Step 8 Closure

Periosteal sutures are not absolutely necessary, but if exposure permits, the can be placed, The conjunctiva is closed with a running 6-0 chromic gut suture. The ends of the suture may be buried. No attempt is made to reapproximate the lower lid retractors because they are intimately in contact with the conjunctiva and will be adequately repositioned with closure of that layer. Once the conjunctiva is closed, an inferior canthopexy is performed (Fig. 3-13).

A 4-0 polyglactin or other long lasting suture is used to reattach the lateral portion of the inferior tarsal plate to the superior portion of the canthal tendon and surrounding tissues. It is important that this suture be securely placed in the appropriate location or the lateral canthal area will never appear normal. When the inferior limb of the canthal tendon is severed during the approach, only a minute amount of canthal tendon remains attached to the lower tarsus. Therefore the canthopexy suture can be placed through the lateral border of the tarsus if the tendon attached is insufficient to hold a suture. It is easier to pass the suture through the lateral border of the lower tarsus and/or cut portion of the lateral canthal tendon if the skin is dissected slightly from them. This is very easily performed by taking a #15 scalpel and incising between the tarsus and the skin. A cleavage plane exists in this location, and the tissue readily separates. The tarsus is grasped with forceps and a suture is passed through either the cut tendon or the lateral border of the tarsus in such a fashion that a firm bit of tissue is engaged. Once a goode bite of lower tarsus has been taken with the suture, the suture needle should be placed through the superior limb of the lateral canthal tendon.

The bulk of the lateral canthal tendon attaches to the orbital tubercle, 3 to 4 mm posterior to the orbital margin. Following canthotomy, the superior limb of the canthal tendon is still attached to the orbital tubercle. It is important to place the suture as deep behind the orbital rim as possible to adapt the lower eyelid to the globe. If the suture is not properly placed, the eyelid will not contact the globe laterally, giving an unnatural appearance. Therefore, the suture needle should pass very far posteriorly and superiorly to ensure that it grasps the superior limb of the tendon. An effective method to pass this suture is to identify the superior limb of the canthal tendon first with small, toothed forceps placed into the incision. The forceps are passe along the medial side of the lateral orbital rim for a few mm until the dense fibers of the superior limb are located. While the tendon is held, the suture needle is passed through the tendon. The surgeon should pull on the two ends of the suture to enclosure that the suture is firmly attached to ligamentous tissue. The suture is then tied, with the lower lid drawn into position.

Finally, subcutaneous sutures and 6-0 skin suture are placed along the horizontal lateral canthotomy.

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