Lateral Canthoplasty

Overview

Larger, brighter eyes may greatly improve the overall appearance of the face. This appearance is achievable with the lateral canthoplasty cosmetic surgery technique.

Many ladies wish for bigger, brighter eyes. Many patients want a bigger eye shape by prolonging the lateral canthal angle and a brighter eye by straightening the elevated outer tail of the eyes with lateral canthoplasty. If the horizontal dimension of the palpebral fissure is short and the lateral canthus is higher than the medial canthus, it can give the impression of being stubborn, furious, and unpleasant.

Lateral canthoplasty is a surgical procedure that anchors the lateral canthus to the lateral orbital rim following surgical division (lateral cantholysis). It is generally combined with lower blepharoplasty to treat lower lid laxity and malposition. Lateral canthoplasty can also be used to adjust the position of the lower lid, resulting in the desired form of the eyelid fissure.

 It is used to adjust the slant of the eyes or extend them based on the fixation position. In the West, the operation is performed to correct the downward slant of the eyelid induced by aging. However, Asians dislike this because an upward slant makes the eyes look smaller and stronger.

As a result, cosmetic lateral canthoplasty is routinely performed in Asia. The lateral canthus is moved posterolaterally or posterolaterally downward to extend the palpebral fissure and reduce the eye slant. The lateral scleral triangle expands, making the eyes look bigger and leaving a smoother appearance.

What is Canthoplasty?

Lateral Canthoplasty is a surgical procedure used to form the outer corner of the eyes. Some individuals who have a particularly round eye-opening or a downward bend of the outer eye seek to improve their eye shape. By altering the outer angle of the eye and stretching the eye in a horizontal dimension, this surgery can assist enhance the size of the eye.

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 split into two parts: the SLPL and the DLPL. The SLPL runs from the tarsal plate's lateral ends to the periosteum of the lateral orbital rim. The DLPL runs deep into the origin of the SLPL from the lateral edges of the tarsal plate to Whitnall's tubercle on the zygomatic bone inside the orbital edge. It is situated beneath the SLPL. The lateral orbital tubercle (Whitnall's tubercle) is connected to the DLPL. Whitnall's tubercle was found 2.9–0.8 mm inside the zygoma's orbital margin.

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.

Who's a Good Candidate?

Someone who is uncomfortable with the look of their eye or eyelids is an excellent candidate. The most common complaint we get from our patients is that their eyes are too tiny and that they wish they were bigger. It is also critical that the candidate has realistic expectations of what the procedure may achieve. Aside from that, ideal candidates are healthy people who do not smoke.

People consider undergoing canthoplasties 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 melancholy expression.
• Eye damage that causes lower eyelid laxity or retraction may need a canthoplasty to rectify the misalignment 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)
• Canthoplasty surgery is used by certain individuals to obtain a more almond-shaped eye by elevating a downward slanting eyelid and expanding the horizontal length of the eye.

What Type of Surgeon Should Perform Lateral Canthoplasty?

Lateral canthoplasty is a delicate and subtle procedure, and it is critical to identify an oculofacial plastic surgeon who has completed an official fellowship with the American Society of Ophthalmic Plastic and Reconstructive Surgery. This indicates the surgeon completed four years of ocular surgery training and two years of advanced oculofacial plastic surgery training. When it comes to your eyelids, it's vital to go with someone who specializes in eye and eyelid surgery. 

Benefits of Canthoplasty

Canthoplasty has several benefits cosmetically and aesthetically. Some of the benefits of undergoing canthoplasty are the following: 

• Improved shape and symmetry of the eyes.
• Gets rid of a stuffy appearance.
• Increased length of the horizontal line of the eyes.
• Elimination of the Mongolian Folds.
• Bigger and brighter looking eyes.

Difference Between Canthoplasty & Blepharoplasty

Canthoplasty surgery should not be confused with blepharoplasty, which is another 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 a summary, a blepharoplasty removes "baggage."

A 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. 

Pre-operative Evaluation

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 thorough examination and medical history by a specialist where they will examine your eyes' anatomy and treatment options.

Patient history:

Inquire about complaints of tearing, ocular discomfort, exposure symptoms. Tearing often multifactorial: excessive reflex tearing and deficient lacrimal outflow.

Conditions that can cause or exacerbate involutional changes:

• Facial nerve paralysis:

1. Bell's palsy.
2. Facial trauma.
3. Surgery (e.g., vestibular schwannoma resection).
4. CNS tumor.

• Blepharospasm

• Obstructive sleep apnea (OSA):

1. Risk factor for floppy eyelid syndrome. 
2. Should be referred for sleep study if OSA suspected due to risk of systemic complications.

