Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, 675e681

Bridge of bone canthopexy: Technique andmorphologic assessment

Miles J. Pfaff, Christopher C. Chang, Anup Patel, Derek M. Steinbacher*

Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA

Received 24 October 2012; accepted 20 December 2012

KEYWORDSBridge of bonecanthopexy;Lateral canthopexy;Bone-anchoredcanthopexy;Morphometricevaluation;Anthropometricevaluation;Lateral canthalangulation

* Corresponding author. Tel.: þ1 203E-mail address: derek.steinbacher

1748-6815/$-seefrontmatterª2013Brihttp://dx.doi.org/10.1016/j.bjps.2012.1

Summary Introduction: Malposition of the lower eyelid may disrupt facial aesthetics andimpair proper eyelid function. Multiple techniques have been proposed to restore lower eyelidposition. The purpose of this study is to report on a modified bridge of bone canthopexytechnique and assess its effect on lower eyelid and palpebral fissure restoration.Methods: A retrospective chart review was conducted. Pre- and post-operative photographs ofpatients were evaluated by a blinded observer. Pair-wise and chi-square tests were conductedwith an observed p-value of 0.05 or less considered statistically significant.Results: 12 patients (7 females) with a mean age of 42 (range Z 7e87) were included. Canthaltilt and scleral show decreased significantly following surgery (p Z 0.05), and the eye fissureindex and inferior coverage of the iris approached significance (p Z 0.16 and p Z 0.07,respectively). Two minor complications were encountered in our series.Conclusion: The modified bridge of bone canthopexy is a safe and effective technique foralteration of the lower eyelid and is broadly applicable to all causes of negative canthalangulation. Further studies are necessary to test the longevity and stability of this procedure.ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Introduction

Malposition of the lower eyelid can occur secondary tomyriad aberrant lower eyelid and lateral canthal proc-esses.1e5 Lower eyelid laxity and compromised orbicularisfunction (e.g. facial nerve paresis) may cause malpositionof the lower eyelid and influence canthal angulation.Similarly, cicatrix of the lower lid and lateral canthal

785 4559; fax: þ1 203 785 7514@yale.edu (D.M. Steinbacher).

tishAssociationofPlastic,Reconstruc2.028

tendon following trauma, surgery, and radiotherapy mayresult in lower eyelid retraction. With increasing age, laxityof the lateral canthal tendon may also occur, causingabnormal palpebral fissure shape. Finally, deficiency in theintrinsic supportive hard and soft tissue structures of thelower eyelid following trauma and surgery or in congenitaldisorders (e.g. Treacher Collins syndrome) can predisposethe patient to canthal malposition. Downward horizontal

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tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Table 1 Anthropometric landmarks.

Landmark Abbreviation Definition

Palpebralesuperius

Ps Highest point in themidportion of the freemargin of the uppereyelid

Palpebraleinferius

Pi Lowest point in themidportion of the freemargin of the lowereyelid

Endocanthion en Most medial point ofmedial commissure

Exocanthion ex Most lateral point oflateral commissure

Pupil center P Center point of iris

676 M.J. Pfaff et al.

palpebral fissure angulation (negative canthal tilt),increased palpebral fissure height, and scleral show mayoccur, disrupting facial symmetry and producing an agedand glum appearance.6e10 The consequences can extendbeyond aesthetics to include functional deficits, such asconjunctival irritation and abnormal tearing, with cornealulceration developing in the most severe of cases.1,2

Multiple surgical procedures have been described toaddress lower eyelid malposition. Approaches includehorizontal shortening of the lower eyelid,3 methods toenhance lower eyelid structure,11,12 lateral cantho-plasty,1,2,10,13,14 and lateral canthopexy.1,2,15,16 Lateralcanthopexy affords the ability to reposition, and poten-tially tighten, the lateral canthus to alter the palpebralfissure angle without horizontal shortening of the lowereyelid. Multiple iterations of the lateral canthopexy havebeen described, all sharing the goals of restoring and/orimproving lateral commissure and lower eyelid angulation,while optimizing globe-lower eyelid adaptation. Mostapproaches conserve the intent of first releasing the lateralcanthal tendon from its deep ligamentous and orbital rimattachments, followed by resuspension of the tendon.Engagment of the lateral canthal tendon may be performedusing an intraorbital or trans-commissure (gray line)-basedsuture or wire with subsequent re-suspension to eitherthe periosteum (suture) or bone (suture or wire) followingfavorable reposition.

