Operative Technique in Plastic Surgery – Kevin C.Chung

■ External (anterior) approach: levator resection
■ Frontal approach: frontalis suspension
T E C H N I Q U E S
■ Frontalis Suspension
Markings and Eyelid Sutures
■ Place topical tetracaine on the conjunctival surface.
■ Mark the lid crease prior to injecting local anesthetic.
■ Inject 1 to 2 cc 2% lidocaine with 1:100 000 epinephrine subcutaneously
inferior to the brow.
■ Mark desired lid crease with a sterile marking pen. This is typically 8 and 10
mm above the eyelid margin in males and females, respectively.
■ Mark one midpupillary point on the eyelid skin. Mark two points 4 mm
medial and lateral to the marked “central point” superior to the brow (TECH
FIG 1A).
■ Make one stab incision at each of the marked stab sites above the brow with
a no. 15 blade.
■ Make an incision with a no. 15 blade along the previously marked eyelid
crease.
■ Attach a free needle to the sling material. The authors prefer Supramid
(polyfilament, cable-type 3-0 suture). Pass this needle laterally to medially
along the eyelid crease beneath the orbicularis muscle and just anterior to the
tarsus (TECH FIG 1B). If the skin puckers while doing this, the needle is
being passed too superficially.
■ Check the eyelid contour to ensure the tarsus pass does not create squared
off lid (too broad of a pass) or a peaked eyelid (too narrow of a pass).
■ Both medial and lateral ends of the sling material are then passed just deep
to the dermis to the stab incision sites immediately superior to the brow
(TECH FIG 1C).
■ Close the eyelid crease incision with 6-0 fast gut running sutures (TECH
FIG 1D).
Brow Sutures

■ Pass the needle from the lateral brow stab incision to the medial stab incision
deep to the dermis (TECH FIG 2A).
■ Tighten the sling material with care not to break the sling elevating the lid to
the height of the superior limbus or 1 mm below the superior limbus. Assess
eyelid contour.
■ If using synthetic material, pass a cuff around both sling ends (TECH FIG
2B).
■ Secure the sling with two square knots.
■ Close the stab incisions with a deep pass using 5-0 Vicryl suture on a P-2
needle and finally closing the eyelid crease and superficial tissues of the stab
incisions with 5-0 fast gut interrupted sutures (TECH FIG 2C,D).
TECH FIG 1 • Frontalis sling. A. Markings are made,
importantly including one midpupillary point on the
eyelid skin and two points 4 mm medial and lateral to
the marked midpupillary point superior to the brow. B.
A free needle attached to the sling material of choice
is passed laterally to medially beneath the orbicularis
and anterior to the tarsus. C. Both medial and lateral

ends of the sling material are passed just deep to the
dermis to the stab incision sites superior to the brow.
D. The eyelid crease incision is closed in running
fashion.
TECH FIG 2 • Frontalis sling. A. The sling needle is
passed from the lateral brow stab incision to the
medial stab incision deep to the dermis. B.
Demonstration of passing a cuff around both ends of a
silicone sling to be buried subcutaneously. C. Deep 5-
0 Vicryl suture is placed underneath the sling prior to
tying the sling. The Vicryl suture is then passed
through subcutaneous tissue anterior to the enclosed
sling. D. The stab incisions are closed with a deep
pass using 5-0 Vicryl suture on a P-2 needle.
■ Levator Resection

Markings and Dissection
■ Place topical tetracaine on the conjunctival surface.
■ Mark the desired lid crease (8 to 10 mm) with a sterile marking pen aligning
symmetry with the fellow eye.
■ Inject 1 to 2 cc 2% lidocaine with 1:100 000 epinephrine into the
subcutaneous space adjacent and superior to the tarsus. Take care not to
infiltrate the levator muscle with local anesthetic or add too much volume to
the lids, distorting surgical landmarks.
■ Use a no. 15 blade to incise the marked eyelid crease deepening the incision
with scissors to the level of the tarsus (TECH FIG 3A).
■ Using Westcott scissors, make short cuts along the inferior edge of the
incision to dissect to the superior tarsus (TECH FIG 3B,C).
■ Tent up the eyelid septum by holding and gently retracting the tarsus and the
superior septum away from each other. Carefully cut shallowly to dissect
through the septal plane revealing the levator aponeurosis (TECH FIG 3D).
Suturing and Closure
■ Pass 2 double-armed 5-0 Vicryl sutures through the anterior upper tarsus
border via partial-thickness passes (TECH FIG 3E). Take care to avoid
making full-thickness passes, checking the palpebral conjunctiva for suture
by flipping the eyelid after each pass (TECH FIG 3F).

(Trang không có chữ)

TECH FIG 3 • Levator resection. A. An incision is
made along the marked eyelid crease and deepened
with Westcott scissors to the level of the tarsus. B.
Careful sharp dissection is made to dissect to the
superior tarsus. C. The tarsus is seen by glistening
white tissue (arrow). D. The tarsus and superior
septum are retracted to allow a dissection through this
pocket to the levator aponeurosis (arrow). E. Two
double-armed 5-0 Vicryl sutures are passed through
the anterior upper tarsus border via partial-thickness
passes. F. The eyelid is flipped using a blunt needle
driver to ensure full-thickness passes have been
avoided. G. Sutures are passed through the levator
aponeurosis to the junction of Whitnall ligament,
demarcated by a white linear band (white dashes). H.
A temporary knot is tied, and the contour of the eyelid
is checked. I. Excess levator aponeurosis (between
black brackets) can be excised. J. The skin is closed

in running fashion.
■ Per the graded resection anticipated prior to the procedure, each suture is
then passed through the levator aponeurosis, near the junction of Whitnall
ligament (TECH FIG 3G).
■ A temporary knot is tied and the contour of the eyelid is checked (TECH
FIG 3H). If appropriate lid height is achieved, the sutures can be
permanently tied using a surgeon’s knot.
■ Excess levator aponeurosis (TECH FIG 3I) can be excised if needed.
■ Close the skin with 6-0 fast gut in running fashion (TECH FIG 3J).
■ If interested in recreating the eyelid crease, make a single pass of 6-0 gut
suture through the inferior edge of skin, orbicularis, passing partial thickness
through the levator aponeurosis, and exiting via the superior orbicularis and
skin. This effectively attaches it to the levator aponeurosis to recreate the skin
crease.
■ Conjunctivomullerectomy
■ Place topical tetracaine on the conjunctival surface.
■ Place a subcutaneous eyelid block below the brow using 2 cc 2% lidocaine
with 1:100 000 epinephrine. Evert the eyelid and inject 1 cc lidocaine into the
superior tarsal border deep to the conjunctiva (TECH FIG 4A).
■ Pass a 4-0 silk suture deeply through the gray line to serve as traction sutures
(TECH FIG 4B).
■ Evert the eyelid using a Desmarres retractor.
■ Using a caliper, measure the amount of Muller muscle to resect and mark
inside the lateral borders of the tarsus with handheld cautery (TECH FIG
4C).
■ Pass a two 4-0 silk sutures through the conjunctiva and Muller muscle at the
marked sites (TECH FIG 4D).
■ Elevate Muller muscle and the conjunctiva via the silk sutures into a
mullerectomy clamp at the marked sites (TECH FIG 4E).
■ Lock the clamp. Cut and remove the silk traction sutures from the Muller
muscle.
■ Hold the clamp in the nondominant hand between the middle and index
finger leaving the thumb and index finger to load suture.

