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Tarsal strip procedure and plication sutures combined with lower blepharoplasty
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TARSAL STRIP PROCEDURE AND PLICATION SUTURES COMBINED WITH LOWER BLEPHAROPLASTY ALLEN M. PUTTERMAN, MD, TIMOTHY J. WOOLFORD, FRCS
Acquired ectropion may result from both horizontal lower eyelid laxity and attenuation of the lateral canthal tendon. The tarsal strip procedure ensures a normal horizontal length of the lower eyelid and also corrects the attenuated lateral canthal tendon. Lateral plication sutures, which unite the temporal lower lid orblcularis muscle to periosteum of the lateral orbital rim, can also be used to suspend lower eyelid skin. This article describes the technique of combining the tarsal strip and plication suture procedure with a lower eyelid blepharoplasty.
Many cases of acquired ectropion result from both horizontal laxity of the lower eyelid and attenuation of the lateral canthal tendon. The tarsal strip procedure ensures a normal horizontal length of the lower eyelid and also corrects the attenuated lateral canthal tendon. This procedure was initially described by Tenzel 1 as a method of treating acquired ectropion and can also be used to treat lower lid retraction following cosmetic blepharoplasty. 2 Lateral plication sutures which unite the temporal lower lid orbicularis muscle to periosteum of the lateral orbital rim will also aid in supporting the lower eyelid skin. 3 These sutures can be combined with the tarsal strip procedure or used alone. This article describes the technique of combining the tarsal strip and plication suture procedure with a lower eyelid blepharoplasty. The tarsal strip and plication suture stage of the procedure are described in detail.
OPERATIVE TECHNIQUE ANESTHESIA Topical tetracaine drops are instilled over the eye and a protective tinted scleral lens is applied. Several milliliters of 2% lidocaine with 1:100,000 epinephrine are injected subcutaneously over the temporal upper and lower eyelids and along the lateral orbital wall. The volume and location of local anesthetic injection will depend on the intended approach to blepharoplasty.
BLEPHAROPLASTY Initially, a skin or skin-muscle approach to blepharoplasty is performed. A line is drawn, beginning 2 to 3 mm temporal to the lateral canthus and extending laterFrom the Department of Ophthalmology, The Eye and Ear Inftrmary, Unwersity of Ilhnois at Chicago. Address reprint requests to Allen M Putterman, MD, Professor of Ophthalmology and Director of Oculoplastic Surgery, Department of Ophthalmology, The Eye and Ear Infirmary, Untversity of Illinois at Chtcago, 1855 W Taylor St, Chtcago, IL 60612. Copyright © 1995 by W.B Saunders Company 1043-1810/95/0604-0007505 00/0
ally approximately 1 cm in one of the horizontal periorbital rhytids. With a No. 15 blade, the skin is incised 2 mm below the lashes, beginning 1 to 2 m m temporal to the punctum and extending across the horizontal length of the eyelid to 2 mm lateral to the lateral canthus. The incision is then extended laterally 1 cm in a horizontal rhytid, as previously marked (Fig 1). Blepharoplasty is then continued up to the stage of creating the flaps and excising orbital fat. If a transconjunctival blepharoplasty is performed, a lateral canthotomy and lower cantholysis are performed and the procedure continued to the steps of removing fat and closing the conjunctiva.
LATERAL CANTHOTOMY Westcott scissors are used to perform a lateral canthotomy by cutting from lateral canthus to lateral orbital wall (Fig 2). The conjunctiva is dissected from the posterior surface of the lower limb of the lateral canthal tendon, and orbicularis muscle is undermined from the anterior surface of this tendon limb. Forceps are used to pull the lower eyelid nasally, and the taut lower lateral canthal tendon is identified. The tendon is divided where it attaches to the lateral orbital wall (Fig 3). Successful division of this tendon is confirmed by the surgeon feeling a sudden nasal migration of the lower eyelid. The lateral canthal tissues are retracted and hemostasis secured with bipolar electrocautery.