The purpose of this study is to describe a modified bone-anchored canthopexy technique and anthropometricallyassess the pre- and post-operative lower eyelid andpalpebral positions. It is hypothesized that the proposedtechnique will improve lower eyelid and canthal position,with restoration of the lateral palpebral fissure.

Table 2 Anthropometric measurements.

Measurement Abbreviation Definition

Eye fissureheight

EFH Ps to Pi

Eye fissurewidth

EFW en to ex

Eye fissureindex

EFI EFH:EFW

Iris coverage IC (PePi)/(½ � iris diameter)

Canthal tilt e Angle of EFW to horizontalreference line (en to en)

Patients and methods

This is a retrospective case series approved by the YaleUniversity School of Medicine Human InvestigationsCommittee (HIC number: 1110009253). Patients undergoingmodified bridge-of-bone canthopexy, between 2011 and2012, without confounding periorbital procedures wereincluded. Informed consent was obtained preoperativelyfrom all patients. Medical charts were reviewed froma single surgeon (DMS) and demographic information, pastmedical history, surgical indication, procedure-relatedcomplications, and follow-up, was recorded.

Anthropometric periorbital assessment of pre- and post-operative photographs was performed using Image J(http://rsbweb.nih.gov/ij/). Photographs were prospec-tively obtained from patients in a neutral expression posi-tioned in the coronal and Frankfort horizontal planesfrom a fixed distance using the same camera and lens.Measurements of eye morphometry were performed asdescribed previously (Tables 1 and 2, Figure 1).7,10,19 Inaddition to quantitative analysis, the presence or absenceof scleral show was documented pre- and post-operatively.A blinded observer performed all measurements, and theaverage of three measurements was calculated and usedfor analysis.

Statistical analysis was performed using Microsoft Excel(Version 14.0.0, Microsoft Office 2011, Microsoft; Redmond,

WA) and SPSS Statistics (Version 19, IBM; Armonk, NY). Allmedian values were reported with the range. A pairwisecomparison was performed to evaluate pre- and post-operative differences in eye fissure index (EFI), canthaltilt, and scleral area. A c2 test was performed to comparethe presence of scleral show pre- and post-operatively. Forall comparisons, an observed p-value of 0.05 was consid-ered statistically significant.

Surgical technique

The surgical field is prepared and local anesthesia admin-istered. An incision is created along the previouslyidentified supratarsal crease (superolateral aspect),approximately 1.5 cm in length, down through the orbicu-laris muscle. A plane between the orbicularis and under-lying orbital septum is identified and followed to the lateralorbital rim. A vertical subperiosteal incision is made, andthe periorbita and lateral canthus is freed endo-orbitally.The intraorbital dissection continues along the inferiororbital rim and anterior orbital floor to freely mobilize thelower lid. The anterior temporalis muscle edge is reflectedand the zygomaticofrontal (ZF) suture is exposed (Figure 2).Two holes, 1.3 mm in diameter, are drilled through theorbital wall, from superficial lateral to deep intraorbital,using a wire-passing burr at and above the ZF suture 5 mm

Figure 1 Anthropometric landmarks (top) and measure-ments (bottom).7,10,19 ex, exocanthion; en, endocanthion; Ps,palebrale superior; Pi, palpebrale inferior; P, pupil center;EFW, eye fissure width (line eneex); EFH, eye fissure height(line PsePi); canthal tilt, angle of line eneen (horizontalreference line) and line eneex. All distances were reported inproportions with the corresponding standard deviation andangles in degrees.