■ Holding this position, run a 6-0 double-armed Vicryl suture in running
horizontal mattress fashion along the entire end of the locked clamp. Repeat
the running horizontal mattress passes with the second suture arm (TECH
FIG 4F).
■ Tie the two Vicryl suture arms with a surgeon’s knot.
■ With slight upward tension, use a no. 15 blade to incise the tissue held by the
clamp with attention to incising as close to the metal clamp edge as possible
keeping a metal-on-metal feel to ensure the suture is not cut (TECH FIG
4G).
■ Remove the mullerectomy clamp and retraction sutures (TECH FIG 4H).

TECH FIG 4 • Conjunctivomullerectomy. A. Anesthetic
is injected into the superior tarsal border deep to the
conjunctiva. B. A 4-0 silk suture is passed deeply

through the gray line to serve as traction sutures. C.
The predetermined amount of Muller muscle to resect
is measured with calipers inside the lateral borders of
the tarsus and marked with handheld cautery. D. Two
4-0 silk sutures are passed through conjunctiva and
Muller muscle at the marked sites. E. Grasping the
sutures, Muller muscle and the conjunctiva are
elevated into a mullerectomy clamp at the marked
sites. F. Running horizontal mattress sutures passed
below the clamp. G. Incision of Muller muscle and
conjunctiva held in the clamp ensuring sutures are not
cut. H. Final appearance after removal of clamp.
PEARLS AND PITFALLS
Creating an eyelid
crease
■ Gently push superiorly on the upper eyelid lashes. This
will manifest an eyelid crease that may be otherwise
underrepresented.
■ If a natural eyelid crease is not present and is surgically
desired, create a crease with an incision 8–10 mm superior
to the upper eyelid margin for males and 10–12 mm for
females.
Undercorrection
■ Utilize the results from the phenylephrine test to plan for
the degree of expected correction for mullerectomy
procedures.
■ Adjustable sutures may be used for early postoperative
adjustment.
■ Err on the side of undercorrection, unless performing
levator resection, in which case aim for 1 mm
overcorrection.
Irregular eyelid
contour
■ Avoid closing or removing levator aponeurosis with the
mullerectomy by grasping conjunctiva with Muller muscle
from the more posterior structures.
■ Place or adjust sutures where the deformity is greatest after
applying tension under this region.

■ Postoperatively, lid massage may be of benefit in mild to
moderate cases.
Ectropion/entropion
■ Avoid suture tension at the inferior tarsus.
■ Avoid applying too much tension to sutures.
Postoperative
lagophthalmos
■ Consider graded mullerectomy and tarsectomy in patients
with significant preoperative lagophthalmos.
■ If frontal sling is needed in a setting of significant
preoperative lagophthalmos, place a temporal tarsorrhaphy
at the end of the procedure.
■ Place Frost sutures after levator resection procedures.
POSTOPERATIVE CARE
■ Patients undergoing frontalis sling should be given an oral antibiotic for 7
days.
■ Coordinate care with pediatric ophthalmologist to monitor for postoperative
refractive error including induced amblyopia.
■ Aggressive lubrication cannot be overstressed.
■ If used, lower lid traction sutures should be removed at postoperative day 2.
■ Topical antibiotic ointment should be applied 4 times a day for 1 week.
■ If adjustable sutures are employed, the postoperative visit should be within 1
week.
OUTCOMES
■ Overall, the reported successful outcome is 70% to 90% in pediatric ptosis
cases with undercorrection accounting for the majority of poor results or
failures.2,8
■ Frontalis sling procedures using synthetic material historically have had
recurrence rates as high as 29% to 40%; however, autogenous fascia lata grafts
and newer graft materials used in a sling procedure may offer superior
results.5,6,9 Lee et al.2 reported 5% to 10% poor outcomes with fascia lata
grafts or Mersilene mesh.
■ Anterior levator resection procedures result in poor outcomes in approximately
10% to 20%.2,7
■ Although not generally agreed upon, some surgeons find external levator
resection to be associated with less reoperation rate.10
■ An asymmetry of greater than 1 to 2 mm between eyelids may be as common

as 30% postoperatively.8
COMPLICATIONS
■ Lagophthalmos
■ Overcorrection
■ Ectropion
■ Exposure keratopathy
■ Irregular eyelid contour or skin crease
■ Implant infection or extrusion6
■ Development or worsening of astigmatism postoperatively4
■ Suture site granulomas over synthetic material
REFERENCES
1. Griepentrog GJ, Diehl NN, Mohney BG. Incidence and demographics of
childhood ptosis. Ophthalmology. 2011;118(6):1180-1183.
2. Lee V, Konrad H, Bunce C, et al. Aetiology and surgical treatment of
childhood blepharoptosis. Br J Ophthalmol. 2002;86(11):1282-1286.
3. Griepentrog GJ, Mohney BG. Strabismus in childhood eyelid ptosis. Am J
Ophthalmol. 2014;158(1):208.e1-210.e1.
4. Merriam WW, Ellis FD, Helveston EM. Congenital blepharoptosis,
anisometropia, and amblyopia. Am J Ophthalmol. 1980;89(3):401-407.
5. SooHoo JR, Davies BW, Allard FD, Durairaj VD. Congenital ptosis. Surv
Ophthalmol. 2014;59(5):483-492.
6. Wasserman BN, Sprunger DT, Helveston EM. Comparison of materials used
in frontalis suspension. Arch Ophthalmol. 2001;119(5):687-691.
7. Berke RN. Results of resection of the levator muscle through a skin incision in
congenital ptosis. AMA Arch Ophthalmol. 1959;61(2):177-201.
8. Cates CA, Tyers AG. Outcomes of anterior levator resection in congenital
blepharoptosis. Eye (Lond). 2001;15(Pt 6):770-773.
9. Elsamkary MA, Roshdy MM. Clinical trial comparing autogenous fascia lata
sling and Gore-Tex suspension in bilateral congenital ptosis. Clin Ophthalmol.
2016;10:405-409.
10. Skaat A, Fabian D, Fabian ID, et al. Congenital ptosis repair-surgical,
cosmetic, and functional outcome: a report of 162 cases. Can J Ophthalmol.
2013;48(2):93-98.

