Surgical correction of medial canthal widening associated with aging: two case reports

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Arch Aesthetic Plast Surg. 2024;30(4):141-145

Publication date (electronic) : 2024 October 30

doi : https://doi.org/10.14730/aaps.2024.01207

Youngwoong Choi, Jeong Min Ji, Choong Hyeon Kim

Department of Plastic and Reconstructive Surgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea

Correspondence: Choong Hyeon Kim Department of Plastic and Reconstructive Surgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, 170 Juhwa-ro, Ilsanseo-gu, Goyang 10380, Korea E-mail: ps068@naver.com

Received 2024 October 4; Revised 2024 October 16; Accepted 2024 October 16.

Abstract

INTRODUCTION

In elderly individuals, age-related morphological changes at the medial canthus, such as canthal widening, may lead to cosmetic dissatisfaction. These changes include elongation of the canthus and exposure of the caruncle [1]. In younger patients, caruncle exposure is often a consequence of medial epicanthoplasty, a procedure that can also involve excessive skin resection and postoperative scarring. In such cases, revision surgery or medial epicanthal fold reconstruction may be employed for correction [2]. Furthermore, demand has been growing for surgical interventions to address age-related aesthetic changes around the eyes.

While methods for medial canthal reconstruction following conventional medial epicanthoplasty may be extensible to age-related widening, it is necessary to also consider the specific characteristics of aging. We report a case in which medial canthal widening was corrected through reconstruction using a V-Y flap combined with a canthal tendon tightening procedure, and we introduce the surgical method. Two surgical cases are presented: one involving an overexposed medial caruncle and the other entailing a deformed medial canthus with lengthening due to aging.

CASE REPORT

Surgical technique

The surgical procedure was performed under local anesthesia, with the patient in the supine position. The surgical method was a modification of the conventional reconstruction technique used after medial epicanthoplasty. As illustrated in Fig. 1, the approach resembled traditional V-Y advancement reconstruction, including the determination of points a, a’, b, and c. Point a represented the most medial end of the currently exposed medial canthus, while point a’ was the anticipated final position to which the V flap would be advanced to cover the red caruncle. Points b and c were respectively located at the vertices of the upper and lower portions of the V flap, the points where the upper and lower eyelids intersected with an imaginary vertical tangent line drawn from the lateral border of the exposed caruncle, and the points just above and below the eyelash line. Initially, as depicted in Fig. 1, incisions were made along the lines connecting points a to b and b to c. The V-Y advancement skin-muscle flap was then elevated along the medial canthal margin. When elevating the V flap, a portion of the pretarsal orbicularis oculi muscle was included. Dissection continued in the same layer medially and towards the upper and lower regions. To tighten the lax medial canthal tendon (MCT), the underlying pretarsal orbicularis oculi muscle and MCT were sutured using a horizontal mattress technique with buried sutures in the upper and lower sections, respectively, using 6-0 nylon (Fig. 2). Although anatomical variations exist among patients, point b’ in Fig. 2 generally corresponds to point b in Fig. 1 and is located approximately 1 mm above it. Similarly, point c’ corresponds to point c and is situated approximately 1 mm below it. Point a1 is approximately 1 to 2 mm medial to and 1 mm above point a, while point a2 is 2 mm below a1. Next, point a of the upper area of the V flap and point a’ of the lower area were advanced, and a buried suture was placed using 7-0 monofilament polydioxanone suture material (Fig. 1). The positions of points a and a’ should be adjusted based on the individual’s anatomy. Finally, skin closure was achieved with 7-0 silk sutures to complete the Y flap (Fig. 1). Notably, the locations and measurements of landmarks in this surgical technique may require modification based on the patient’s features.

Fig. 1.

Graphical explanation of V-Y advancement to correct elongation of the medial canthus due to aging. (A) The preoperative state. (B, C) The a, b, c, and a’ points (refer to the surgical technique). (D) The advancement process. (E) Scar was observed in the early postoperative period. (F) The postoperative state with faded scar over time.

Fig. 2.

Schematic illustration of the surgical technique. (A) Anatomy of the medial canthal tendon. (B, C) To tighten the lax medial canthal tendon, the pretarsal orbicularis oculi muscle and the medial canthal tendon in the area beneath the V flap are secured using a horizontal mattress suture technique. This involves placing buried sutures in the upper and lower sections, respectively (points a1 and a2 correspond to points 1 mm above and below point a in Fig. 1, while points b’ and c’ are located 1 mm above point b and 1 mm below point c in Fig. 1, respectively).

Case 1

An 85-year-old man presented with drooping of the right medial canthus and exposure of the right caruncle. He had no history of eye surgery, and the changes in his eye were attributed to the aging process, without any specific ocular conditions. Due to the excessive exposure of the caruncle and asymmetry of the medial canthal area, surgical intervention was undertaken to correct the overexposure and improve symmetry. The surgical technique described was applied to the right side of the affected area. The stitches at the sutured area were removed 7 days after the surgery. Throughout 4 months of follow-up, the patient was satisfied with the postoperative cosmetic improvement, and no complications were noted during wound healing. No noteworthy deformity or recurrence was observed during the follow-up period (Fig. 3).

Fig. 3.

Photographs of case 1. (A) Preoperative photograph. (B) Photograph taken 4 months postoperatively.