Bridge of bone canthopexy 677

apart (Figure 2). Skin hooks are placed on the superior andinferior palpebrale fissures at the lateral commissure. Asingle 5 mm incision is made along the gray line of thelateral commissure with a 69 Beaver blade. A 28-gaugestainless steel wire suture is drawn through the incision topurchase the lateral canthal tendon. A Keith needle isinserted through a drill hole back-end first, superficial todeep, threaded through the needle’s eye, and drawn outthrough the same drill hole, deep to superficial. Theremaining wire end is brought through the second drill holein an identical fashion. The two wire ends are twistedclockwise to secure the lateral canthal tendon, achieveappropriate canthal tilt, and re-approximate the lower lidto the inferior limbus (Figure 2). The twisted wire is cut to8 mm in length, folded into a rosette, and inserted underthe temporalis muscle. The incision is closed in layers anda temporary tarsorrhaphy suture is placed at the lateralcommissure.

Results

Twelve patients were identified and included in this study(Table 3). There were seven females and five males witha mean age of 42 � a standard deviation of 30 (range:7e87). Comorbidities included hypertension (n Z 3),ischemic cardiomyopathy (n Z 2), type 2 diabetes mellitus(n Z 2), and congenital disorders (n Z 2; Oral-Facial-Digital syndrome and Treacher Collins syndrome). Threepatients were current smokers.

Fourteen bridge-of-bone canthopexy procedures wereperformed (10 unilateral and 2 bilateral) for post-traumaticperiorbital deformities (n Z 6), repair following excision ofa malignancy (n Z 4), and congenital deformities (n Z 2;both cases were bilateral). Follow-up data were availablefor all patients (mean follow-up time: 4.4 � 2.6 months,range: 0.3e9). Two complications were encountered in ourseries. Patient 11 developed subconjunctival hemorrhageintraoperatively. Patient 4 experienced continued neo-lidretraction and, at 2.5 months post-operatively, underwentfurther surgical repair.

Objective evaluation of pre- and post-operative eyelidmorphometry are presented in Table 4. The mean time inweeks of post-operative photographs analyzed was 6.1(standard deviation: 3.4; range: 2e13). EFI was found todecrease from 38.85% to 35.62% following bridge of bonecanthopexy on the operated eye, but did not achievestatistical significance (p Z 0.16); EFI of the contralateral(non-operated) eye remained relatively unchanged at35.33% pre-operatively and 36.44% post-operatively(p Z 0.42). As expected, canthal tilt of the operated eyeincreased significantly after surgery from �1.64� to 4.87�

(pZ 0.006) while the contralateral eye changed only slightlyfrom 1.11� to 1.38� (p Z 0.79). Following surgery, the pres-ence of scleral show improved significantly in operated eyeof patients (p Z 0.01), but remained unchanged in thecontralateral eye (p Z 1.00). IC was found to change from0.00% to 2.69% in the operated eye following surgery(pZ 0.07). The contralateral eye was found to change from7.37% to 5.51% following surgery (p Z 0.17). Clinicaloutcomes following canthopexy are presented in Figure 3.

Discussion

The lateral canthopexy is a versatile, yet technically chal-lenging, procedure with broad applicability to severaldisorders of the eyelid. Numerous methodological varia-tions of the lateral canthopexy have been described withassociated advantages and disadvantages; however, allshare the common goal of reconstructing the lower eyelidto restore palpebral fissure shape. When performed well,globe-eyelid alteration (anteroposterior and super-oinferior) and lateral canthal tendon repositioning canincrease iris coverage to minimize/eliminate scleral showand improve canthal angulation.