FORMATION OF TARSAL STRIP After removal of the protective scleral contact lens, forceps are used to grasp the temporal aspect of the lower lid and pull it temporally and superiorly. With the eyelid under slight tension, a scratch incision is made on the lower eyelid margin that is n o w adjacent to the temporal cut edge of the upper eyelid margin (Fig 4). The distance from the temporal cut edge of the lower lid to the scratch incision is m e a s u r e d . This d e t e r m i n e s the length of the tarsal strip. The lid is divided into two lamellae by cutting along the gray line with Westcott scissors from the temporal end of
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 6, NO 4 (DEC), 1995: PP 253-256
253
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FIGURE 1. An incision is made in the lower eyelid, 2 mm below the eyelashes, beginning 1 to 2 mm temporal to the punctum and extending 2 mm beyond the lateral canthus. The incision is then extended in the marked lateral canthal line. the eyelid to the scratch incision. Scissors are used to remove skin and orbicularis muscle from the anterior surface of the tarsus of this lid segment (Fig 5). The conjunctiva, Muller's muscle, and capsulopalpebral fascia are cut from the inferior tarsal edge and conjunctival epithelium is scraped off the posterior surface of the tarsus with a No. 15 blade. The epithelium on the superior edge of tarsus is trimmed off with a small strip. This action prevents late formation of epithelial inclusion cysts.
ATTACHMENT OF TARSAL STRIP Each needle of a double-ended 4-0 polypropylene suture is passed internally to externally through the tarsal strip at the junction of the strip and the eyelid. The strip is pulled temporally towards the lateral orbital rim, and then drawn superiorly and internally until it appears to be in acceptable position with the temporal lower lid in contact with the eye. The tarsal strip should be placed more anteriorly in cases in which the eye is proptopic, as in thyroid disease. It is also important that the lower lid does not retract from the inferior corneal limbus and pull behind and under the eye. Excessive tension on the lid can result in lower lid retraction. Once the desired lateral position is determined, each arm of the suture is passed internally to externally through the orbital periosteum or through the upper limb of the lateral canthal tendon (Fig 6). The suture is tied with one throw over a 4-0 silk knot
....~~.:~,.~
".....'_~~.~.'
releasing suture. If possible, the patient sits up to check the position of the lateral canthus and lower eyelid. The top of a metal ruler is aligned with each medial canthus and the level at which the ruler bisects each lateral canthus is noted. Also, the position of the lower lid adjacent to the eyes is judged. If necessary, the knot is released and the suture repositioned. This procedure is repeated until the desired position of the lateral canthus and lower eyelid is achieved, at which time the suture is tied. If both eyes are operated on simultaneously, the procedure is continued bilaterally through to the placement of the tarsal strips, at which time the positions of the lateral canthus on either side should be compared. A 4-0 polyglactin (Vicryl, Ethicon, Somerville, NJ) suture is used to further secure the tarsal strip to lateral orbital periosteum and bury the polypropylene knot. The tarsal strip on the temporal side of this suture is then excised (Fig 7). A 6-0 silk suture is placed through the
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FIGURE 2. Lateral canthotomy is performed by cutting from the lateral canthus to the lateral orbital wall.
254
FIGURE 3. The inferior limb of the lateral canthal tendon is severed from the lateral orbital wall.
FIGURE 4. A scratch incision is made on the lower eyelid margin at the nasal end of the tarsal strip. TARSAL STRIP PROCEDURE
FIGURE 5. The lid is divided into two lamellae by cutting along the gray line from the temporal end of the eyelid to the scratch incision. Skin and orbicularis muscle are excised from the anterior surface of the tarsus of this lid segment. corner of each temporal upper and lower eyelid to form the lateral canthal angle. The suture ends are left long and eventually tied over the 6-0 silk sutures in the lateral canthal skin so that the knot can be easily found and the ends do not drag over the eye.
SKIN-MUSCLE EXCISION The patient is asked to gaze upwards and both lower eyelid skin and the orbicularis muscle are draped over the lid margin and lateral canthus. Any excessive tissue is excised, using Westcott scissors (Fig 8). The orbicularis muscle temporal to the lateral canthus is closed with interrupted buried 5-0 polyglactin sutures. Two additional 6-0 polyglactin sutures pass through the skin edges and inferior tarsal border at the temporal end of the eyelid. Finally the skin edges are closed with a continuous 6-0 silk suture.
FIGURE 7. A silk suture is passed through the corner of each temporal upper and lower eyelid and the excess tarsal strip is excised.
PLICATION SUTURES Plication sutures may be combined with a skin-muscle flap lower eyelid blepharoplasty approach. They are used to tighten and suspend the lower eyelid skin and orbicularis muscle. A 6-0 silk suture connects the skin 2 mm temporal to the lateral canthus. Two 5-0 polyglactin sutures are placed through the orbicularis muscle of the lateral skin muscle flap and then through superior orbicularis muscle and periosteum of the lateral orbital rim. The sutures are tied with the knots deep, causing the lower eyelid skin to become taut (Fig 9).
