These patients often complain of tear overflow laterally. When the lid margin is pulled forwards and medially, the lateral canthal corner seems to follow the pull and can be dragged to the extent that the laxity of the lower limb of the lateral canthal tendon will allow. In an intact lateral canthal tendon, there is an immediate resistant tug that appears to refuse to let go of the orbital wall. Lateral canthal laxity is often associated with tarsal sag and poor snap-back response: these can be corrected with a lateral tarsal strip.
This procedure as described by Anderson is itself a modification of Tenzel's lateral canthal sling. The lateral canthal corner is opened with a horizontal incision, and the inferior limb of the lateral canthal tendon is exposed and divided. The medial end of the wound is lifted upwards and laterally to overlap the surgical site and determine how much horizontal shortening is required: this is where the new medial wound edge and strip will be. The strip is fashioned by clearing it of skin and orbicularis anteriorly, lash margin superiorly, and conjunctiva posteriorly. Conjunctiva is usually quite adherent to the tarsus and may need to be scraped off gently with something like a D15 blade. The inevitable venous ooze from this posterior surface is best controlled by pinching the tarsal strip in a damp gauze between finger and thumb for two minutes rather than jeopardise the integrity of the strip with aggressive cautery.
The newly fashioned strip is attached with a non-absorbable suture to the periosteum just inside the lateral orbital rim at the mid pupillary level (Figure 3.3), which places it just under the upper limb of the lateral canthal tendon. The mobilised anterior lamella is lifted up and out, as for a blepharoplasty, and
the estimated excess resected. Two or three long-acting, absorbable sutures secure the cut orbicularis: the long non-absorbable suture is thereby buried and the skin edges nearly apposed. Skin closure is standard.
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