The Role of Midface Lift and Lateral Canthal Repositioning in the Managementof Euryblepharon FREE

Euryblepharon is a congenital eyelid anomaly characterized by horizontalenlargement of the palpebral fissure. The eyelid is shortened vertically comparedwith the horizontal dimension, with associated lateral canthal malpositioningand lateral ectropion.^{1 - 2} Itmay be an isolated finding or associated with ocular anomalies such as lateraldisplacement of the proximal lacrimal drainage system, a double row of meibomiangland orifices,² telecanthus, and strabismus.³ In severe cases, it may result in lagophthalmosand exposure keratopathy² and may requiresurgical treatment. We report the results of 2 patients with hereditary disordersand euryblepharon treated successfully with midface lift and lateral canthalrepositioning surgery. The surgical technique is described.

Case 1. A 17-year-old girl with Noonan syndrome(Online Mendelian Inheritance in Man 163950) and bilateral lower eyelid euryblepharonsince birth was seen with eye irritation and nocturnal lagophthalmos. Theparents were also concerned about the aesthetic appearance of their child.An examination revealed upper eyelid ptosis, bilateral inferolateral displacementof the lateral canthi, lateral ectropion (Figure 1), and lagophthalmos with mild punctuate keratitis.

She was treated with bilateral midface lift via a swinging eyelid transconjunctivalapproach and lateral canthal repositioning. Postoperatively, the lateral canthiwere positioned symmetrically at a higher level, with good eyelid closure.The results have remained stable at the fourth postoperative month (Figure 2).

Case 2. A 5-year-old boy with Jacobsen syndrome(Online Mendelian Inheritance in Man 147791) and bilateral congenital ptosisand lower eyelid euryblepharon was seen. He had a history of esotropia treatedwith surgery. The ptosis was visually significant, with poor levator functionof 5 mm bilaterally. He had lateral ectropion and canthal malpositioning Figure 3), but the corneas were compensated.

He first underwent bilateral midface lift and lateral canthal repositioningsurgery via the same technique as used in case 1 to reconstruct the lowereyelid to minimize exposure. He was then treated 3 months later with bilateralfrontalis suspension (using silicone slings). He achieved elevation of theupper eyelids and correction of his lower eyelid anomaly without lagophthalmos.The lower eyelid and lateral canthal positions were maintained during thefirst postoperative year (Figure 4).

We use a preperiosteal midface lift surgery via a swinging eyelid transconjunctivalroute in both cases. A 3-mm lateral canthal incision is made with a No. 15blade. The superior and inferior limbs of the lateral canthal tendons arecut with curved Steven scissors to mobilize the entire lateral canthus. Thelateral lower eyelid retractors are lysed from the inferior tarsal border,and a myocutaneous flap is then raised over the malar eminence by dissectinginferiorly along a preperiosteal plane to recruit cheek tissues. Dissectionover the medial aspect is performed cautiously to avoid the infraorbital neurovascularbundle. The flap is anchored to the arcus marginalis of the inferior orbitwith 4 interrupted 4-0 polydioxanone sutures. The excess horizontal eyelidtissue is excised over the lateral aspect conservatively to shorten the upperand lower eyelids. Lateral tarsal strips of the eyelids are then fashioned(by dissecting the anterior lamella and eyelid margin off the lateral tarsalend) and sutured to the periosteum of the lateral orbit at a higher and moreposterior position. The lateral canthus is reformed, and the lateral canthalincision is closed with a 6-0 plain gut suture.

The lack of anterior lamella vertically in the lower eyelid is reportedto be responsible for the ectropion and lagophthalmos.² Wehave observed intraoperatively in our patients that the lateral canthal tendonsare elongated and abnormally attached at a lower and more anterior positionon the lateral orbit. The former probably contributes partly to the widenedhorizontal eyelid width, while the latter may account for the canthal malpositioningand lateral ectropion.

The vertical shortness of skin in patients with euryblepharon has promptedtreatment with full-thickness skin grafting,¹ whichmay be effective but aesthetically unappealing to patients. Lateral canthalresuspension surgery alone will not be adequate to address the downward tractionforce from skin deficiency and does not correct the canthal malpositioningfully. Midface elevation recruits skin from the cheek to augment the deficientanterior lamella of the lower eyelid.

The lateral canthal repositioning surgery corrects the canthal malpositioning,while the midface lift corrects the vertical eyelid shortening and supportsthe lateral canthus. The ideal plane for midface lift is controversial, althoughthere seems to be a trend toward subperiosteal dissection.^{4 - 5} Webelieve that these young patients have robust osteocutaneous ligamentous attachments,normal midface musculature, and a superficial musculoaponeurotic system withno midface descent or deflation. Hence, limited dissection along a preperiostealplane over the malar eminence to recruit some cheek tissues may suffice toavoid temporal dissection, with the potential risk for facial nerve injury(frontal branch).

In the management of euryblepharon, our surgical technique is an effectivetreatment alternative to full-thickness skin grafting, with the advantageof having small incisions and superior aesthetic results. However, the durabilityof the surgical results will require further evaluation with long-term follow-up.

The authors have no relevant financial interest in this article.

Correspondence: Dr McCann, Division of Orbital and Ophthalmic PlasticSurgery, Jules Stein Eye Institute, Room 2-267, The David Geffen School ofMedicine at UCLA, 100 Stein Plaza, Los Angeles, CA 90095-7006 (McCann@jsei.ucla.edu).