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Lower Lid Tightening (Lower Lid Tarsal Strip for correction of ectropion)

return to:Facial Paralysis (surgery for facial nerve paralysis weakness)

See: Lower Eyelid Lift (Lateral Tarsal Strip) Case Example

Case examples provided by Dr. Douglas Henstrom, Director of University of Iowa Facial Plastic and Reconstructive Surgery, Department of Otolaryngology
Dr. Henstrom's profile page.
For appointment please call: 319-356-3600

  1. GENERAL CONSIDERATIONS: The lateral tarsal strip procedure has the combined effect of increasing horizontal lid tension and adjusting the level of the lateral canthus. The technique involves a lateral canthotomy and transection of a portion of the lateral canthal tendon (cantholysis). The eyelid is then split into anterior and posterior lamellae, and a tarsal strip is fashioned from the posterior lamellae. The tarsal strip is then sutured to the periosteum inside the lateral orbital wall, thereby adjusting the height and tension of the lateral canthus and the lower lid.
  2. Medical treatment of lower lid laxity with lubricants tends to offer only temporary, symptomatic relief. Surgery to tighten the lower lid remains the mainstay of therapy for this condition.
        1. Indications:
          1. General guidelines group the indications for lower lid tightening into several groupings (in order of significance) including:
            1. Senile or Paralytic Ectropion
            2. Recurrent Ectropion
            3. Congenital Malposition of the lower eyelid
            4. Lower Lid Laxity Following trauma or enucleation 
        2. Relevant Anatomy: Thorough understanding of eyelid anatomy is essential to appreciate the etiology and surgical intervention of lower eyelid abnormalities. The eyelid can be conceptualized to consist of an anterior and posterior lamella.
          1. Anterior Lamella:The anterior lamella consists of the skin and orbicularis muscle. The thin delicate skin of the eyelid lacks dermal-like connective tissue and pilosebaceous apparatus that would reduce eyelid mobility. The orbicularis muscle is categorized as either orbital or palpebral portions based on adjacent anatomic structures. Orbital orbicularis muscle overlies the orbital rim. Palpebral orbicularis muscle is further classified as preseptal or pretarsal based on the proximity of the orbital septum or tarsus, respectively. At the eyelid margin a strip of orbiculars muscle, the muscle of Riolan, is directly associated with the eyelashes.
          2. Posterior Lamella: The posterior lamella consists of the eyelid retractor, tarsus, and the conjunctiva. The tarsus provides the primary support or foundation for the eyelids. Although degeneration of the tarsus may promote eyelid laxity, the principal focus of weakness of the eyelids is at the lateral and medial canthal tendons. The lateral canthal tendon has contributions from the lateral aspects of the tarsus and the preseptal and pretarsal orbicularis muscle; these insert on the inner aspect of the lateral orbital rim at the Whitnall (lateral orbital) tubercle. Posterior deep insertion of the lateral canthal tendon allows the lateral aspect of the eyelids to approximate the globe.
        3.  
  3. PREOPERATIVE PREPARATIONS
    1. Consent: Patients should be made aware of general surgical complications which include : Bleeding, Infection, Hematoma, Wound Dehiscence, Pain, Scarring. In addition, complications primarily related to this procedure include corneal damage (ulceration, breakdown) pain and epiphora.  Most commonly this procedure is done under a local anesthetic only.
  4. NURSING CONSIDERATIONS
    1. Room Setup
      1. See Basic Soft Tissue Room Setup|display/protocols/Basic+Soft+Tissue+Room+Setup&|||||||\
        1. Use ENT Supply Pack|display/protocols/ENT+pack|||||||\ instead of the Basic soft tissue pack|display/protocols/Basic+soft+tissue+pack&#124|||||||\
    2. Instrumentation and Equipment
      1. Standard
        1. Bipolar Forceps Trays|display/protocols/Bipolar+Forceps+Trays|||||||\
      2. Special
        1. 3 cc Syringe with Luer tip, 30 guage needle
    3. Medications (specific to nursing)
      1. 1% lidocaine with 1:100,000 epinephrine with Bicarb (9:1 raio)
    4. Prep and Drape
      1. Standard prep, 10% providone iodine-diluted with saline to ensure no damage to eye
      2. Drape: Draping is performed in similar fashion to a blepharoplasty procedure.
    5. Special Considerations
      1.  
  5. OPERATIVE PROCEDURE 
    1. Using a fine tipped marker, design an incision line along a natural wrinkle line in the lateral canthal area.
    2. The area of the lateral canthus and lower lid is injected with approximately 0.5 cc 1% Lidocaine with 1:100,000 Epinephrine. 
    3. Incision is made through the lateral skin and the canthus (Canthotomy)
    4. Sharp scissors are used to cut through the orbicularis oculi down to the level of the periosteum of the lateral orbital rim (without exposing bone) and through the inferior division of the lateral canthal tendon (cantholysis)
    5. The gray line of both inferior and superior lids are denuded for for approximately 3-5 mm.  This distance reflects the distance of advancement of the lower lid.  This will serve to help reset the lateral canthal angle at closure
    6. The anterior lamellar flap (skin and muscle) is dissected inferiorly and off the lateral aspect of the inferior canthal tendon-thus seperating anterior and posterior lamellae.
    7. Next, the conjunctiva is denuded from the inferior canthal tendon using a scraping motion with a 15 blade
    8. The lower canthal tendon is stretched to the orbital rim, to allow for estimation of the degree of shortening required for proper lid tension. The lateral tarsal strip is shortened accordingly.
    9. The flap of excess skin and muscle is trimmed.
    10.  A 5-0 Vicryl is placed at the edge of the cut gray line in both lids to reestablish the canthal angle.  This suture is not tied down until the lateral canthal tendon has been suspended.
    11. The lower canthal tendon is then suspended to the periosteum over Whitnall's tubercle utilizing a 4-0 double armed Polydek or Mersilene suture
    12. The skin of the lateral canthus is then trimmed as needed and reapproximated with a running 6-0 fast absorbing suture
    13.  Erythromycin Ophthalmic ointment is used on the incision twice daily until the sutures dissolve
  6. Relevant CPT Codes: 67917 (tarsal strip operation) ; 67916 (repair of ectropion)

References

1. Della Roca DA. The Lateral Tarsal Strip: Illustrated Pearls. Facial Plast Surg.2007 Aug 23 (3) 200-2

2.Smith DS, Wax MK. The Lower-eyelid tarsal strip procedure. Ear Nose Throat J. 2005 Nov; 84 (11) 698

3. Carroll RP. Tarsal strip procedure. Ophthalmic Surg.1992 May; 23(5) 367

4. Marzouk MA, Shouman AA, Elzakzouk ES, Elnaggar MTA. Lateral tarsal strip technique for correction of lower eyelid ectropion. Journal of American Science 2011; 7(5)