Case 2

A 71-year-old woman presented with widening of both medial canthals. She had no specific medical conditions affecting her eyes and no history of eye surgery, and she exhibited age-related changes to both eyes. The patient had noticed bilateral caruncle exposure and horizontal elongation of the medial canthus over many years. No other ophthalmic symptoms were noted; however, the patient did exhibit left-sided blepharoptosis, which was also addressed during surgery. The surgical technique to correct the medial canthal widening was performed bilaterally. Furthermore, left levator advancement was conducted to correct the left blepharoptosis concurrently with the medial canthal procedure. Postoperatively, the previously elongated bilateral medial canthus appeared horizontally shortened in comparison to the medial end of the eyebrow, with an increased inner canthal distance. The patient was satisfied with the cosmetic outcome (Fig. 4). Over 6 months of follow-up, no complications arose during the wound healing process, and no specific scar management products were required. No postoperative deformity or recurrence was observed.

Fig. 4.

Photographs of case 2. (A) Preoperative photograph. (B) Photograph taken 6 months postoperatively.

DISCUSSION

Aging leads to changes in the skin, bones, and soft tissues. These changes are evident in various aspects of our appearance, including the eyes [3]. Components of the skin, such as elastin and collagen, diminish over time, leading to wrinkles and a reduction in the number of epicanthal folds [1]. With age, the levator aponeurosis weakens, and the orbital bone undergoes resorption, enlarging the orbit and giving the eyes a sunken appearance [2]. This characteristic of aging muscle is not only cosmetically unappealing but also functionally obstructive. It can be addressed by shortening the muscle to counteract its lengthening or by realigning the attenuated muscle to the upper edge of the tarsus. In the lower eyelid, the weakening of the orbital septum, along with the aging of the zygomatic-cutaneous ligaments and the orbicularis retaining ligament, leads to a protrusion of orbital fat [4]. As the orbital contents sag and the canthal tendon weakens, more of the sclera is exposed below the inferior limbus, and senile ectropion may develop [5]. The increased periorbital volume, caused by bone resorption, skin laxity, and diminished muscle tone, including that of the MCT, may lead to excessive exposure of the caruncle, generating aesthetic concerns (Fig. 5).

Fig. 5.

Illustration of the change in eye shape between a young and an old person. (A) The younger individual has a slightly exposed eye caruncle. (B) In the elderly individual, the degree of caruncle exposure is greater, and the eyelid skin appears droopy.

In addition to aging, medial canthal widening is commonly observed as a possible complication of medial epicanthoplasty. Specifically, hypertrophic scarring and excessive surgery may result in a medial canthus that is wider than the normal range [6]. Overcorrection can produce an unnatural appearance, revealing more of the sclera and potentially leading to blepharoptosis. Excessive exposure of the caruncle can also create the impression of an aged appearance. Other issues include increased visibility of the lacrimal lake and sclera, ectropion, and bilateral asymmetry, as well as cosmetic concerns due to a reduced distance between the eyes [7]. Such complications may be caused by hypertrophy or misalignment of the orbicularis oculi muscle or adjacent medial canthal structures or by the excessive removal of fatty tissue between the muscle and skin [8]. Accordingly, various surgical methods have been developed for the reconstruction of the epicanthal fold to address complications and patient dissatisfaction following medial epicanthoplasty. Established surgical approaches include skin excision, flap techniques, plication of the medial canthal ligament, and myomectomy of the preseptal orbicularis muscle [9]. Flap procedures, such as the V-W flap and the V-Y advancement flap, have been employed to correct upper eyelid wrinkles since the introduction of epicanthal fold reconstruction by von Ammon [10]. Ha et al. described a Z-plasty technique, while Shin et al. reported the performance of epicanthal fold reconstruction in 246 patients using V-Y-plasty and a rotational flap [6,8,11].

The exposure of the caruncle and the lengthening of the medial canthus due to aging have prompted increasing numbers of patients to seek surgical correction. A method to address the complications of medial epicanthoplasty could logically enable correction of age-associated epicanthal widening. On top of the techniques used for conventional medial epicanthoplasty and revision, surgical methods must consider specific characteristics of the aging process. The MCT is a key structure that occupies a large portion of the medial canthus area [12]. The pretarsal muscle divides medially into superficial and deep heads, with the superficial head merging with its counterpart from the opposite eyelid to form the MCT [13]. This tendon originates above and anterior to the anterior lacrimal crest and inserts into the medial orbit in a tripartite manner, featuring an anteriorly positioned horizontal and vertical component as well as a deeper horizontal element [14]. The importance of the MCT tightening procedure in these cases lies in its capacity to restore the MCT, which becomes weakened and loses tone due to aging. Moreover, the tightening technique supports the maintenance of the advanced skin-muscle flap by organizing the underlying structures, rather than merely manipulating the skin. This helps prevent widening of the postoperative Y-flap scar that can occur due to the characteristics of the eye with dynamic movement and thus helps to obtain cosmetically satisfactory results (Fig. 1E and F). In short, through advancing conventional medial epicanthoplasty after traditional reconstruction and elevating V-Y advancement skin-muscle flaps along the medial canthal margin, followed by MCT tightening, it is possible to achieve aesthetically favorable outcomes with reduced scarring, fewer complications, and a lower rate of recurrence.

In conclusion, medial canthal widening, which is frequently observed following cosmetic surgery, can also be caused by aging. When addressing this issue surgically, age-related characteristics must be considered, as opposed to directly applying conventional surgical approaches. This report proposes that for medial canthal widening caused by aging, MCT tightening may be effective—particularly in combination with a V-Y advancement skin-muscle flap—to address associated tendon and ligament laxity. This method may offer a surgical alternative for improving the eye shape by correcting medial canthal widening, a condition more prevalent in the elderly population than previously recognized.

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