POSTOPERATIVE CARE Topical gentamicin ointment is applied over the sutures, and the patient places cold compresses over the eyelids for 24 hours postoperatively. Nursing staff should check for bleeding associated with proptosis, pain, or loss of vision every 15 minutes for 3 to 4 hours postoperatively. During this time, patients are usually kept at the surgical facility. The patient should then monitor the ability to count fingers every hour, and should be aware of the significance of proptosis and pain. In the event of these complications the patient must immediately return to the hospital. Sutures should be released to prevent
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FIGURE 6. Once the desired lateral position of the tarsal strip is determined, each arm of the suture is passed through the periosteum of the lateral orbital rim or through the upper limb of the lateral canthal tendon. PUTTERMAN AND WOOLFORD
FIGURE 8. The skin muscle flap is draped over the incision site and excess skin-muscle is excised. 255
11
'~:=
/ FIGURE 9. Plication sutures umte temporal lower eyelid orbicularis muscle to superior orbicularis and periosteum of the lateral orbital rim. permanent loss of vision caused by retrobulbar hemorrhage. 4
COMPLICATIONS A granulomatous cyst around the polypropylene suture is a rare complication after the tarsal strip procedure. Treatment involves severing the lateral canthal skin and
256
removing the cyst and polypropylene suture. Nasal migration of the lateral canthal angle is another occasional complication. This is rectified by performing a lateral canthotomy and suturing the temporal edge of upper and lower eyelid conjunctiva to skin. This increases the horizontal length of the lid and makes it equal to the opposite side. A rare complication is diplopia, which might be related to scar tissue formation. Where plication sutures are used, it is important that the suture does not pass through the orbicularis muscle too close to the skin, causing puckering. If this is observed at the time of surgery, the suture should be replaced. If the skin pucker forms postoperatively, it is relieved by skin massage and the dissolving of sutures.
REFERENCES 1. TenzelRR. Treatment of lagophthalmosof the lower eyehd Arch Ophthalmol 81.366-368, 1969 2. Hamako CH, Bayhs HI: Lower eyelid retraction after blepharoplasty. Am J Ophthalmol89.517-521, 1980 3. SmallRG' Extendedlower eyelidblepharoplasty. Arch Ophthalmol 99.1402-1405, 1981 4. Putterman AM Temporary bhndness after cosmetic blepharoplasty Am J Ophthalmol80.1081-1083, 1985
TARSAL STRIP PROCEDURE
TARSAL STRIP PROCEDURE AND PLICATION SUTURES COMBINED WITH LOWER BLEPHAROPLASTY ALLEN M. PUTTERMAN, MD, TIMOTHY J. WOOLFORD, FRCS
Acquired ectropion may result from both horizontal lower eyelid laxity and attenuation of the lateral canthal tendon. The tarsal strip procedure ensures a normal horizontal length of the lower eyelid and also corrects the attenuated lateral canthal tendon. Lateral plication sutures, which unite the temporal lower lid orblcularis muscle to periosteum of the lateral orbital rim, can also be used to suspend lower eyelid skin. This article describes the technique of combining the tarsal strip and plication suture procedure with a lower eyelid blepharoplasty.
Many cases of acquired ectropion result from both horizontal laxity of the lower eyelid and attenuation of the lateral canthal tendon. The tarsal strip procedure ensures a normal horizontal length of the lower eyelid and also corrects the attenuated lateral canthal tendon. This procedure was initially described by Tenzel 1 as a method of treating acquired ectropion and can also be used to treat lower lid retraction following cosmetic blepharoplasty. 2 Lateral plication sutures which unite the temporal lower lid orbicularis muscle to periosteum of the lateral orbital rim will also aid in supporting the lower eyelid skin. 3 These sutures can be combined with the tarsal strip procedure or used alone. This article describes the technique of combining the tarsal strip and plication suture procedure with a lower eyelid blepharoplasty. The tarsal strip and plication suture stage of the procedure are described in detail.
OPERATIVE TECHNIQUE ANESTHESIA Topical tetracaine drops are instilled over the eye and a protective tinted scleral lens is applied. Several milliliters of 2% lidocaine with 1:100,000 epinephrine are injected subcutaneously over the temporal upper and lower eyelids and along the lateral orbital wall. The volume and location of local anesthetic injection will depend on the intended approach to blepharoplasty.
