Primary goal: Strengthening the lateral canthal tendon and/or orbicularis muscle at the outer corner of the eyelids (lateral canthus).
Secondary goals: Preventing ectropion (an eversion of the eyelid away from the eye) with transcutaneous lower blepharoplasty.
Anesthesia: Determined by the primary procedure (lateral canthal reinforcement is typically employed as an "adjunct" to improve the outcome of lower blepharoplasty, although the operation can be performed independently or to treat complications).
Operative technique: Tarsal strip resuspension: Scissors are placed at the junction of the outer upper and lower eyelids (the lateral commissure) and a full-thickness cut is made into the lateral canthus towards the orbital bony rim. The lower half of the lateral canthal tendon extending from the bony rim into the lower eyelid is isolated and cut free from its attachment to the bone. An incision is made on the eyelid margin a small distance (approximately 1/5 inch) from the cut tendon, and the tarsal plate closest the tendon is cleaned of all adherent skin and conjunctiva. This creates a small strip of tarsal plate tissue, a cartilage-like structure that will be used to create "a new and tighter tendon". A non-absorbable suture is used to sew this strip of tarsal plate to the periosteum (the lining of the bone) located just inside the socket's bony rim. The attachment is reinforced with dissolving sutures, and the overlying muscle and skin are closed.
Variations: There are many variations in surgical technique, which allow for the amount of reinforcement to range from mild to marked. For instance, rather than tightening the lateral canthal tendon, it is possible to remove a full-thickness "chunk" of lower eyelid and sew the raw edges together ("full thickness horizontal resection"). While this simplified approach does help the lower eyelid to grip the eye a bit 'tighter," it is inferior to a tarsal strip resuspension because (1) it does not "reconstruct" a tendon, and (2) it is risky in individuals with prominent eyes in that it may cause the eyelid to retract downward and actually worsen the final eyelid position. A common variation on lateral canthal tendon tightening is to "tuck" the orbicularis muscle (as opposed to working with the tarsal plate) by pulling it upward and sewing it to the underlying periosteum at the orbital bony rim ("lateral canthal plication", "lateral canthoplasty", etc.).
Advantages: If the lateral canthal tendon and orbicularis muscle are stretched, tightening restores the normal support to the rest of the lower eyelid. Not only does this help to prevent ectropion both at the time of surgery and some years later, but it also creates a slight upward pull on the lid that softens wrinkles and improves the eye's handling of tears. The "key" step in almost all of these closely related operations is the attachment of either supporting tendon, muscle, or tarsal plate to the firm periosteum lining of the bone.
Limitations: None, except as noted in (2) above.
Care and recovery: Swelling in the upper eyelid may be prolonged after lateral canthal surgery. A skin "dimple" may be created above a "plication" suture, but it usually disappears in a few weeks.
Risks and complications: If not well performed, the lateral commissure (the junction between the upper and lower eyelids) may become round or deformed. Uncommonly, there can be inflammation around the deep permanent suture placed in the tarsal strip resuspension, which may require more surgery to remedy.
Comments: Properly performed, lateral canthal tightening is a valuable addition to standard blepharoplasty (transcutaneous or transconjunctival) and may substantially enhance the final result.