Conditions that can cause or exacerbate cicatricial abnormalities:

• Infection:

1. Trachoma.
2. HSV/HZV.
3. Necrotizing fasciitis.

• Inflammation:

1. Stevens-Johnson syndrome.
2. Ocular cicatricial pemphigoid (OCP).
3. Sarcoidosis.
4. Sezary syndrome, mycosis fungoides.

• Tumors (primary or following resection/reconstruction):

1. Basal cell carcinoma.
2. Squamous cell carcinoma.
3. Sebaceous carcinoma.
4. Melanoma.

• Trauma:

1. Periorbital lacerations.
2. Burns (thermal or chemical).

• Surgery:

1. Lower-lid blepharoplasty.
2. Laser skin resurfacing.
3. Facial/orbital fracture repair.

Conditions associated with medial or lateral canthal deformities:

• Congenital anomalies. 
• Down syndrome.
• Craniosynostoses (Crouzon, Apert syndrome etc.).
• Euryblepharon.
• Mandibulofacial dysostosis (Treacher-Collins syndrome).
• Oculoariculovertebral dysplasia (Goldenhar syndrome).
• Blepharophimosis syndrome (Narrowed horizontal palpebral fissure,Ptosis, Epicanthus inversus).

Clinical examination:

Lid laxity:

• Snap-back test, lid distraction.
• MCT laxity: Distract lid laterally and observe punctal position.
• Floppy eyelids ( Easily evertable upper lids, Papillary conjunctivitis).
• Eyelid imbrication: upper lid overlaps lower with lid closure.

Lid malposition:

• Ectropion, entropion, or retraction.
• Punctal ectropion or override ("kissing puncta").

Retractor disinsertion:

• Associated with involutional entropion and severe involutional ectropion.
• With lower lid eversion, edge of disinserted retractor can be visualized subconjunctivally as a transition from white to pink below the inferior border of the tarsus.

Lamellar shortening:

• Scarring or shortening of anterior or posterior lamella can cause ectropion or entropion, respectively.
• Scarring of the orbital septum (middle lamella) can cause tethering of the lid to the orbital rim.

Midface ptosis and/or hypoplasia:

• Downward traction exerted by cheek on lower lid can exacerbate retraction and ectropion.
• Malar hypoplasia (developmental or age-related) can create negative vector of forces apposing lid to globe.

Signs of corneal exposure:

• Epithelial erosions/defects, scarring, etc.

Lacrimal outflow evaluation as indicated:

• Primary dye test or dye disappearance test.
• Canalicular probing and irrigation.

Procedure Alternatives

Non-surgical:

1. Observation.

2. Ocular lubrication:

• Corneal protection
• Burns, severe cicatrization
• Moisture chambers
• PROSE lens 
• Amniotic membrane (ProKera) 

3. Horizontal lid taping:

• Involutional entropion

Surgical:

1. Lagophthalmos:

• Tarsorrhaphy 
• Lid weight implantation 
• Upper-lid recession 
• Full-thickness blepharotomy 

2. Involutional entropion

3. Lid tightening:

• Full-thickness wedge resection

Surgical procedure

1. Lateral tarsal strip procedure

• Infiltrate local anesthetic.
• Perform lateral canthotomy and inferior cantholysis.
• Determine amount of horizontal laxity:

1. Place lateral traction on lid and mark point where lid crosses lateral rim and commissure.

• Create tarsal strip:

1. Dissect anterior lamella and excise to point where lid crosses lateral commissure.
2. Excise marginal epithelium.
3. Detach retractors/conjunctiva from inferior edge.
4. Remove palpebral conjunctiva with blade, low energy cautery, or radiofrequency ablation.

• Trim tarsal strip to point where lid crosses orbital rim.

• Suspend strip from periosteum over inner aspect of rim:

1. 4-0 or 5-0 absorbable or nonabsorbable suture (e.g., polyglactin, polydiaxanone, or polypropylene) on a small half-circle needle (P‑2 or OPS‑5).
2. Horizontal mattress or half-horizontal mattress pattern, ensuring positioning of strim posterior to lateral rim.
3. Slight overcorrection advisable: about 2–3 mm superior to intended final position of lateral commissure.

• Reform lateral canthal angle. 
• Trim redundant skin.
• Close skin.

2. Modified Bick procedure:

• Lateral canthotomy/inferior cantholysis.
• Distract lid laterally and mark point where lid crosses lateral rim.
• Excise triangular wedge of lateral canthal tendon and tarsus.
• Suspend end of tarsus to periosteum as above.
• Reform lateral canthal angle.
• Close skin.

3. Reinforcement lateral canthoplasty:

• For complex or recurrent LCT laxity/dehiscence.
• Superior and inferior crus of LCT approached through supraciliary/subciliary incisions.
• LCT plicated and suspended from periosteum behind lateral orbital rim.
• Y-shaped graft (e.g., autogenous fascia lata, acellular dermal matix, porcine dermal collagen) sutured to limbs of LCT and periosteum over lateral rim.