BLEPHAROPLASTY Initially, a skin or skin-muscle approach to blepharoplasty is performed. A line is drawn, beginning 2 to 3 mm temporal to the lateral canthus and extending laterFrom the Department of Ophthalmology, The Eye and Ear Inftrmary, Unwersity of Ilhnois at Chicago. Address reprint requests to Allen M Putterman, MD, Professor of Ophthalmology and Director of Oculoplastic Surgery, Department of Ophthalmology, The Eye and Ear Infirmary, Untversity of Illinois at Chtcago, 1855 W Taylor St, Chtcago, IL 60612. Copyright © 1995 by W.B Saunders Company 1043-1810/95/0604-0007505 00/0
ally approximately 1 cm in one of the horizontal periorbital rhytids. With a No. 15 blade, the skin is incised 2 mm below the lashes, beginning 1 to 2 m m temporal to the punctum and extending across the horizontal length of the eyelid to 2 mm lateral to the lateral canthus. The incision is then extended laterally 1 cm in a horizontal rhytid, as previously marked (Fig 1). Blepharoplasty is then continued up to the stage of creating the flaps and excising orbital fat. If a transconjunctival blepharoplasty is performed, a lateral canthotomy and lower cantholysis are performed and the procedure continued to the steps of removing fat and closing the conjunctiva.
LATERAL CANTHOTOMY Westcott scissors are used to perform a lateral canthotomy by cutting from lateral canthus to lateral orbital wall (Fig 2). The conjunctiva is dissected from the posterior surface of the lower limb of the lateral canthal tendon, and orbicularis muscle is undermined from the anterior surface of this tendon limb. Forceps are used to pull the lower eyelid nasally, and the taut lower lateral canthal tendon is identified. The tendon is divided where it attaches to the lateral orbital wall (Fig 3). Successful division of this tendon is confirmed by the surgeon feeling a sudden nasal migration of the lower eyelid. The lateral canthal tissues are retracted and hemostasis secured with bipolar electrocautery.
FORMATION OF TARSAL STRIP After removal of the protective scleral contact lens, forceps are used to grasp the temporal aspect of the lower lid and pull it temporally and superiorly. With the eyelid under slight tension, a scratch incision is made on the lower eyelid margin that is n o w adjacent to the temporal cut edge of the upper eyelid margin (Fig 4). The distance from the temporal cut edge of the lower lid to the scratch incision is m e a s u r e d . This d e t e r m i n e s the length of the tarsal strip. The lid is divided into two lamellae by cutting along the gray line with Westcott scissors from the temporal end of
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 6, NO 4 (DEC), 1995: PP 253-256
253
;.~
N,
/ ~
0
FIGURE 1. An incision is made in the lower eyelid, 2 mm below the eyelashes, beginning 1 to 2 mm temporal to the punctum and extending 2 mm beyond the lateral canthus. The incision is then extended in the marked lateral canthal line. the eyelid to the scratch incision. Scissors are used to remove skin and orbicularis muscle from the anterior surface of the tarsus of this lid segment (Fig 5). The conjunctiva, Muller's muscle, and capsulopalpebral fascia are cut from the inferior tarsal edge and conjunctival epithelium is scraped off the posterior surface of the tarsus with a No. 15 blade. The epithelium on the superior edge of tarsus is trimmed off with a small strip. This action prevents late formation of epithelial inclusion cysts.
ATTACHMENT OF TARSAL STRIP Each needle of a double-ended 4-0 polypropylene suture is passed internally to externally through the tarsal strip at the junction of the strip and the eyelid. The strip is pulled temporally towards the lateral orbital rim, and then drawn superiorly and internally until it appears to be in acceptable position with the temporal lower lid in contact with the eye. The tarsal strip should be placed more anteriorly in cases in which the eye is proptopic, as in thyroid disease. It is also important that the lower lid does not retract from the inferior corneal limbus and pull behind and under the eye. Excessive tension on the lid can result in lower lid retraction. Once the desired lateral position is determined, each arm of the suture is passed internally to externally through the orbital periosteum or through the upper limb of the lateral canthal tendon (Fig 6). The suture is tied with one throw over a 4-0 silk knot
....~~.:~,.~
".....'_~~.~.'
releasing suture. If possible, the patient sits up to check the position of the lateral canthus and lower eyelid. The top of a metal ruler is aligned with each medial canthus and the level at which the ruler bisects each lateral canthus is noted. Also, the position of the lower lid adjacent to the eyes is judged. If necessary, the knot is released and the suture repositioned. This procedure is repeated until the desired position of the lateral canthus and lower eyelid is achieved, at which time the suture is tied. If both eyes are operated on simultaneously, the procedure is continued bilaterally through to the placement of the tarsal strips, at which time the positions of the lateral canthus on either side should be compared. A 4-0 polyglactin (Vicryl, Ethicon, Somerville, NJ) suture is used to further secure the tarsal strip to lateral orbital periosteum and bury the polypropylene knot. The tarsal strip on the temporal side of this suture is then excised (Fig 7). A 6-0 silk suture is placed through the
q~
FIGURE 2. Lateral canthotomy is performed by cutting from the lateral canthus to the lateral orbital wall.