The decision to perform a lateral canthopexy, as opposedto canthoplasty, in this series of patients was multifactorial.Lateral canthoplasty, which aims to recreate the lateralpalpebral angle via canthotomy and cantholysis followed bylateral canthal tendon resuspension, typically to the lateralorbital rim periosteum, is generally reserved for those with

Figure 2 Bridge of bone canthopexy surgical technique. The frontozygomatic (FZ) suture along the lateral orbital wall is iden-tified through a supratarsal incision (left image). Two drill holes (arrows) are placed on each side of the FZ suture (center image).Stainless steel wires (arrowhead) are threaded through the drill holes in the lateral orbital wall and twisted to secure and positionthe lateral canthal tendon and lower eyelid, respectively (right image).

678 M.J. Pfaff et al.

severe horizontal laxity of the lower lid structures (asopposed to canthal tendon loosening alone). Moreover,canthoplasty requires horizontal shortening of the lowereyelid, which can lead to the appearance of a smaller eye(decreased aperture), is not reversible should over-correction be performed, and untoward complications, such

Table 3 Patient characteristics.

Patient Sex Age Co-morbidities Indication forprocedure

1 M 20 e Post-traumaticperiorbital deformity

2 F 10 Oral-facial-digitalsyndrome

Congenital orbitaldeformity

3 M 7 Treacher collinssyndrome

Congenital orbitaldeformity

4 M 77 HTN, ICM, T2DM Ectropion followingexcision of malignancy

5 F 24 e Post-traumaticperiorbital deformity

6 F 22 Smoking history Post-traumaticperiorbital deformity

7 M 20 Smoking history Post-traumaticperiorbital deformity

8 F 22 Smoking history Post-traumaticperiorbital deformity

9 F 87 e Ectropion followingexcision of malignancy

10 F 50 e Post-traumaticperiorbital deformity

11 F 84 HTN Ectropion followingexcision of malignancy

12 M 80 HTN, ICM, T2DM Periorbital defectfollowing exicison ofmalignancy with facialnerve palsy

BCC, basal cell carcinoma; HTN, hypertension; ICM, ischemiccardiomyopathy; T2DM, type 2 diabetes mellitis.

as webbing and globe-lid disjunction, may be seen.1 Forthose patients with severe horizontal lower eyelid structurelaxity, signified by positive snap and lower eyelid distractiontests, the lateral canthoplasty is indicated.1e4 In this series,no patient met these criteria.

The canthopexy described here combines a trans-commissure approach to engage the lateral canthaltendon15,16 with bone-anchored fixation through the lateralorbital rim.8,9,17,18 Insertion of a suture wire beyond thelateral commissure simplifies engagement of the lateralcanthal tendon and enables certain purchase of the superiorand inferior aspects of the lateral canthal tendon and, withcomplete sub-periosteal release of the tendon and adequatetension provided by the wire, greater pull of the eyelids.15,16

Fixation to bone, intraorbitally, then up and out through thelateral orbital rim, allows favorable anteroposterior lidadaption and correction of the lateral angulation, with theability to tighten or loosen based on the number of coiledwire rosettes. Furthermore, the wire can even be manipu-lated post-operatively should under- or over-correctionoccur.1,8 One criticism of wire fixation, however, is theoccurrence of cheesewiring of the wire through the lateralcanthal tendon under scar tissue contraction forces in thepatient with significant cicatrix of the middle and anteriorlamella or in those with severe vertical lid deficiency.1,8 Wefeel this is minimized by avoiding over-tightening of the wireduring clockwise rotation.

Additional technical improvements utilized in our bridgeof bone canthopexy include altered positioning of the drillholes and use of a Keith needle for wire retrieval. In ourprocedural design, the drill holes’ interior openings aremade more posteriorly, deeper, along the lateral orbitalwall to allow greater lid e globe anterosuperior re-approximation. The authors find that the use of a Keithneedle facilitates the process of intraorbital wire retrievaland lateral canthal fixation, thus reducing operation time.

Two complications were encountered in this study. Inboth patients there was a history of previous partial lowereyelid structure and margin excision, with local skin flapreconstruction. This neo-lid tissue did not represent the

Table 4 Pre- and post-operative eyelid morphometry.

