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(Above) Rounding and nasal migration of the lateral canthus. (center) A Westcott scissors severs the lateral canthus. (Below) Silk sutures (6-0) connect conjunctiva to skin over the temporal upper and lower eyelids.

Lateral canthal nasal migration and rounding occasionally occur after lateral canthoplasties and cosmetic blepharoplasties (Fig. 1, above). It has been my experience that many plastic surgeons treat this by reattaching the inferior temporal tarsus to the lateral orbital wall with a tarsal strip or pexy procedure, with or without lateral orbital wall drill holes. Although lateral canthal tendon tightening and tarsal strip procedures are indicated in some cases, a point is commonly reached where the lower eyelid is so horizontally tight that these procedures are no longer effective. Because the lower lid is already horizontally tight preoperatively, this technique frequently displaces the lower punctum temporally with secondary epiphora and, with time, leads to recurrent nasal migration of the lateral canthus. In these cases, a lateral canthotomy with reconstruction of the temporal upper and lower eyelids is a relatively simple method of achieving a longer horizontal palpebral fissure and a more acute angle to the lateral canthus. It can also improve temporal peripheral vision that might be compromised on abduction of the eye because of the lateral canthus covering the eye in this position of gaze.

The procedure is usually performed in the office under local anesthesia. Following preparation and draping of the eyelids, topical tetracaine is applied over the eye and a scleral shield is placed over the eye to protect it. Then, 2% lidocaine with epinephrine is injected subcutaneously and subconjunctivally over the temporal upper and lower eyelids and lateral canthus. A Westcott scissors severs the lateral canthus horizontally by the distance (in millimeters) that is needed to make the horizontal palpebral fissure equal to the opposite normal side (Fig. 1, center). If both sides are in need of treatment, the distance (in millimeters) is based on the normal horizontal palpebral fissure of 30 to 32 mm. Usually, this amounts to an opening of 2 to 4 mm. Several 6-0 silk sutures are placed in the temporal upper and lower lids, connecting skin to conjunctiva (Fig. 1, below). The internal suture ends are cut on the knot, and the ends pointing away from the eye are cut 2 to 3 mm from the knot. The scleral lens is removed and a topical eye ointment is applied to the lateral canthus. Sutures are usually removed 7 days postoperatively.

(Above) Patient with lateral canthal nasal deviation and rounding after having had a ptosis procedure in the upper lid and a tarsal strip procedure of the lower lid to treat horizontal lower lid laxity. (Below) Same patient after horizontal lateral canthal lengthening.

Although this might not be a new procedure to many surgeons, I find it is one that is commonly overlooked in the treatment of lateral canthal nasal deviation and rounding in patients who have a tight lower lid after previous eyelid surgery. Also, I have observed that patients find this procedure very acceptable, because of its simplicity and the possibility that it can be reversed by reconnecting the temporal eyelids, if necessary. I have performed this procedure on over 75 eyelids with good success (Fig. 2).


The author has no financial interest to declare in relation to the content of this article.


This work was supported by an unrestricted grant from Research to Prevent Blindness, New York, N.Y. (EY001792).

Allen M. Putterman, M.D., 111 North Wabash, Suite 1722, Chicago, Ill. 60602


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