Surgical Solutions for the Reconstruction of the Lower Eyelid: Canthotomy and Lateral Cantholisis for Full-thickness Reconstruction of the Lower Eyelid

Patients and Methods

Patients. From January 1997 to March 2012, we treated 28 patients affected by lower eyelid neoplasms. We excluded from this study six cases where complete eyelid restoration was obtained with a venous graft, as described in another article (4). Therefore we selected 22 cases (Table I), whose age ranged from 67 to 92 years (average 77.5 years), 13 women and 9 men. They all were affected by basocellular skin neoplasms of the lower eyelid.

Methods. We always removed the tumor with a radical intent, but also with a functional aim to the reconstructive project; the lines of incision and suture were conducted along the Langer's lines to reduce tension and to improve the aesthetic result (5). Another point to be considered is that the shape, contour, height and mobility of the eyelid tissue, that define the palpebral fissure, must provide adequate eye protection (1): the widest horizontal interpalpebral distance usually ranges from 28 to 30 mm, and the maximum vertical interpalpebral distance ranges from 9 to 12 mm.

If the tumor, even if small, infiltrates and extends to the free margin, we usually perform a full-thickness excision. In these cases, when the loss of substance is centrally located and it is equal or inferior to one quarter of the eyelid width, we affix thin silk stitches in the tarsal margin to attempt, when possible, a tension-free closure for direct approximation. When the loss of substance is greater (more than 10 mm), in order to obtain tension-free sutures, we medially mobilize the eyelid by the means of an external canthotomy.

Surgical technique. The procedure is performed through an incision in the lateral palpebral fissure with a horizontal cut extending from the lateral canthus to the orbital margin, wide enough to expose the upper and the lower limbs of the lateral canthal tendon (6). With gentle medial traction of the lid, the inferior limb can be recognized as a band located posteriorly to the orbicularis muscle. The skin and the orbicularis muscle can be isolated from the lower limb by spreading scissors; the conjunctiva is also separated from the limb and the branch is finally divided, obtaining cantholisis of the inferolateral tendon of the canthus, thus releasing the lateral part of the eyelid in order to directly close the defect (Figure 1). This procedure allows full-thickness defect covering since the lateral fornical conjunctiva rotates together with the lower eyelid when it moves medially to close.

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Figure 1.

A: The surgical operation layout. B: Performance of the canthotomy.

When lateral canthotomy with cantholisis does not allow the closure, it may be necessary to mobilize larger flaps, such as the so-called Mc Gregor temporal flap (6, 7). This is created by a curved incision which extends beyond the canthal region to the edge of the tail of the eyebrow leading to the auricle. The flap can be anchored in the deep layers and then sutured to the margins of the loss of substance; it is associated with Z-shaped plastic at the lateral edge of the flap to reduce the tension and is also frequently used for upper eyelid reconstruction; a clinical case is shown in Figure 2.

The procedure is somewhat an extension into the temporal area using an older reconstructive technique, that is the semicircular flap, described in 1975 by Tenzel (6, 8, 9); this is a semicircular advancement flap on the lateral canthal region combined with an inferolateral canthotomy to reconstruct defects of the central lower eyelid, involving up to 50% of the length of the lid. The flap is designed in such a way that the incision begins at the lateral canthus and the curves proceed superiorly and temporally in a semicircular shape. The actual incision is not exactly semi-circular, but usually extends more horizontally than vertically. The incision extends to the lateral canthal ligament to create a flap of skin and muscle that can be advanced medially to directly close the defect. The lateral canthus is reconstructed using a direct suture; a clinical case is shown in Figure 3.

We decided to perform reconstruction based on a venous and cutaneous graft in six patients presenting a full-thickness wider defect of the lower eyelid following a tumoral removal, as described elsewhere (4).