Measurement n Pre-operative Post-operative Pre- versuspost-intervention (P e value)

Operated Contralateralb Operated Contralateralb Operated Contralateralb

EFI (%)a 13/9 38.85 � 9.47 35.33 � 6.22 35.62 � 6.06 36.44 � 4.74 0.16 0.46Canthal tilt(degrees)a

13/8 �1.64 � 4.67 1.11 � 2.82 4.87 � 6.98 1.38 � 3.26 0.006 0.79

Scleral showpresence

14/10 13 3 7 3 0.01 1

Iris coverage (%)a 13/8 0.67 7.37 2.48 5.51 0.07 0.17

n, number of sides analyzed (operated/contralateral); EFI, eye fissure index.a Mean � standard deviation.b Both bilateral cases did not have a non-operated, contralateral eye.

Bridge of bone canthopexy 679

usual normal lower eyelid anatomy. In patient 11, subcon-junctival hemorrhage was observed during dissection andwire fixation. The wire tension was subsequently decreased(uncoiled) to avoid excessive tension on the globe, andpostoperative tonometric pressures and visual acuity werechecked serially, revealing no abnormalities. Patient 4required further eyelid reconstruction several months later,as the neo-lid tissue underwent a degree of retractionfollowing post-operative radiotherapy. There were nocomplications relating to the performance of the tech-nique, dissection, or fixation.

In this study, we examined alteration of palpebral fissureshape and canthal angulation following surgery via

Figure 3 Surgical outcomes following modified bridge of bone cunderwent a right-sided bridge of bone canthopexy for a post-trauoperatively (bottom image). B, Pre-operative view of a 22 year-deformity on the right side. Post-operative view one month after aoperative view of a 10 year-old female who underwent bilateral bridimage). One month post-operatively (bottom image). D, Pre-operacongential orbital deformity (top image). Three weeks post-operat

objective evaluation of EFI, canthal tilt, scleral show, andiris coverage. Photographic analysis as an approach to post-operative evaluation is reliable as long as appropriateanthropometric landmarks are employed and the process ofphotographic documentation is standardized.4,6,7,20 Whenperforming photographic analysis, the choice of properlandmarks is crucial. Soft tissue is a dynamic structure andcan change, as seen with age or trauma, rendering soft-tissue based anthropometric landmarks unreliable.4 Thelandmarks used in this study, however, with the exceptionof Ps and Pi, are more bony-based and thus not as suscep-tible to such changes. Moreover, Farkas et al. found thatcanthal tilt, endocanthion line (eneen, the horizontal

anthopexy. A, Pre-operative view of a 24 year-old female whomatic periorbital deformity (top image). Eleven months post-old female who presented with a post-traumatic periorbitalright-sided bridge of bone canthopexy (bottom image). C, Pre-ge of bone canthopexies for a congential orbital deformity (toptive view of a 7 year-old male who presented with a bilateralively (bottom image). Arrow indicates operated eye.

680 M.J. Pfaff et al.

reference line for canthal tilt), and EFH (PsePi) to bereliable measurements by photogrammetry when comparedto direct anthropometric measurements.20 Standardizationof the photographic technique is also important as minordifferences, such as in facial expressions and deviations inthe angles of the photographic frame, can distortmeasurements.4 Thus, all patient were photographed in anidentical position (coronal and Frankfort horizontal planes)with a neutral expression at the patient’s eye-level froma fixed distance using the same camera and lens. Finally,a benefit of photographic analysis is the ability to performmeasurements in a blinded fashion, thus reducing thepotential risk of bias.