40
CHAPTEREpiblepharon
Adam R. Sweeney and Christopher B. Chambers
DEFINITION
■ Epiblepharon is a congenital eyelid anomaly in which inward rotation of the
normal lash line toward the globe results in eyelash approximation to the
cornea and/or conjunctiva.
ANATOMY
■ A horizontal eyelid fold composed of skin and orbicularis is evident inferior to
the eyelid margin. This is caused by the absence of the adhesion between the
thin smooth muscle contributing to lower eyelid retraction and the soft tissue
immediately deep to the lower eyelid skin.1,2
■ Often, the fold is more pronounced or isolated to the medial eyelid.
■ The Asian lower eyelid has a higher attachment of the septum on the tarsus or
inferior retractor. Additionally, there often is an absence or paucity of retractor
septa attached to the overlying skin, similar to the Asian upper eyelid.1
■ The tarsus is not rolled in, nor is there rotation of the eyelid muscle, separating
this condition from entropion.3
PATHOGENESIS
■ Epiblepharon is one of the most common eyelid abnormalities among Asian
children, with majority demonstrating spontaneous resolution throughout
childhood.4
■ Up to 95% of Asian children with epiblepharon will have it bilaterally.2,4,5
■ Epiblepharon much more commonly involves the lower eyelid than it does
both upper and lower eyelids with a small minority of cases involving solely
the upper eyelid.2

■ There is no gender predilection.2
■ Epiblepharon is less commonly seen in adults.
■ Asian children with higher BMI are more likely to have epiblepharon.6
■ Acquired epiblepharon is rare and often secondary to thyroid eye disease.7
NATURAL HISTORY
■ The majority of patients will have spontaneous resolution with growth of the
midface stretching and flattening the redundant fold.
■ Patients with untreated epiblepharon may have a continuum of sequelae with
some asymptomatic until development of thicker eyelashes, whereas others
may develop conjunctival epithelial defects, corneal defects, recurrent corneal
infections, and even corneal scarring.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients may be asymptomatic or have inciting surface irritation evident by
rubbing of eyes, photophobia, persistent tearing, or discharge.
■ Eyelashes may be vertically oriented and may touch the cornea. This often is
exacerbated in down gaze.
■ Fluorescein staining may reveal epithelial defects.
■ Epiblepharon may be associated with astigmatism.
■ Diagnosis is by physical exam with the eyelashes directed vertically in the
setting of normal eyelid position (FIG 1). Additionally, an eyelid fold may be
found to be mechanically corrected with downward pressure applied on the
skin away from the eyelid involved.
IMAGING
■ Preoperative quality external photos documenting resolution of the
epiblepharon with eyelid fold excursion are recommended prior to undergoing
surgery.
DIFFERENTIAL DIAGNOSIS
■ Entropion with or without epiblepharon
■ Trichiasis, or misdirected growth of eyelashes toward the eye
■ Epicanthus tarsalis
■ Dermatochalasis with lash ptosis
■ Ptosis
■ Discharge in nonverbal children may be a sign of backflow from the tear

drainage pathway, caused by nasolacrimal duct obstruction.
FIG 1 • Lower lid epiblepharon. Eyelashes are seen
directed vertically with inferior eyelid fold.
NONOPERATIVE MANAGEMENT
■ Monitoring is appropriate in asymptomatic cases without corneal eyelash
apposition.
■ Lubrication with scheduled artificial tears may suffice in asymptomatic cases
with mild epiblepharon or conjunctival eyelash apposition.
SURGICAL MANAGEMENT
Preoperative Planning
■ General anesthesia is recommended for pediatric cases.
■ Surgical intervention is warranted in children whose lid abnormality causes
keratopathy or conjunctivopathy, considerable irritation, or in cases where
lubrication is not tolerated.
■ Goals of surgical management are to achieve eyelid retractor tightening,
removal of a strip of orbicularis and skin, and creation of a scar in a region
between the preseptal and pretarsal orbicularis.
■ In patients for whom a surgical eyelid crease is not desired, the standard

technique for epiblepharon is used. If a surgical eyelid crease is desired, the
modified Hotz technique is used.
■ A noninvasive everting suture technique may be offered. This modality may be
appropriate for mild cases of epiblepharon, parents wishing to avoid creation of
an eyelid crease/scar, or avoidance of general anesthesia.
Positioning
■ The patient is positioned supine on a surgical table with an adjustable headrest
lowered to give the surgeon the best access. The patient should be prepped and
draped, leaving the full face exposed.
Approach
■ An external approach to the lower lid tarsus and eyelid retractors is classically
used. Alternatively, a noninvasive suture technique may also be used.
T E C H N I Q U E S
■ Standard Technique
Markings and Incisions
■ Place topical tetracaine on the conjunctival surface.
■ Inject 1 to 2 cc 2% lidocaine with 1:100 000 epinephrine into the
subcutaneous space adjacent to the eyelid margin of the lid involved.
■ Using a sterile marking pen, outline the deficit nasally and temporally with a
horizontal mark placed along the nonmarginal tarsus border (TECH FIG
1A).
■ Use calipers to ensure the measured strip does not exceed 2 to 2.5 mm
vertically (TECH FIG 1B).
■ Use a no. 15 blade to incise a vertical semilunar-shaped strip of orbicularis
and skin (TECH FIG 1C).
■ Remove the incised skin using Westcott scissors (TECH FIG 1D).

TECH FIG 1 • A. Epiblepharon with outlining markings
including a horizontal marking along the nonmarginal
tarsus border. B. Calipers are used to confirm less
than 2 mm of vertical tissue to be excised. C. The
outlining incision is made. D. Westcott scissors are
used to excise outlined skin.
Suturing
■ Maintain hemostasis with monopolar cautery.
■ Remove the incised orbicularis using handheld cautery (TECH FIG 2A).
■ Using a 5-0 Vicryl suture, make a pass through the orbital septum and
through the lower eyelid retractors (TECH FIG 2B).
■ Continue this pass through the inferior edge of the tarsus, rotating the needle
to pass out through the septum (TECH FIG 2C).
■ Rotate the eyelid to ensure a full-thickness eyelid suture has not been placed
and tie this knot using a surgeon’s knot (TECH FIG 2D).

■ Pass two identical sutures separated by approximately 2 to 3 mm closing the
horizontal length of the strip (TECH FIG 2E–G).
■ Using 5-0 Vicryl suture, close the superior and inferior edges of the incised
orbicularis tissue in buried subcutaneous-interrupted passes.
■ Close the skin with 6-0 fast gut running sutures (TECH FIG 2H).

E G H

TECH FIG 2 • A. Handheld cautery is used to remove
underlying orbicularis within the previously marked
region. B. Vicryl suture is passed through the orbital
septum and lower eyelid retractors. C. The pass is
continued through the inferior edge of the tarsus. D. A
surgeon’s knot is used to reapproximate the sutured
tissues. E. The retractors are reapproximated to the
tarsus. F. Suture tails are cut just above the knot. G.
Eyelashes are checked for resolution of corneal
apposition. H. Skin is closed using 6-0 fast gut in a
running fashion.
■ Modified Hotz Technique
Markings and Incisions
■ Place topical tetracaine on the conjunctival surface.
■ Inject 1 to 2 cc 2% lidocaine with 1:100 000 epinephrine into the
subcutaneous space adjacent to the eyelid margin of the lid involved (TECH
FIG 3A).
■ Using a sterile marking pen, outline the eyelid crease prior to marking the
epiblepharon deficit nasally and temporally with a horizontal mark placed
along the nonmarginal tarsus border.
■ Use a no. 15 blade to incise a 2- to 2.5-mm vertical semilunar-shaped strip of
orbicularis and skin (TECH FIG 3B).
■ Remove the incised skin using Westcott scissors (TECH FIG 3C).
■ Maintain hemostasis with monopolar cautery.
■ Remove the incised orbicularis using handheld cautery (TECH FIG 3D).
Suturing
■ Using a 5-0 Vicryl suture, pass the needle externally through the skin inferior
to the incision, through the orbital septum, and through the lower eyelid
retractors (TECH FIG 4A).
■ Proceed by passing this needle through the inferior edge of the tarsus
(TECH FIG 4B), rotating the needle to pass out through the septum, the

