Lateral Canthal Eyelid Reconstruction
Daniel R. Lefebvre
Summary
The lateral canthus is not as anatomically complex as the medial canthus; nonetheless, this region is of major importance to facial cosmesis and ocular health. Incorrect reconstruction at the lateral canthus can lead to postoperative ectropion, tearing, and eye pain. The techniques presented in this chapter will offer reconstructive options to enable the surgeon to achieve the goal of reconstructing the outer eyelid area for optimal functional and cosmetic result.
Keywords: lateral canthus, Mohs reconstruction, Tenzel, Mustarde, advancement, periosteal flap, Fricke, Tripier
7.1 Introduction
While the lateral canthus is not as anatomically complex as the three-dimensional concavities of the medial canthus, and does not contain critical structures such as the lacrimal canaliculi, it does have an important role functionally and cosmetically. From a cosmetic standpoint, the lateral canthal angle is an important visual landmark and should have symmetry to the contralateral side. Generally, the lateral canthus is positioned several millimeters superior to the medial canthus. Additionally, the lateral canthal angle should be sharp, not rounded. These are principles that are wisely heeded during cosmetic eyelid surgery, and play no less of a role in reconstructive surgery.
The adage “form follows function” rings true. An inferiorly displaced lateral canthus, while unsightly, may also contribute to epiphora and lateral ocular exposure as well as upper eyelid malposition from downward traction. A rounded lateral canthal angle or lateral canthal web is unnatural and can shorten the horizontal palpebral aperture, potentially causing trichiasis and discomfort, as adjacent lashes are pulled inward by the web. The reconstructive surgeon must take measures to avoid these problems as they can be challenging to satisfactorily remedy via secondary revision surgery.
The conceptual approach to lateral canthal reconstruction follows the standard hierarchy of healing by secondary intention, direct closure, adjacent tissue transfer, and tissue grafting.
7.2 Secondary Intention Healing
The lateral canthal area and lateral commissure can heal quite satisfactorily via secondary intention healing. For example, when a lateral canthotomy and cantholysis are performed in the emergency setting for orbital compartment syndrome, the wound often heals acceptably without subsequent surgical revision (▶ Fig. 7.1). However, unlike reconstruction after skin cancer removal, lateral canthotomy, and cantholysis requires no removal of tissue.
The ideal lateral canthal defect for secondary intention healing is small and superficial and does not involve the lateral commissure. There are no strict rules regarding this, however, and a larger defect certainly could be allowed to granulate in a patient who is not a good operative candidate (e.g., due to medical comorbidities) for formal reconstruction. One must pay attention to the possibility of resultant lateral canthal dystopia, the risk of which is proportional to the size and location of the defect. Defects at highest risk are those inferior to the horizontal raphe and those in close proximity to the lateral canthus. Additionally, if the lower eyelid has significant horizontal laxity, a lateral canthoplasty (in the form of a lateral tarsal strip, etc.) is advised to stabilize the lid and reduce the likelihood of canthal dystopia or ectropion. However, if surgical eyelid tightening is performed, it is reasonable to proceed with complete reconstruction rather than secondary intention healing.
There are a variety of wound care protocols regarding secondary intention healing, ranging from wet-to-dry dressing changes, petrolatum gauze packing and redressing, and ointment applications. For most small to moderately sized defects undergoing secondary intention healing, the author prefers to keep it simple and apply ophthalmic antibiotic ointment (such as erythromycin) to the wound several times daily until fully granulated.
7.3 Primary Closure
In most cases, particularly in older patients, the lateral canthal area generally has ample excess skin with prominent relaxed skin tension lines
(“laugh lines” or “crow’s feet”), which can be used to recruit skin and hide scars. If possible, defects for primary closure should be oriented within the relaxed skin tension lines, unless doing so would impart downward vertical traction on the eyelid, particularly the lower eyelid, as this area is at high risk for the development of ectropion or eyelid retraction. As mentioned, lateral canthopexy or lateral tarsal strip horizontal eyelid tightening should be considered when necessary to stabilize the lateral canthus and lower eyelid (▶ Fig. 7.2).
(“laugh lines” or “crow’s feet”), which can be used to recruit skin and hide scars. If possible, defects for primary closure should be oriented within the relaxed skin tension lines, unless doing so would impart downward vertical traction on the eyelid, particularly the lower eyelid, as this area is at high risk for the development of ectropion or eyelid retraction. As mentioned, lateral canthopexy or lateral tarsal strip horizontal eyelid tightening should be considered when necessary to stabilize the lateral canthus and lower eyelid (▶ Fig. 7.2).