4. Upper-lid tightening:

• Full-thickness wedge resection (traditional).
• Lateral tarsal strip procedure or modified Bick procedure can be performed on upper lid in similar manner as lower lid.
• 4-lid lateral tarsal strip-periosteal flap technique: 

1. 5-mm lateral canthus incision to expose lateral rim.
2. 6-mm periosteal flap created and reflected medially.
3. Lateral tarsal strips fashioned in standard fashion and fixated to periosteal flaps with 5-0 polyglactin suture.

Recovery After Surgery

If you remove your protective eye shields following your operation, you will discover that your eyesight is clouded. This is due to an antibiotic ointment that is administered to your eyes during surgery to keep them from drying out. To avoid infection, you'll be given this ointment and told to apply it multiple times each day inside your eye and on your incision.

You will be told to bring someone with you to surgery who will drive you home. It is recommended that you have someone stay with you for the first day or two following surgery since you will be most comfortable with your eyes closed and covered with protective eye shields.

Recovery from a canthoplasty is comparable to that of other eyelid surgeries: it usually takes two to three weeks. Most patients report edema and bruising, which go away within two weeks but may take many more weeks to completely recover. After a few months, the complete results will be seen.

It is very crucial to follow your doctor's post-op recommendations during this period to minimize problems and damage of 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.

At initially, recovery may be a little unpleasant. In the case that pain medication is required, your doctor can prescribe it.

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.

Lateral Canthoplasty Risks

Of course, any operation has some risk, but major complications from a canthoplasty are quite rare. Swelling and bruising are normal in the first few weeks after surgery, and they usually go away within two to three weeks. During the first several weeks following surgery, you may also have dry eyes, excessive tears, and hazy vision.

During your pre-operative appointment, your surgeon will go through all of the potential risks and problems of your surgical procedure in detail. This information will also be sent to you in writing so that you may evaluate it as part of the consent process.

Lateral Canthoplasty Cost

Canthoplasty procedure costs approximately $1,700. It includes the plastic surgeon fee, anaesthesia, anaesthesiologist, and facility fee. It is an approximate cost, and the total price of the procedure will vary depending on your needs and aesthetic goals. You can consult the surgeon of your choice to get the estimated cost for your customized procedure.

Common Inquiries About Lateral Canthoplasty

• Is canthoplasty permanent?

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 competent board-certified oculoplastics surgeon, and revision operations are seldom required.

• Will there be visible scars after having canthoplasty surgery?

Scars are unavoidable with any surgery, and the best surgeons always strive to conceal surgical scars as much as possible in the skin's natural creases. The visibility of the scar after canthoplasty is determined by the procedure utilized. Vertical incisions result in apparent scarring, whereas incisions parallel with the lower eyelid edge result in a less evident scar.

• How long can you see the results of canthoplasty surgery?

Because of swelling, you may not be able to completely evaluate the effects immediately following the surgery. Because edema has gone by 90% over that time, you should notice obvious benefits within three weeks to a month.

Conclusion

One of the most important aspects of human facial beauty is the look of the eyelids. Beyond cosmesis, eyelids have a practical purpose and, as such, constitute an inadvertent component of the underlying globe.

Lateral Canthoplasty is the name given to an eyelid operation that is performed to strengthen the lateral canthal tendon and the surrounding supportive tissue. The objective is to strengthen the canthus tissues in order to keep the eyelid and eyeball in their proper posture and connection.

Lateral canthoplasty is one of the most important oculoplastic surgical procedures for correcting lid defects. Ectropion, entropion, lateral canthal dystopia, horizontal lid laxity, lid border eversion, lid retraction with or without soft tissue deficit, paralytic lagophthalmos, and aesthetic improvement are among the indications. This surgery is a beneficial adjuvant to lower blepharoplasty, orbital tumor delivery, and the prevention of some of the above mentioned entities.

Canthoplasty (also known as canthopexy) is a procedure that lifts the muscles at the outside corners of the lower lids, similar to elevating one end of a hammock. Canthoplasty can also be done to alter the contour of the outer corner of the eye if needed. A more thorough treatment is often necessary, and a new lower-lid tendon must be fashioned to address the lid laxity.

Incisions are made on the outer surface of the lower lids for this technique. Complications are possible, although they are uncommon. Infection is always a risk, although it is uncommon following lid surgery. Although hemorrhage can occur and have an impact on vision, it is extremely rare with laser surgery. A drooping eyelid can be caused by damage to the muscle in the upper or lower lid. Precautions are made to prevent this from happening, but if it does, it is repairable. Damage to a lower lid muscle might cause double vision.