orbicularis, and the skin superior to the incision (TECH FIG 4C).
■ Rotate the eyelid to ensure a full-thickness eyelid suture has not been placed.
■ The suture can then be tied with an external surgeon’s knot.
■ Pass one identical suture both nasal and lateral to the central suture 2 mm
from the nasal and lateral tarsal edge, respectively (TECH FIG 4D).
TECH FIG 3 • A. Anesthetic is injected into the
subcutaneous space along the defect. B. The outlining
incision is made. C. Westcott scissors are used to
excise outlined skin. D. Handheld cautery is used to
remove underlying orbicularis within the previously
marked region.

TECH FIG 4 • A. 5-0 Vicryl suture is passed externally
through the skin, through the orbital septum, and
through the lower eyelid retractors. B. The pass is
continued through the inferior edge of the tarsus and
out through the skin. C. Eyelashes are checked for
resolution of corneal apposition. D. The final outcome
and appearance of the surgically created lid crease.

TECH FIG 5 • Illustration outlining the trajectory of the
suture through the central cul-de-sac of the palpebral
conjunctiva directed superiorly to exit 3 mm below the
eyelid margin.
■ Everting Sutures/Buried Sutures Technique
■ Place topical tetracaine on the conjunctival surface.
■ Inject 1 to 2 cc 2% lidocaine with 1:100 000 epinephrine into the
subcutaneous space adjacent to the eyelid margin of the lid involved.
■ Using a double-armed 3-0 silk suture, make a pass from the central cul-de-
sac through the palpebral conjunctiva, orbicularis, and the eyelid skin (TECH
FIG 5).
■ The ideal exit of this suture is 3 mm below the eyelid margin for inferior
epiblepharon repair and 3 to 4 mm above the eyelid margin for superior

epiblepharon repair.8,9
■ An identical suture is passed 2 to 3 mm medial to the central suture in the
same fashion.
■ The sutures are tied with long tails and the tails.
■ Antibiotic ointment is applied over the suture site.
■ The tails of the sutures are taped away from the eyelid margin.
PEARLS AND PITFALLS
Technique
■ In very large epiblepharon cases, a modified Z-epicanthoplasty to
tighten the lower eyelid to the medial canthus may be performed
prior to the standard or modified Hotz procedure.10
Inadequate
postoperative
eversion
■ Overcorrect the eversion slightly to adjust for postoperative
scarring.
Asymmetry
■ More orbicularis/skin may be taken medially to avoid recurrence
and asymmetry.
Scar
■ Avoid tension on the skin.
■ Lubricate and protect the incision site from sun exposure
postoperatively.
POSTOPERATIVE CARE
■ Apply antibiotic eye ointment to the operative site 4 times a day for 1 week.
■ Remove everting nonabsorbable sutures at 1-week follow-up, allowing for
orbicularis scarring.
OUTCOMES
■ Following incisional epiblepharon repair, 80% to 90% of patients are either
asymptomatic or anatomically repaired.2,5
■ The everting sutures/buried sutures technique may be associated with up to a
23% recurrence rate.9
■ There is no agreed-upon interval between surgical correction and possible
recurrence.

COMPLICATIONS
■ Suture abscesses
■ Wound dehiscence
■ Lid retraction, ectropion
■ Canalicular trauma
■ Lagophthalmos
REFERENCES
1. Jordan R. The lower-lid retractors in congenital entropion and epiblepharon.
Ophthalmic Surg. 1993;24(7):494-496.
2. Sundar G, Young SM, Tara S, et al. Epiblepharon in East Asian patients: the
Singapore experience. Ophthalmology. 2010;117(1):184-189.
3. Bartley GB, Nerad JA, Kersten RC, Maguire LJ. Congenital entropion with
intact lower eyelid retractor insertion. Am J Ophthalmol. 1991;112(4):437-441.
4. Noda S, Hayasaka S, Setogawa T. Epiblepharon with inverted eyelashes in
Japanese children. I. Incidence and symptoms. Br J Ophthalmol.
1989;73(2):126-127.
5. Woo KI, Yi K, Kim YD. Surgical correction for lower lid epiblepharon in
Asians. Br J Ophthalmol. 2000;84(12):1407-1410.
6. Hayasaka Y, Hayasaka S. Epiblepharon with inverted eyelashes and high body
mass index in Japanese children. J Pediatr Ophthalmol Strabismus.
2005;42(5):300-303.
7. Chang EL, Hayes J, Hatton M, Rubin PA. Acquired lower eyelid epiblepharon
in patients with thyroid eye disease. Ophthal Plast Reconstr Surg.
2005;21(3):192-196.
8. Quickert MH, Wilkes TD, Dryden RM. Nonincisional correction of
epiblepharon and congenital entropion. Arch Ophthalmol. 1983;101(5):778-
781.
9. Hayasaka S, Noda S, Setogawa T. Epiblepharon with inverted eyelashes in
Japanese children. II Surgical repairs. Br J Ophthalmol. 1989;73(2):128-130.
10. Ni J, Shao C, Wang K, et al. Modified Hotz procedure combined with
modified Z-epicanthoplasty versus modified Hotz procedure alone for
epiblepharon repair. Ophthalmic Plast Reconstr Surg. 2017;33(2):120-123.

41
CHAPTERCanthopexy
Adam R. Sweeney and Christopher B. Chambers
DEFINITION
■ Canthopexy is a resuspension of the canthus to the bony orbit used to treat
eyelid laxity, ectropion, or misalignment.
■ A common surgery in adult facial rejuvenation, canthopexy is an indispensable
tool for treating children with eyelid positioning defects or deformities.
ANATOMY
■ The canthal tendons maintain the shape of the palpebral fissure and also
maintain lid apposition to the globe, important for proper corneal lubrication
and tear drainage.
■ The medial canthus has origins at the anterior and posterior lacrimal crests that
fuse temporal to the lacrimal sac, enveloping the lacrimal sac. The medial
canthus then divides into upper and lower segments that attach to the tarsus of
the upper and lower lid.
■ The medial canthus is involved in the lacrimal pump mechanism and
intimately associated with the lacrimal sac.
■ The lateral canthal tendon originates at the lateral orbital tubercle 4 to 5 mm
posterior to the lateral orbital rim. This provides a posterior vector opposing
the lid to the globe. The lateral canthal tendon then splits into superior and
inferior segments that attach to the tarsal plates (FIG 1).
■ The lateral canthal tendon inserts approximately 2 mm higher than does the
medial canthal tendon. This creates a superior tilt to the palpebral fissure
moving laterally.
■ The orbital septum overlies the lateral canthus as it approaches the orbital rim
and acts as a “superficial lateral canthus,” which can be used for suspension in

mild cosmetic defects.1
PATHOGENESIS
■ Common conditions that may cause eyelid laxity or malposition including
congenital facial clefting (ie, Tessier 2 to 12 clefts), amniotic band syndrome,
congenital eyelid malposition, or deformities resulting from other etiologies
including trauma and cancer resection or from craniofacial manipulation
(iatrogenic)
NATURAL HISTORY
■ Eyelid laxity is both a cosmetic and a functional problem.
■ Uncorrected, lower lid laxity may cause exposure keratopathy, epiphora, or
problems with the lacrimal pump mechanism.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Lower eyelid laxity
■ Canthal dystopia
FIG 1 • Anatomy of the medial and lateral canthal
tendons.
■ Poor eyelid snap back test: This test refers to evaluating the time for the eyelid
to return to normal position after pulling the lower lid down and away from the
globe. It is graded from 0 (brisk snap back) to IV (severe laxity).

