Lateral Tarsoconjunctival Flap for Lid Tightening

S. A. LAUER

EDITORIAL COMMENT

Laxity of the lower lid occurs quite commonly in elderly patients. If recognized and corrected by this method, such postoperative problems as temporary atrophia may be prevented. The lateral tarsoconjunctival flap to correct horizontal tightness is a relatively effective technique. One of the editors, although preferring to use a tendon sling for facial paralysis of the lower lid, in fact uses the lateral tarsorrhaphy in mild depressions of the lower lid. It is an excellent and simple technique to bring the lid back into its normal position without closing any portion of the lid.

The lateral tarsoconjunctival flap is designed to restore horizontal tension in the lower eyelid. As soft tissues of the face stretch with age, the tarsoligamentous sling becomes weakened and lax, due primarily to stretching of the canthal tendons. Constant pulling and stretching of the eyelid eventually can produce an involutional ectropion, which occurs when horizontal laxity is sufficient for gravity to pull the eyelid away from the eye.

Restoration of tension in the tarsoligamentous sling can be accomplished in a number of ways, some of which threaten the underlying lacrimal drainage apparatus and the stability of the tear film. Tightening the lateral canthal tendon (1) with the lateral tarsoconjunctival flap has become the preferred means of restoring horizontal tension in the lower eyelid.

INDICATIONS

The primary indications for use of the flap are correction of an involutional ectropion or, in some instances, to provide corneal protection in cases of seventh-nerve paralytic ectropion that do not resolve spontaneously. In the latter case, the flap is usually employed in combination with implantation of an upper-lid gold weight to restore upper-lid mobility. Where additional protection of the corneal epithelium is required, such as with tumors at the cerebellopontine angle that produce fifth- and seventh-nerve palsies, the lower lid is not only tightened by a lateral tarsoconjunctival flap, but is concurrently elevated with a sling such as a fascial sling, or by inserting spacer material beneath the tarsus.

The flap can also be utilized to prevent vertical lid retraction after skin excision during a lower-lid blepharoplasty. In addition, it can be used to correct an entropion, or in-turning, of the lower lid; although this condition, resulting from a combination of forces, may require additional surgery, the flap alone may be used to reverse horizontal lid laxity.

Cicatricial ectropion or vertical lid retraction can be produced by scarring and shortening of the skin in the lower eyelid. The lateral tarsoconjunctival flap can then be used, in combination with skin augmentation with a full-thickness skin graft or regional skin flap (2, 3) (Fig. 16.1A-C).

ANATOMY

It is now generally accepted that the lateral canthal tendon is a fibrous connective tissue arising from the lateral ends of the superior and inferior tarsal plates (1, 4). It inserts at the lateral orbital tubercle within the orbit, approximately 1.5 mm posterior to the lateral orbital rim. The tendon averages 10.6 mm in length from the lateral canthal angle to its bony insertion and 6.6 mm in width, with the distance from the midpoint of the tendon to the frontozygomatic suture averaging 9.7 mm. Superiorly, the tendon is contiguous with the lateral horn of the levator palpebrae superioris; posteriorly, it is contiguous with the check ligament of the lateral rectus muscle. Both of these structures also insert at the lateral orbital tubercle. Anteriorly, there is a small pocket of fat (Eisler’s fat pad), which is situated between the orbital septum and the lateral canthal tendon.

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