 Fig. 7.1 (a) A 68-year-old female status-post right emergency right lateral canthotomy and inferior cantholysis for orbital compartment syndrome due to hemorrhage. (b) One month after the procedure, the eyelid is healing well without surgical intervention. (c) Three months-post, without any secondary revision procedures. The eyelid and lateral canthus have healed to quite normal and satisfactory position and cosmesis. |
 Fig. 7.2 (a) A 50-year-old male with post-Mohs defect of right lower lid/lateral canthal area following the removal of basal cell carcinoma. (b) Hiding the reconstruction was of paramount importance to this patient, and thus the repair was performed as a complex linear closure within a lateral canthal rhytid combined with lower lid stabilization performed as a lateral canthoplasty to deter formation of lower lid ectropion. (c) Postoperative month 6 following reconstruction. |
Direct linear closure often best involves undermining of surrounding tissue in the subcutaneous plane. Small or superficial wounds may be closed with a single layer, such as 6-0 plain gut or 6-0 nylon, if nonabsorbable suture is preferred. In cases with deeper wounds or with wound tension, a layered closure should be employed, such as 5-0 or 6-0 poliglecaprone or polyglactin inverted interrupted deep sutures and 6-0 fast absorbing plain gut simple interrupted or simple running sutures for the epidermis. Surgical tissue adhesive or bandage strips may be applied to further stabilize the skin to minimize tension, movement, and scarring.
7.4 Adjacent Tissue Transfer
As the defect increases in size beyond the scope of primary closure, adjacent tissue transfer or flap reconstruction may be appropriate. The surgeon must consider the area from which the flap is based, both in terms of skin mobility to enable acceptable wound-edge tension, and the resultant force vector applied to the eyelids and lateral canthus proper. In general, the skin of the cheek area is mobile and amenable to recruitment for flap construction and has the risk of pulling the lower eyelid inferiorly. The skin of the temple and lateral forehead is relatively less mobile.
7.4.1 Bilobed Rotational Flap
Adjacent tissue transfers such as bilobed flaps are possible in the lateral canthal region; however, the surgeon must be prepared for wide undermining, robust layered closure, and possible wound tension forces above what is acceptable, which could lead to scar widening and even frank wound dehiscence (▶ Fig. 7.3). Whether in the temple, forehead, or cheek, the dissection plane is in the subcutaneous layer to avoid injury to underlying facial nerve branches. A description of creation of this flap can be found in Chapter 4.
7.4.2 Heterotopic Eyelid Flap
A heterotopic or transposition eyelid flap, such as a modified Tripier flap, can be used as a cutaneous or myocutaneous flap for the lateral canthal area.1 This is a flap with a relatively narrow pedicle, and is prone to prolonged postoperative edema, sometimes requiring flap revision (▶ Fig. 7.4). This is likely due to damage to the lymphatic system confluence draining the lateral canthus and lower eyelid to the preauricular basin.
The author most commonly employs this flap with a laterally based pedicle; however, a lateral
and medial pedicle can be used to create a “bucket-handle” flap. The procedure begins with marking the upper lid as in a blepharoplasty, that is, marking the eyelid crease and determining the upper extent of the incision based on a pinch technique. An elliptical marking is made; however, the lateral aspect of the ellipse serves as the pedicle. The incision is made with a no. 15 blade, and then Westcott scissors are used to elevate a skin-muscle flap. It is important to keep the orbicularis layer intact across the flap, and particularly important to keep the pedicle intact at the lateral base. The flap is transposed into the area to be reconstructed and secured with skin sutures of choice. The donor site is closed as in a blepharoplasty. This flap has the advantage of providing an upward vector to the lateral lower eyelid and lateral canthal area to combat ectropion or dystopia. Edema postoperatively can be significant and may take months to resolve; occasionally, a revision in which the skin is elevated as a flap and the underlying edematous tissue and orbicularis oculi muscle is debulked if the edema has not resolved by 6 to 12 months postoperatively.
and medial pedicle can be used to create a “bucket-handle” flap. The procedure begins with marking the upper lid as in a blepharoplasty, that is, marking the eyelid crease and determining the upper extent of the incision based on a pinch technique. An elliptical marking is made; however, the lateral aspect of the ellipse serves as the pedicle. The incision is made with a no. 15 blade, and then Westcott scissors are used to elevate a skin-muscle flap. It is important to keep the orbicularis layer intact across the flap, and particularly important to keep the pedicle intact at the lateral base. The flap is transposed into the area to be reconstructed and secured with skin sutures of choice. The donor site is closed as in a blepharoplasty. This flap has the advantage of providing an upward vector to the lateral lower eyelid and lateral canthal area to combat ectropion or dystopia. Edema postoperatively can be significant and may take months to resolve; occasionally, a revision in which the skin is elevated as a flap and the underlying edematous tissue and orbicularis oculi muscle is debulked if the edema has not resolved by 6 to 12 months postoperatively.
 Fig. 7.3 (a) A 71-year-old male with amelanotic malignant melanoma of the right temple and lateral canthus marked for wide local excision. (b) Postexcision defect showing abutment to the lateral commissure. (c) Decision was made to close via an adjacent tissue transfer as opposed to a skin graft. A bilobed flap was selected. (d) Postoperative month 6 following reconstruction; there is satisfactory cosmesis and lower lid anatomy; there is evidence of scar widening owing to wound tension at time of reconstruction as the forehead and temple region is not an area of great skin distensibility or mobility. (e) Head-on view post-reconstruction.
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