■ Eyelid distraction—5 mm of eyelid distraction often considered excessively
lax.
■ Dry eye including exposure keratopathy or punctate epithelial erosions
■ Punctual stenosis from keratinization of the lid margin in medial ectropion2
IMAGING
■ CT imaging of the face is appropriate in the evaluation of congenital
craniofacial abnormalities. In the setting of orbital trauma, CT imaging is
useful to assess for naso-orbital-ethmoid fractures.
NONOPERATIVE MANAGEMENT
■ In patients not bothered by the cosmetic defect, scheduled application of
lubricant artificial tears may provide the necessary corneal protection to defer
or prevent surgery in mild cases.
■ Careful attention must be made to prevent deprivation amblyopia by constant
application of ointments, taping the eyelid shut, or patching of the eye.
SURGICAL MANAGEMENT
■ If the cosmetic defect is bothersome or the patient is symptomatic, canthopexy,
canthoplasty, or both may be performed to correct the eyelid abnormality.
■ Medial canthopexy in the absence of nasal fractures may be performed either
with or without wiring as adapted from Mustarde3 and Callahan,4 respectively.
Preoperative Planning
■ General anesthesia is recommended for pediatric cases.
■ Preoperative photos should be reviewed assessing the degree of
malpositioning and marking of the face at the desired canthi position to create
the proper slight superolateral contour of the eyelid with appropriate eyelid
tightening achieved.
Positioning
■ Patients should be positioned supine in an operating bed with adjustable head
positioning. The contralateral eyelid may be temporarily taped shut or
lubricated rather than covered to serve as a reference point during surgery.
Approach
■ Medial, lateral, or a combination of approaches may be performed depending
on the location of the lid abnormality or the desired results.

T E C H N I Q U E S
■ Lateral Canthopexy
■ The lateral canthopexy procedure tightens the canthal tendon with sutured
reconstruction of the canthal tendon. This effectively tightens the eyelid.
■ Place 2 drops of topical tetracaine on the conjunctival surface.
■ Inject 1 to 2 cc 2% lidocaine with 1:100 000 epinephrine subcutaneously
above and below the lateral canthus.
■ Using a no. 15 blade, make a 1-cm horizontal subciliary incision at the
lateral canthal angle (TECH FIG 1A).
■ Retract the skin with skin hooks and bluntly dissect down to the periosteum
using blunt-tipped scissors.
■ Undermine and dissect in this plane to the lateral canthal tendon under the
orbital septum (TECH FIG 1B).
■ The lateral canthal tendon is identified by tension and the ability to “strum”
if manipulated by closed blunt-tipped scissors. Grasping the lateral canthal
tendon, vertically transect the lateral canthal tendon at its lateral insertion
taking care to avoid the levator aponeurosis (TECH FIG 1C).
■ Pass a double-armed 4-0 Vicryl suture on a P-2 needle (Ethicon, Somerville,
NJ) entering anteriorly through the lateral canthus at its transected superior
and inferior attachment points (TECH FIG 1D).

TECH FIG 1 • Lateral canthopexy. A. A 1-cm
horizontal subciliary incision is made at the lateral
canthal angle. B. Blunt-tipped scissors are used to
dissect down to the periosteum. C. The lateral canthal
tendon is grasped following undermining to assist in
further dissection. D. A double-armed 4-0 Vicryl suture
on a P-2 needle is used to make two passes from
anterior to posterior through the lateral canthal tendon.
E. Deep suture placement ensuring a bite of
periosteum is achieved at the (medial) aspect of the
lateral orbital rim. F. The eyelid laxity in the operative
eye (arrow) is assessed for appropriate tension.
■ Pass each suture through the periosteum of the inner (medial) aspect of the
lateral orbital rim approximately 1 cm superior to the medial canthus (TECH
FIG 1E). Ensure tension is achieved with a strong bite.
■ Check the tension of the eyelid to ensure slightly exaggerated tension,
anticipating slight laxity after postoperative healing (TECH FIG 1F).

■ Close with 2 deep passes to approximate soft tissues including the
periosteum and orbicularis using 4-0 Vicryl suture.
■ Close the skin with 6-0 fast gut suture.
■ Lateral Canthoplasty (Lateral Tarsal Strip)
■ The terms lateral canthoplasty and lateral tarsal strip are interchangeable.
This procedure involves reconstruction of the lateral canthal tendon with lysis
and reattachment of the tendon.
■ Place 2 drops of topical tetracaine on the conjunctival surface.
■ Inject 1 to 2 cc 2% lidocaine with 1:100 000 epinephrine subcutaneously
above and below the lateral canthus.
■ Using a no. 15 blade, make a 2-cm partial-thickness skin incision at the
lateral canthus (TECH FIG 2A).
■ Use Westcott scissors to make a full-thickness cut at the site of the prior
incision.
■ Disinsert the inferior arm of the lateral canthus from the periosteum at the
lateral incision site using Westcott scissors, strumming the canthal attachment
points with closed scissors to find remaining canthal tendon arms that need to
be released (TECH FIG 2B).
■ The lower eyelid should be freely mobile to the superior orbital rim once all
canthal attachments have been cut.
■ Grasping the lateral tarsus at the lateral most point with toothed forceps, use
Westcott scissors to separate the anterior and posterior lamellae (TECH FIG
2C,D).
Creating the Lateral Tarsal Strip
■ Remove the mucocutaneous junction prior along the length of the desired
lateral tarsal strip (TECH FIG 3A).
■ Using Westcott scissors, cut the grasped tissue inferior to the inferior border
of the tarsus, 5 mm inferior to the lid margin (TECH FIG 3B).
■ De-epithelialize the skin and conjunctiva off the strip using a scraping
technique with a no. 15 blade (TECH FIG 3C).

TECH FIG 2 • Lateral tarsal strip (lateral canthoplasty).
A. Lateral canthotomy is performed. B. Cantholysis is
performed using Westcott scissors. There may be
multiple arms of the tendon that need to be cut. C,D.
Westcott scissors are used to separate the anterior
and posterior lamellae.

