Q: Dr. Eppley, I am interested in eyelid surgery to correct negative canthal tilt. I know lateral canthopexy can be done to raise the lateral canthus but i also need the medial canthus to be lowered in both eyes. I talked to one doctor who told me it is impossible to do. I started researching this and found many articles on the topic that have been published throughout the years. All of them describe methods and techniques for reattaching the medial canthal tendon. When i sent one of those articles to the surgeon he told me those techniques do work but they’re only for “medical problems”. I even saw a video of of the procedure being done. I e-mailed another surgeon asking him if it is possible to do and i suggested cutting the bone to which the tendon is attached and moving it down then fixing it in that position. I asked him if that would work and he said that it would and that he’s done things like that before. I just don’t see any reason why this can be done for people who have severe skull fractures/shattered orbitals but not people who are perfectly normal? Is it possible to do or is it impossible? I’m confused and just looking for a real explanation.
A: Medial canthoplasty is a far more challenging procedure than lateral canthoplasty due to the more limited access of the inner eye and the very thin bones to which the tendon is attached. It is also a procedure that is far less successful as a result. While attempting to do it for reconstructive purposes has merit, manipulation of the medial canthal tendon for aesthetic purposes must be considered far more carefully. I would doubt that moving the inner corner of the eye down will be successful if attempted by trying to move the medial canthal tendon downward. The bones of the medial orbital wall are very thin due to the sinus cavity that lies on the other side. This makes secure fixation very difficult. If the goal is to move the inner corner of the eye downward boy a few millimeters it would far more sense to do so by skin manipulation such as a small z-plasty. It would be more effective and incur none of the risks of destabilizing the medial canthal tendon attachments.
Dr. Barry Eppley