eye-opening. As a result, the eye seems brighter, larger, and more alert.

 

Why Do People Undergo Canthoplasty?

 People consider undergoing canthoplasty for a number of reasons:

• Lower eyelid drooping or sagging (known as ectropion) – as we age, the skin and tendons surrounding our eyes lose elasticity, resulting in drooping or laxity of the lower eyelids, giving us a fatigued or sad appearance.
• Eye damage that causes lower eyelid laxity or retraction may need a canthoplasty to correct the imbalance of the outer corner of the eye.
• Dissatisfaction with a previous surgical outcome – Some canthoplasties are performed as revisional surgery to repair lower lid issues caused by previous surgery, such as drooping lower lids or eversion abnormalities that reveal too much white of the eye (scleral show).
• Some patients seek out canthoplasty surgery to achieve a more almond-shaped eye by uplifting a downward slanting eyelid and increasing the horizontal length of the eye.

 

Candidates for Dual Canthoplasty Surgery

Drooping of the outer corner of the lower eyelids is expected when the lids loosen with age. However, it can also be caused by skin tightening as a result of inadequate cosmetic surgery, UV damage, and skin cancer surgery. Patients with drooping, sagging, or baggy lower eyelids are often suitable candidates for this sort of surgery, especially if the existing look and shape of the eye make them stressed. When it comes to eyelid surgery, however, there is no one-size-fits-all approach, and what many patients believe they require may not be the sort of surgical treatment that is best for them.

As a result, at a first consultation, the surgeon must thoroughly examine each patient's lower lid function, tone, laxity, and position, as well as their overall face shape. In most cases, the surgeon will do this during consultations with patients who want to have blepharoplasty and may recommend canthal suspension (canthoplasty) at the same time. 

In some cases, the surgeon may recommend a different type of procedure entirely, which would be more appropriate for addressing the patient's concerns. It is critical that canthoplasty surgery be conducted only by an experienced, highly educated oculoplastic surgeon, as the consequences of improper surgery can be very difficult to repair.

When you are admitted for the operation, the surgeon will generally begin by marking on the eyes with a pen where the incisions will be made after a meticulous evaluation by a specialist where they will examine your eyes' structure and treatment alternatives. Following that, an anesthetic will be provided. This operation is most usually performed under local anesthesia.

 

How Should I Prepare?

In preparing for dual canthoplasty, you may be asked to:

• Get lab testing or a medical evaluation.
• Take certain medications or adjust your current medications.
• Stop smoking.
• Avoid taking aspirin, anti-inflammatory drugs and herbal supplements as they can increase bleeding and bruising.

Dual Canthoplasty surgery should be conducted in a hospital or a certified office-based surgical facility. Make arrangements for a friend or family member to drive you to and from surgery, as well as to remain with you the first night after surgery.

 

The Dual Canthoplasty Procedure

The design of the surgery is very simple. Following the crease around the lateral canthus, the end point of the incision line is marked. At this time, the end point should not go past the lateral wall of the bony orbit. Marking the lowest point of the bony orbit will help to find a fixation point during surgery.

 

Local infiltration

First, anesthetic eye drops (Alcaine 0.5%, proparacaine hydrochloride) are applied to the eye. Using a 30 gauge 1/2 inch needle, an anesthetic containing 1:100,000 epinephrine mixed with a 1:1 solution of 0.5% bupivacaine hydrochloride and saline solution is injected.

 

Incision and dissection

Before beginning the operation, traction sutures are applied to the upper and lower eyelids. A skin incision is then carried out from lateral canthus. After incision and dissection of the LPR and the SLPL, the lower lid is pulled lightly in order to check whether it has become sufficiently released. At this point, care should be taken not to damage the DLPL through excessively deep dissection. A critical zone delineates a circle with a radius of 0.5 cm, and its center is located 30° inferiorly and laterally, and 2.5 cm from the lateral canthus.

Canthopexy is done at the periosteum and lower lid with a 6-0 nylon suture. Suturing is done twice to ensure a firm fixation, and the site of fixation should be within 3 mm of the lower lid edge. A solid fixation should be applied at the inner side of the bony orbit's lateral wall when affixing to the periosteum to avoid issues such as eversion of the lower eyelid following surgery.

 

Skin closure

A skin suture was placed using 7-0 black silk. As the area of surgery is close to the eyeball, soft thread should be used in order to reduce irritation to the eyeball.

 

Factors to consider after surgery

Following surgery, oral antibiotics and ophthalmic ointment, as well as three types of eye drops (antibiotics, steroids, and artificial tears), are recommended. When the palpebral conjunctiva is swollen, steroid eye drops should only be taken for a brief amount of time. It is important not to open or massage the wound.

While the patient may wash their face or take a light shower after the sutures are removed, they should wait three weeks before going to a sauna or swimming pool or using contact lenses.

 

Postoperative progress

The stitches are removed five to seven days after surgery. Within one month after surgery, swelling is reduced by more than 90%. Palpebral conjunctival swelling and bloodshot eyes mostly disappear within three weeks. While the incision line can appear red for about two to three months, as time passes, it blends in with the surrounding skin color and is no longer noticeable. 

