Inverting sutures with upper canthoplasty and lateral tarsal strip (LTS)
This is Richard Allen at the University of Iowa. This video demonstrates repair of involutional lower lid ectropion using inverting sutures with a lateral tarsal strip and upper canthoplasty. A lateral canthotomy and inferior canthoysis are performed with the needle tip cautery. A transconjunctival incision is then performed with the needle tip cautery extending from the punctum medially to the lateral canthotomy incision laterally just inferior to the inferior border of the tarsus. Dissection is then carried out between the orbicularis muscle and orbital septum to the inferior orbital rim. Using a 5-0 vicryl suture, inverting sutures are placed. The suture is placed transcutaneous approximately 1 cm inferior to the inferior border of the tarsus to exit out the orbicularis muscle. The suture then engages the inferior border of the tarsus. The suture is then placed transcutaneously back through the orbicularis and skin to exit adjacent to the entry site. An additional suture is then placed centrally. Again, transcutaneous, followed by engaging the inferior border of the tarsus, followed by exiting transcutaneous. A third suture is then placed laterally. These sutures are left untied until the end of the case. The transconjunctival incision is then closed with interrupted or running 7-0 vicryl sutures. In this case the sutures are placed in an interrupted fashion. Attention is then directed to the lateral upper eyelid where the lateral 5 mm of the mucocutaneous junction is excised for the subsequent lateral canthoplasty. The upper canthoplasty is performed to give additional support laterally to repair the ectropion. A lateral tarsal strip is then fashioned by dissecting between the anterior and posterior lamella for approximately 1 cm. The mucocutaneous junction of the posterior lamella is then excised with the Westcott scissors. The posterior surface of the strip is then scraped with a 15 blade. The strip is then shortened the appropriate amount. A double armed 4-0 mersilene suture on an S2 needle is then used to engage the [tarsal] strip. The lateral tarsal strip is then sutured to the lateral orbital rim at the level of Whitnalls tubercle. Prior to tying the sutures, the lateral portion of the mucocutaneous junction of the upper eyelid is engaged with the 5-0 vicryl suture. This suture then engages the superior border of the lateral tarsal strip and is tied. This attaches the lateral upper lid to the lateral tarsal strip. Tying the lateral tarsal strip then tightens both the upper and lower eyelid. The inverting sutures are then tied to gently invert the lower lid. These can be tied over bolsters, if preferred. My goal here is usually to have the lashes of the lower lid be vertical at the conclusion of the case. The lateral canthotomy incision is then repaired with 7-0 vicryl suture.