254
FIGURE 3. The inferior limb of the lateral canthal tendon is severed from the lateral orbital wall.
FIGURE 4. A scratch incision is made on the lower eyelid margin at the nasal end of the tarsal strip. TARSAL STRIP PROCEDURE
FIGURE 5. The lid is divided into two lamellae by cutting along the gray line from the temporal end of the eyelid to the scratch incision. Skin and orbicularis muscle are excised from the anterior surface of the tarsus of this lid segment. corner of each temporal upper and lower eyelid to form the lateral canthal angle. The suture ends are left long and eventually tied over the 6-0 silk sutures in the lateral canthal skin so that the knot can be easily found and the ends do not drag over the eye.
SKIN-MUSCLE EXCISION The patient is asked to gaze upwards and both lower eyelid skin and the orbicularis muscle are draped over the lid margin and lateral canthus. Any excessive tissue is excised, using Westcott scissors (Fig 8). The orbicularis muscle temporal to the lateral canthus is closed with interrupted buried 5-0 polyglactin sutures. Two additional 6-0 polyglactin sutures pass through the skin edges and inferior tarsal border at the temporal end of the eyelid. Finally the skin edges are closed with a continuous 6-0 silk suture.
FIGURE 7. A silk suture is passed through the corner of each temporal upper and lower eyelid and the excess tarsal strip is excised.
PLICATION SUTURES Plication sutures may be combined with a skin-muscle flap lower eyelid blepharoplasty approach. They are used to tighten and suspend the lower eyelid skin and orbicularis muscle. A 6-0 silk suture connects the skin 2 mm temporal to the lateral canthus. Two 5-0 polyglactin sutures are placed through the orbicularis muscle of the lateral skin muscle flap and then through superior orbicularis muscle and periosteum of the lateral orbital rim. The sutures are tied with the knots deep, causing the lower eyelid skin to become taut (Fig 9).
POSTOPERATIVE CARE Topical gentamicin ointment is applied over the sutures, and the patient places cold compresses over the eyelids for 24 hours postoperatively. Nursing staff should check for bleeding associated with proptosis, pain, or loss of vision every 15 minutes for 3 to 4 hours postoperatively. During this time, patients are usually kept at the surgical facility. The patient should then monitor the ability to count fingers every hour, and should be aware of the significance of proptosis and pain. In the event of these complications the patient must immediately return to the hospital. Sutures should be released to prevent
• ~q "Lm'-
FIGURE 6. Once the desired lateral position of the tarsal strip is determined, each arm of the suture is passed through the periosteum of the lateral orbital rim or through the upper limb of the lateral canthal tendon. PUTTERMAN AND WOOLFORD
FIGURE 8. The skin muscle flap is draped over the incision site and excess skin-muscle is excised. 255
11
'~:=
/ FIGURE 9. Plication sutures umte temporal lower eyelid orbicularis muscle to superior orbicularis and periosteum of the lateral orbital rim. permanent loss of vision caused by retrobulbar hemorrhage. 4
COMPLICATIONS A granulomatous cyst around the polypropylene suture is a rare complication after the tarsal strip procedure. Treatment involves severing the lateral canthal skin and
256
removing the cyst and polypropylene suture. Nasal migration of the lateral canthal angle is another occasional complication. This is rectified by performing a lateral canthotomy and suturing the temporal edge of upper and lower eyelid conjunctiva to skin. This increases the horizontal length of the lid and makes it equal to the opposite side. A rare complication is diplopia, which might be related to scar tissue formation. Where plication sutures are used, it is important that the suture does not pass through the orbicularis muscle too close to the skin, causing puckering. If this is observed at the time of surgery, the suture should be replaced. If the skin pucker forms postoperatively, it is relieved by skin massage and the dissolving of sutures.
REFERENCES 1. TenzelRR. Treatment of lagophthalmosof the lower eyehd Arch Ophthalmol 81.366-368, 1969 2. Hamako CH, Bayhs HI: Lower eyelid retraction after blepharoplasty. Am J Ophthalmol89.517-521, 1980 3. SmallRG' Extendedlower eyelidblepharoplasty. Arch Ophthalmol 99.1402-1405, 1981 4. Putterman AM Temporary bhndness after cosmetic blepharoplasty Am J Ophthalmol80.1081-1083, 1985
TARSAL STRIP PROCEDURE