 

What Happens After Dual Canthoplasty Surgery

Following the treatment, your eyes are covered with a temporary protective covering. When you remove your protective eye shields after your procedure, you will notice that your vision has become blurred. This is because an antibiotic ointment is used to protect your eyes from drying up during surgery. To avoid infection, you'll be given this ointment and instructed to put it inside your eye and on your incision many times every day.

You will be instructed to bring someone to surgery who will drive you home. It is advised that you have someone stay with you for the first day or two after surgery since you will be most comfortable with your eyes closed and protected by eye shields.

Canthoplasty recovery time is comparable to that of other eyelid procedures, generally two to three weeks. Most patients have edema and bruising, which resolve within two weeks but may take several weeks longer to totally resolve. The final results will be seen in a few months.

It is very crucial to follow your doctor's post-op recommendations during this period to minimize problems and damage to the sensitive soft tissue surrounding your eyes. In addition to artificial tears, you may be prescribed ointments or eye drops to prevent infection. To treat eye edema, steroid drops may be required.

Recovery may be uncomfortable at first. Your doctor can prescribe pain medication if it is necessary. You can take paracetamol tablets for pain relief. A small amount of blood ooze is normal within the first 24 hours following surgery.

No bending, heavy lifting, or strenuous exercise for 10 days. Swelling is natural and ranges from mild to severe. During the first two days, a cold compress should be used often. Fill a clean dish halfway with cold water, then soak and squeeze a clean facecloth in it. A facecloth should be used to cover the incision. Rinse the cloth in cold water again when it is no longer cold. A cool compress will reduce swelling and soreness.

For at least one month following surgery, you should avoid taking showers, splashing your face, and wiping your eyes. Strenuous activity should be avoided for at least two weeks, or until your doctor visits you and confirms it's safe. Makeup is normally allowed after two weeks.

Pain, bruising, and swelling are common after eye surgery, but they should subside in 7-14 days. Initially, keep your head up and get as much rest as you can. Patients should avoid from exercising, rubbing their eyes, or applying make-up for two weeks.

People's eyesight may shift under certain conditions, but this should only be temporary, with normal vision returning without medical intervention. Patients should avoid placing strain on their eyes after surgery by not gazing at their phones, reading, or watching TV. Contact lenses should be avoided for many weeks after surgery.

Following dual canthoplasty surgery, full recovery usually takes 2-4 weeks, during which time it is critical to follow your surgeon's post-operative instructions and attend any planned follow-up visits. A good surgeon will aim to make the scar less visible and covered by the natural crease of the eye.

To be conducted properly, canthoplasties need a high degree of expertise and experience. Canthoplasty is considered a permanent remedy for eyelid malposition when performed by a highly trained board-certified oculoplastic surgeon, and revision operations are seldom required.

 

Are there Any Risks or Complications?

This technique should only be performed by specialists who have substantial experience in oculoplastic surgery. When badly done, the consequences might be severe.

Every procedure has some risk, although serious problems from a canthoplasty are unusual. Swelling and bruises are common in the first few weeks following surgery and typically resolve within two to three weeks. You may also have dry eyes, excessive tears, and blurred vision in the weeks following surgery.

For this method, incisions are created on the outer surface of the lower lids. Complications are possible, although they are rare. Infection is always a risk, although it is uncommon after lid surgery. Although bleeding can occur and impair vision, it is relatively uncommon with laser surgery.

Damage to the muscle in the upper or lower lid might result in a drooping eyelid. Precautions are taken to avoid this, but if it does occur, it is repairable. Damage to a lower lid muscle may result in double vision, but this is extremely unusual.

Closing the eye may become difficult if too much skin is removed from the upper eyelid. Lower lid surgery causes the lid to sit away from the eye due to swelling, however this usually resolves quickly. As the top lid skin is incised, a scar may emerge. The incision lies in the crease of the eyelid and will fade with time. However, if a scar is significant, it may become apparent and require repair.

Asymmetry of the lid is possible and may require treatment. The laser may cause harm if it is pointed directly at the eye. To prevent this from happening, some surgeons use specially designed eye coverings. Some discomfort, swelling, and maybe bruising may occur; fluid may collect over the white of the eye and is usually transient; however, the use of laser decreases this.

During your pre-operative appointment, your surgeon will discuss in more detail all of the potential risks and complications of your surgical procedure. This information will also be provided in writing to you as part of the consent procedure so that you may review it.

 

Are Canthoplasty Results Permanent?

To be conducted properly, canthoplasties need a high degree of experience and knowledge. Canthoplasty is considered a permanent solution for eyelid malposition when performed by a highly competent board-certified oculoplastics surgeon, and revision operations are seldom required.

 

Conclusion

Dual Canthoplasty, which combines Epicanthoplasty with Lateral Canthoplasty, is for patients who desire to optimize the results of the two procedures. Dual Canthoplasty will satisfy you if your eyes are short, narrow, and slanted and you wish to decrease the pointed glare.

• Indications: This procedure is recommended, if you have the Mongolian fold, have a stuffy impression, want to increase the length of horizontal and vertical lines of the eyes.
• Surgery Time: 30 minutes ~ 1 hour
• Anesthesia: Local anesthesia or Hypnoanesthesia (=twilight anesthesia)
• Removing Stitches: After 5 days and 9 days
• After Surgery Check-ups: Twice
• Recovery Time To Daily Activity: None