TECH FIG 3 • Lateral tarsal strip (lateral canthoplasty).
A. The mucocutaneous junction is removed from the
eyelid margin. B. Grasping the lateral canthus, the
lateral tarsal strip is fashioned by cutting the inferior
border of the tarsus 5 mm inferior to the lid margin. C.
An ideal strip is created by de-epithelializing the skin
and conjunctiva off the strip using a scraping
technique with a no. 15 blade. D. Both arms of a
double-armed suture are passed from posterior to
anterior through the lateral end of the tarsal strip.
■ Pass both arms of a double-armed 4-0 Vicryl suture on a P-2 needle from
posterior to anterior through the lateral end of the tarsal strip, with one arm
passing superiorly and one arm passing inferiorly (TECH FIG 3D).
■ Pull the inferior lateral canthus superiorly into the desired position, generally
1 cm superior to the medial canthus.
Suturing
■ Secure both arms of the suture by passing the needles deeply into the medial

periosteum of the lateral orbital rim (TECH FIG 4A).
■ Check the tension of the eyelid to ensure slightly exaggerated tension,
anticipating slight laxity after postoperative healing (TECH FIG 4B).
■ Using 6-0 fast gut suture, reform the lateral canthal angle with a circular
stitch entering from the inferolateral wound, out the gray line of the lower lid,
through the gray line of the upper lid, and out the superolateral wound
(TECH FIG 4C).
■ Close the skin using 6-0 fast gut suture.

TECH FIG 4 • Lateral tarsal strip (lateral canthoplasty).
A. Both arms of the suture are secured deeply in the
medial aspect of the lateral orbital rim periosteum. B.
Tension of the eyelid is checked. C. The lateral
canthal angle is reformed with a circular stitch entering
from the inferolateral wound, out the gray line of the
lower lid, through the gray line of the upper lid, and out
the superolateral wound.

■ Y-V Medial Canthopexy
■ Place 2 drops of topical tetracaine on the conjunctival surface.
■ Inject 1 to 2 cc 2% lidocaine with 1:100 000 epinephrine subcutaneously
above and below the medial canthus.
■ With a sterile marking pen, draw a horizontal V terminating 5 mm medial to
the medial canthal angle. Extend the marking with a 3-mm line horizontally
from the tip of the V (TECH FIG 5A).
■ Incise the skin and orbicularis using a no. 15 blade over the markings.
■ Using Westcott scissors, bluntly dissect through the orbicularis and septum
to the depth of the medial canthus ensuring to stay anterior to the
nasolacrimal system (TECH FIG 5B).
■ Pass both arms of a 4-0 double-armed silk suture underneath the lateral
aspect of the medial canthus exiting anteriorly through the medial canthus.
With each suture arm, make an additional pass through the medial canthus
extending medially. Pull the suture arms to plicate the medial canthus (TECH
FIG 5C).
■ Tie the two suture arms with a surgeon’s knot.
■ Close the soft tissues using 6-0 Vicryl sutures in interrupted fashion and
close the skin with 6-0 fast gut suture (TECH FIG 5D).

TECH FIG 5 • Y-V medial canthopexy. A. Markings of
the V-Y with the point of the V terminating 5 mm
medial to the medial canthal angle with a 3-mm
horizontal extending line that is parallel to the
palpebral fissure. B. Blunt dissection to the level of the
medial canthus. C. Plication of the medial canthus
with two throws of a double-armed suture extending
medially. D. Soft tissue and overlying skin closed
separately in interrupted fashion.
PEARLS AND PITFALLS

Technique
■ In children expected to have multiple facial surgeries, avoid a large
amount of canthal tendon resection as this may render further
procedures on these structures more difficult.
Inadequate
postoperative
suspension
■ Overcorrect the anatomic lateral canthopexy position slightly
aiming for 1 cm superior to the medial canthus to allow for
postsurgical laxity.
■ In procedures requiring a pass through periosteum, ensure the
periosteum has indeed been grasped by applying a moderate
amount of anterior tension on the suture after the pass. The tension
felt on the suture should be firm.
■ When making a pass through the periosteum, aim to create a
posterior vector to ensure the eyelid is approximated to the globes
laterally.
Scar
■ Avoid tension on the skin.
■ Push on the inferior eyelashes to exaggerate the subciliary fold for
accuracy of marking.
POSTOPERATIVE CARE
■ If used, nonabsorbable sutures should be removed at 5 to 7 days
postoperatively.
■ Apply antibiotic eye ointment to the operative site until the suture absorbs.
■ Sunscreen and lotion should be liberally applied over the operative region.
OUTCOMES
■ Lateral canthoplasty is associated with an 83% reduction in discomfort by
subjective grading scales and near universal improvement in objective eyelid
position.5
COMPLICATIONS
■ Improper positioning of fixation arm
■ Loosening of the canthus
■ Persistent pain lasting up to 3 months
■ Eyelid contour abnormalities including rounding of the canthus
■ Chemosis
■ Eyelid imbrication can be seen if the inferior crus of the lateral canthal tendon
is preferentially tightened or positioned too far cephalad.
■ Epithelial inclusion cysts may occur in the lateral tarsal strip procedure if the
tarsus is not denuded of epithelium prior to insertion.

REFERENCES
1. Knize DM. The superficial lateral canthal tendon: anatomic study and clinical
application to lateral canthopexy. Plast Reconstr Surg. 2002;109(3):1149-1157.
2. Georgescu D. Surgical preferences for lateral canthoplasty and canthopexy.
Curr Opin Ophthalmol. 2014;25(5):449-454.
3. Mustarde JC. Epicanthus and telecanthus. Br J Plast Surg. 1963;16:
346-356.
4. Callahan A. Secondary reattachment of the medial canthal ligament. Arch
Ophthalmol. 1963;70:240-241.
5. Moe KS, Linder T. The lateral transorbital canthopexy for correction and
prevention of ectropion: report of a procedure, grading system, and outcome
study. Arch Facial Plast Surg. 2000;2(1):9-15.

42
CHAPTER
Nasolacrimal Duct
Obstruction
Emily M. Zepeda, Sarah M. Jacobs, and Christopher B.
Chambers
DEFINITION
■ Nasolacrimal duct obstruction (NLDO) is an obstruction that occurs within the
duct of the nasolacrimal system, such that tears and mucus that have passed
through the lacrimal sac are unable to appropriately drain into the nose.
■ NLDO results in varying degrees of epiphora (tearing) and is often associated
with mucopurulent discharge, swelling, and pain.
ANATOMY (LACRIMAL SYSTEM)
■ The nasolacrimal duct is a part of the lacrimal drainage system that conveys
tears from the ocular surface to drain into the nose (FIG 1).
■ It is about 15 mm long, starting at the terminus of the nasolacrimal sac.
■ The nasolacrimal duct passes inferiorly, posteriorly, and laterally within the
canal formed by the maxillary and lacrimal bones. It travels into the inferior
meatus and opens under the inferior turbinate. Its outflow is partially covered
by the valve of Hasner.