EFI describes the aperture of the eye and is sensitive tochanges in both EFW and EFH.6,7 Farkas and Munro recordedan EFI of 36% and 33% in 18 year-old females and males,respectively.19 Raschke and colleagues found the restingEFI of the contralateral, non-operated in their populationof 221 patients to be approximately 34.40%.6 These findingsare in line with our own observations (Table 4). Prior tosurgery, the EFI of the operated eye was larger than thecontralateral eye, reflecting the degree of lower eyelidmalposition. As expected, we observed a reduction of theEFI in the operated eye by approximately 3.2% (p Z 0.16)following surgery. This finding is attributable to horizontallengthening of the eye fissure as we detected a meanchange before and after surgery in EFW of 10.72%(pZ 0.16), while the mean change in EFH was subtle (meanchange: 0.8%; p Z 0.38). Moreover, we found the post-operative EFI of the operated and contralateral eyes tobe highly similar (p Z 0.74), suggesting rather symmetricalplacement of the operated lateral canthus.

The ideal canthal tilt projects superiorly from the medialto lateral canthal angle (Figure 1).9 Farkas reported a canthaltilt in young Caucasian females and males of 4.1� and 2.1�,respectively.21 Other studies of have found the angle torange from 10� to 15�13,19 with the lateral canthus resting onaverage 1e2mm above themedial canthus.5,13 Distortions incanthal tilt, such as downward slanting (negative tilt) of thepalpebral fissures, can result in an aged and sad appear-ance.6e10 We found that canthal tilt changed from a meannegative value to a positive value while the non-operated,contralateral eye remained relatively unchanged (Table 4).The final mean value of canthal tilt after surgery was 4.87�,which was 3.49� greater than the contralateral eye(p Z 0.20), indicating over-correction. However, whenperforming the lateral canthopexy, minimal overcorrectionshould be performed in anticipation of periorbital structuralrelaxation and descent.

Scleral show refers to the distance between the inferiorlimbus and lower eyelid margin. Typically, the lower lidcovers the inferior limbus, with normative values of lowerlid coverage reported at 1e2 mm, or 7% of the iris’ diam-eter.4 However, as the lower lid descends (and/or lateralcanthal tendon drifts medially), the inferior limbus departsfrom the lower lid to expose the sclera, resulting ina rounded, aesthetically unappealing eye shape. Thepresence of scleral show in this series was significantlyreduced (p Z 0.01), providing evidence of proper lowerliddglobe re-approximation (Table 4). Similarly, lower iriscoverage in the operated eye increased, but did not reachnormative values. The contralateral eye was near

normative values but changed slightly following surgery,indicating the sensitivity of measurement (Table 4).

Limitations of our study include the retrospective studydesign, heterogeneous population, and absence ofa matched control group. Moreover, studies objectivelyevaluating outcomes using analogous methods with a similarprocedure (lateral canthopexy) are lacking. This study alsoemployed photographic analysis, rather than direct anthro-pometric analysis, to qualitatively analyze the effects ofsurgery. As stated previously, photographic analysis is a reli-able method of evaluation as long as proper technique ispracticed. Finally, the variability in the post-operative timingof analysis within the patient cohort prevents a more accu-rate assessment of eyelid morphometry. In light of this, therewere no significant differences in pre- versus post-operativemeasurements in the non-operated, contralateral eye, indi-cating that reliable measurements were obtained.

Conclusion

The modified bridge of bone canthopexy is a safe andeffective technique, broadly applicable to myriad causes ofnegative canthal angulation. Anthropometric analysisshows improvement in canthal tilt and scleral show intreated patients. Further studies are necessary to assessthe longevity and stability of this approach.

Financial disclosures

All authors have no commercial associations or disclosuresthat may pose or create a conflict of interest with theinformation presented within this manuscript.

Author contributions

DMS conceived the study. MJP and DMS designed the study.MJP and CCC executed the study. MJP, CCC, AP, and DMSprepared the manuscript.

Acknowledgments

All authors have no commercial associations or disclosuresthat may pose or create a conflict of interest with theinformation presented within this manuscript.

This publication was made possible by Grant Number TL1 RR024137 from the National Center for ResearchResources (NCRR), a component of the National Institutesof Health (NIH) and NIH Roadmap for Medical Research. Itscontents are solely the responsibility of the authors and donot necessarily represent office views of NCRR or NIH(Author: MJP).

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