FIG 1 • Anatomy of the nasolacrimal system, which
allows tears from the eye to pass through the puncta,
canaliculi, and lacrimal sac, through the nasolacrimal
duct to drain into the nasal cavity.
PATHOGENESIS
■ NLDO can occur secondary to congenital or acquired disease.
■ Congenital NLDO is usually secondary to a membrane blocking the valve of
Hasner at the nasal end of the NLD.
■ Obstructions become clinically evident in only 2% to 6% of full-term infants
at 3 to 4 weeks of age.
■ Conservative management options of congenital NLDO consist of
observation, lacrimal sac massage, and topical/oral antibiotics. It is estimated
that 90% of symptomatic congenital NLDO resolves in the first year of life
with conservative management.

■ For the remaining 10% of these cases, probing of the NLD can be curative
by creating an opening through the imperforate valve of Hasner.1
■ Infants with craniofacial deformity or Down syndrome are also at higher risk
of congenital NLDO. Dacryocystoceles can also create an obstructive process,
leading to enlargement and potentially abscess of the lacrimal sac.
■ Acquired NLDO may arise from numerous causes such as facial trauma, sinus
disease, chronic allergy and inflammation, radiation treatment to the midface,
toxicity from chemotherapeutic agents or radioactive iodine, or following
sinonasal surgery. Involutional stenosis is the most common cause of NLDO in
adults.
■ Regardless of whether NLDO is congenital or acquired, any obstruction of the
nasolacrimal outflow is capable of causing stagnation of bacteria leading to
infection of the lacrimal sac known as dacryocystitis.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ In both congenital and acquired NLDO, the primary symptom is epiphora as a
result of backflow of tears due to blockage of the duct.
■ At times, enough tear and mucous volume is accumulated within the lacrimal
sac that there is a palpable or visible enlargement of the sac. Light pressure
over the area of the lacrimal sac can often cause mucopurulent discharge to
reflux through the lacrimal drainage system and out the puncta.
■ Evaluation of a patient who presents with epiphora should focus on
determining the underlying etiology of tearing, assessing for nonobstructive
causes (eg, ectropion, reflex tearing, conjunctival infection or inflammation)
and nonbenign entities (eg, nasolacrimal malignancy, granulomatosis with
polyangiitis). Elements of the history and exam with this focus in mind include
the following:
■ A history including duration since tearing onset, percentage of the day it
occurs, how it interferes with activities of daily living, and whether any
particular activities provoke it (eg, cold, heat, wind, visual tasks such as
computers or reading). Any history of facial trauma, prior episodes of
dacryocystitis, radiation, or chemotherapy should be elicited. The patient
should also be asked about bloody tears, which would be a concerning sign
for underlying malignancy.
■ Prior to instilling any eye drops, the tear meniscus height should be noted,
and the tear breakup time should be measured, as a cue to whether dry eye–
related reflex tearing is contributing to the patient’s epiphora.

■ Eyelid structures and position in relation to the globe should be assessed for
concurrent disease states such as ectropion, entropion, and trichiasis. The
upper and lower puncta should be examined for patency and position relative
to the globe. Lower lid tone should be evaluated for degree of laxity.
■ A dye disappearance test can be performed on patients of any age. A
fluorescein eye drop is instilled in each eye. Normal nasolacrimal drainage
will allow the dye to flow through the punctum, such that the yellow dye
disappears from the ocular surface in a matter of minutes. Patients with
nasolacrimal outflow obstruction show delayed clearance of fluorescein.
■ In adults, the lacrimal system should be probed and irrigated. Passage of
saline into the nose and throat with ease and no reflux signifies a patent
system. Reflux of irrigant signifies obstruction, and the pattern of reflux can
reveal where the obstruction is located within the system. Reflux from the
same punctum that is being irrigated indicated obstruction within the
canaliculus. Reflux from the opposite punctum without mucous indicates
obstruction at the common canaliculus. Reflux from the opposite punctum
with mucus indicates obstruction in the nasolacrimal sac or duct.
■ Periocular skin may show erythema, edema, and breakdown of superficial
tissues when the discharge or tearing is profuse and constant.
■ Finally, nasal evaluation should be performed. This may reveal deviated
septum, polyposis, or tumors as a cause of obstruction. Nasal mucosa may
also show erythema and edema indicating chronic sinus inflammation.
DIFFERENTIAL DIAGNOSIS
■ Congenital glaucoma: When the only symptom is epiphora in a child, one
must always rule out congenital glaucoma. The classic triad for congenital
glaucoma is blepharospasm (involuntary squeezing of the eyelids closed),
photophobia (uncomfortable sensitivity to light), and epiphora. Other findings
suggestive of glaucoma include buphthalmos (enlarged globe and corneal
diameter) and Haab striae (breaks in the innermost layer of the cornea, leading
to corneal haze). If concern for congenital glaucoma exists, the child should be
referred to pediatric ophthalmology.
■ Dry eye: Epiphora due to dry eye will typically occur when the patient is
engaged in a visual task such as reading or computer usage, which decreases
their blink rate and exacerbates the dryness of the ocular surface. The patient
experiences blurring, burning or foreign body sensation, and then tear flow.
Symptoms are worse in hot, dry, or windy conditions.

■ Trichiasis: Growth of eyelashes from malrotated lash follicles or metaplastic
Meibomian oil gland orifices results in lashes rubbing and irritating the ocular
surface, which provokes tearing. Penlight exam can locate these lashes, which
can be treated with epilation or more permanent methods such as cryotherapy
or radiofrequency ablation.
■ Conjunctivitis: Infection or inflammation of the conjunctiva can cause
epiphora and ocular discharge. On examination, patients with conjunctivitis
will show injection and papillae or follicles, which appear as fine bumps on the
normally smooth conjunctival surface.
■ Eyelid ectropion or entropion: Poor eyelid position or lax lower eyelid tone
can lead to epiphora. An eyelid with normal tone smoothly sweeps the tears
across the ocular surface with each blink, pumping them down the punctal
drains into the lacrimal sac. Lax eyelids that are rotated outward (ectropion) or
inward (entropion) cannot serve this function effectively, so the unpumped
tears spill over the lid margin onto the cheeks.
IMAGING
■ The diagnosis of NLDO is based on patient history, elevated tear meniscus,
and obstruction observed when the system is probed and irrigated. Imaging is
not often needed for diagnosis.
■ In select cases, maxillofacial computed tomography (CT) and magnetic
resonance (MRI) scans are helpful to evaluate the anatomy after craniofacial
injury, in patients with significant sinus or nasal disease, or to evaluate for
neoplasia.
■ Less commonly, two methods for specific mapping of the lacrimal drainage
system itself can be employed:
■ In contrast, dacryocystography, in which dye is injected into the punctum and
CT or MRI imaging, is used to define the anatomic details of the lacrimal
drainage system outlined by the contrast agent, allowing precise location of the
obstructed site(s).
■ Dacryoscintigraphy uses radionucleotide eye drops to follow tear flow as a
gamma camera takes multiple pictures of the outflow system.
SURGICAL MANAGEMENT
■ As mentioned, most congenital NLDO resolves with nonsurgical management.
■ Approximately 10% of children with congenital NLDO require probing of
the duct. A small subset of those may require repeat probing with balloon

dilation of the duct, infracture of the inferior turbinate, and/or placement of
silicone stents within the nasolacrimal system to relieve their obstruction.
■ Because of the high success rate with these methods, dacryocystorhinostomy
(DCR) is rarely needed in the pediatric population. It is reserved for children
who have persistent tearing following intubation, recurrent dacryocystitis, or
craniofacial abnormalities with bony obstruction of the duct.
■ In adults, however, DCR is the preferred primary surgery for NLDO after the
other causes of tearing have been eliminated or addressed.
FIG 2 • Algorithm for management of epiphora due to
nasolacrimal duct obstruction.
■ The DCR operation can be performed in three ways (FIG 2):2–4
■ External DCR: An incision is made through the skin overlying the lacrimal
sac, allowing external access to the lacrimal sac fossa for bone removal, sac
opening, and stent placement under direct visualization without the need for
endoscopic camera equipment.
■ Literature reports a slightly higher success rate with the external approach in
certain studies. When appropriately placed, the incision heals with a very

subtle and cosmetically acceptable scar.
■ Internal DCR (also known as endonasal or endoscopic DCR): Attention is
brought to the middle meatus, which allows the most direct access to the
lacrimal sac fossa so that the nasolacrimal duct can be bypassed. The middle
meatus is visualized from within the nasal cavity, allowing removal of the nasal
mucosa and the bone encasing the lacrimal sac from the inside, following by
opening of the sac and retrieval of the stents.
■ The reported advantages of the internal approach include the lack of a visible
incision, less discomfort, faster recovery, and lower risk of compromising the
lacrimal pump mechanism.
■ Transcanalicular diode laser: A diode laser probe is passed through the
canaliculus with its tip resting within the lacrimal sac. The laser is used to
ablate the tissue of the lacrimal sac, bone of the lacrimal fossa, and a localized
zone of the underlying nasal mucosa. Silicone stents are then passed through
these laser-cut openings and retrieved within the nose.
■ This method has no skin incision, and it enables a significantly faster
operating time but reports a lower overall success rate.
Preoperative Planning
■ For patients with dacryocystitis, active infection should be treated before
DCR.5 If concern is high for significant nasal septal deviation or other nasal
abnormalities, which may need to be addressed intraoperatively, ENT
evaluation should be considered prior to surgery. The risk of bleeding can be
proactively addressed by ensuring perioperative blood pressure control and
withholding anticoagulants if allowed by the patient’s primary care physician
or prescribing cardiologist.
■ In the preoperative area, the patient is given oxymetazoline nasal spray to help
vasoconstrict and decongest the nasal mucosa. For example, the spray is
administered starting about 30 minutes prior to the procedure, with one dose
every 5 minutes for a total of three doses.
■ In the operating room after anesthesia induction, the middle meatus is injected
with lidocaine with epinephrine, then packed with pledgets soaked in
oxymetazoline to provide additional anesthesia and local vasoconstriction at
the site.
■ Moderate sedation or general anesthesia may be used for the procedure. The
decision is based on surgeon and patient preference. General anesthesia is

recommended for all pediatric cases and most adult cases.
Positioning
■ The patient is positioned supine on a surgical table with an adjustable headrest.
The headrest is lowered to extend the neck slightly which gives the surgeon the
best access. The patient should be prepped and draped leaving adequate
exposure of the eyelids and nose.
T E C H N I Q U E S
■ Internal/Endoscopic DCR
■ The surgical site is accessed through the nose, using an endoscope for
visualization of the middle meatus along the lateral sidewall of the nasal
passage beneath the middle turbinate (TECH FIG 1A,B).
■ If desired, a 23-gauge light pipe can be passed through the canaliculus,
bringing the lit tip to rest in the lacrimal sac. This light pipe provides a point
of illumination through the tissue to help localize the lacrimal fossa (TECH
FIG 1C,D).
■ A crescent blade is used to create a three-sided flap incision through the
nasal mucosa down to the bone, starting just anterior to the uncinate process
and extending inferiorly the height of the turbinate (TECH FIG 1E). A
periosteal elevator is then used to push the mucosa and periosteum away,
exposing bare bone.
■ Rongeurs (typically 2- and 3-mm up-biting Kerrison punches) are used to
remove the bone of the lacrimal fossa and the anterior process of the maxilla
(TECH FIG 1F) to expose the entire lacrimal sac. If necessary, a DCR drill
can be employed to bur away any bone that cannot be removed with the
rongeurs.
■ When bone removal is complete, the light pipe and/or a Bowman probe can
be passed through the canalicular system to visibly put the lacrimal sac on
stretch. A sickle blade is then used to open the lacrimal sac vertically from its
superior to inferior pole, allowing the probe to pass freely into the nasal
cavity (TECH FIG 1G,H). A ball-tipped seeker probe can be used to break
any adhesions within the sac, which are commonly present in patients with a

history of dacryocystitis. An antimetabolite such as mitomycin C can be
applied to the sac to decrease the potential formation of scar adhesions.6
■ Nasolacrimal stents, such as the silicone Crawford bicanalicular stent, are
then passed through the upper and lower puncta and retrieved in the nose
(TECH FIG 1I,J). The stents remain in place for several weeks
postoperatively to maintain patency of the openings during the healing
process.
TECH FIG 1 • A,B. An endoscopic camera is
introduced into the nasal cavity, allowing visualization
of the middle meatus. C,D. A light pipe introduced
through the punctum into the lacrimal sac can be used

to help with internal visualization of the site where
osteotomy should be placed. E. Incision is made
through the mucosa down to bone along the white
dotted line. F. Kerrison rongeurs are used to remove
bone from the site to create the osteotomy. G,H. The
site is confirmed with a light pipe, then the sac is
incised open, and a Bowman probe is passed. I,J.
Silicone stent tubes are passed through the upper and
lower puncta and then visualized and within the nose.
■ External DCR
■ A local anesthetic is injected, then the skin incision is made 3 to 4 mm from
the medial canthus, starting 2 to 3 mm above the medial canthal tendon and
extending over the lacrimal sac, following the direction of the nasojugal fold
(TECH FIG 2A).
■ A hemostat is used to bluntly spread the subcutaneous tissue apart, taking
care to visualize the angular artery and cauterize it if necessary. Blunt
dissection is carried down to the periosteum, which is scored with a blade or
Bovie cautery needle. A periosteal elevator is then used to reflect the
periosteum away from the bare bone, working in a posterolateral direction to
access the bone of the lacrimal sac fossa (TECH FIG 2B).
■ The periosteal elevator or hemostats are used to break through the lacrimal
bone into the nose, and then the osteotomy is enlarged with rongeurs
(typically 2 mm and 3 mm up-biting Kerrison punches) (TECH FIG 2C).
Care is taken to punch through the bone cleanly, rather than rocking the
pieces to break them away. This helps avoid propagating cracks along the
skull base, which can result in cerebrospinal fluid (CSF) leak. An opening of
1 to 1.5 cm should be created through the bone, spanning the entire vertical
height of the lacrimal sac.
■ A Bowman probe is passed through the canaliculus, and its tip is used to tent
the lacrimal sac (TECH FIG 2D,E). While holding the sac on stretch with
the probe, a sickle blade is used to open the lacrimal sac vertically from its
superior to inferior pole and then to make a horizontal cutback at the superior
and inferior ends of the sac incision to create an anteriorly based lacrimal sac