I had a lateral canthal suspension of both eyes for Lagopthalmos that didn't help. Will a canthoplasty fix it?

Question

I have lagopthalmos of the left eye from brain surgery, resulting in facial paralysis. I wear an external lid weight for full closure. The bottom lid droops. The eye still sags. I just had a lateral canthal suspension on both eyes in April. It did nothing to fix the problem and even made the rounding of the bad eye worse. I was told it would require a canthoplasty to fix the shape and sagging. Would they undo what was done (undo suspenison and start from scratch)? Is it possible to get insurance coverage for this?

Brent Moelleken, MD · Answer

In addition to treatment of the upper eyelid, it may be wise to resuspend the lower eyelid via a cheeklift, especially if a canthopexy has failed in the past.
With facial paralysis, the orbicularis (eye closing) muscle is deactivated.  The cheek droops, literally like a weight dragging down the lower eyelid.  Canthopexy or canthoplasty (especially if the lower eyelid is lax) is helpful but we have achieved our best results combining them with a cheek resuspension such as the USIC (ultrashort incision cheeklift).
This is also a good time to critically analyze the asymmetries of the eye, determine which are correctable, and address them.
Your problem is very technical and my colleagues have raised many excellent points and possible methods of repair.
Whatever the repair, no surgery reestablishes the nerve supply to the orbicularis muscle, so perfection, while a nice goal, is not realistic.

Kenneth D. Steinsapir, MD · Answer

Dear A McMillen
This is a not so uncommon situation. I was able to help a woman with severe facial paralysis following the resection of an acoustic neuroma from the brain stem. She had numerous canthoplasties without success. I was able to make a significant difference for her with a surgery that I have developed to address these types of problems.
The key is to understand that simply tightening the lower eyelid, no matter how artfully, will never correct the situation. Generally the weight of the cheek must be taken off of the lower eyelid. This is done with an internal midface lift which is sewn to a hand carved ePTFE implant placed at the orbital rim. This material is placed to create an ultra-strong place to sew to. Next the lower eyelid has to be lengthened using hard palate graft borrowed from the roof of the mouth. Then a canthoplasty is used to adjust the tension and shape of the eyelid.

Chris Thiagarajah, MD · Answer

To help with lagophthalmos after facial nerve palsy, the gold weight in the upper eyelid is helpful. A couple things may help you even more in the lower eyelid

	1. Releasing the retractors and raising the lower lid. This can be done with or without a spacer graft

	2. Raising the cheek to help raise the eyelid

	I believe that tightening laterally the eyelid if it is low can help raise the eyelid only to a certain extent. After that the lid has to elevated in some manner. It is my personal opinion without looking at your photos.

William Portuese, MD · Answer

It is possible to get insurance to cover this since it is of medical necessity in nature. It sounds as though you have got weakness and paralysis of the upper and lower eyelid closure mechanism. A canthoplasty can certainly be performed and the lower lid brought up so that the cornea does not dry out. An oculoplastic surgeon with many years of experience who has performed thousands of these types of procedures would be the best person to look for.

J. Timothy Heffernan, MD · Answer

I am sorry to hear that you are having this difficulty. There are a variety of very useful procedures to help you and others. With such complex problems revision procedures are sometimes needed to get the best results for the patient. While every insurance company is different, in our experience many insurance companies will help.

Jonathan Hoenig, MD · Answer

It's relatively simple to undo the canthopexy which was done in an attempt to improve your situation.
To clarify, lagophthalmos is the inability of the eyelids to close completely. This commonly occurs after nerve damge, as is the case with you. The upper eyelid is being managed with the eyelid weight but the lower lid still is drooping because the nerve to the muscles that hold up the cheek are compromised from your brain surgery.
So, now we need to find the best way to get your lower eyelid and cheek back into a higher position so that your appearance is improved but more importantly, so that you can close your eyes. There are various ways to accomplish this depending on what is discovered on physical examination. Some version of a cheeklift plus eyelid tightening surgery is indicated.
Insurance is likely to cover this as the need for this repair was created from your brain surgery. The amount that they will pay will vary depending on your coverage, copays, deductibles, etc.

Hisham Seify, MD, PhD, FACS · Answer

Canthoplasty is a more powerful procedure that enables the surgeon to have more control on the lower eye lid tension, position, etc.In cases of paralytic ectropion,a combination of upper eye lid gold weight and lower lid reconstruction. Lower lid techniques include canthopexy, canthoplasty, fascia lata or alloderm sling, etc. Each case has to be reviewed separately and an advice from a plastic surgeon with expertise in this field is essential. Best of luck!

Peter A. Aldea, MD · Answer

Dear Amcmillen,
I am truly sorry to hear of your predicament.
Paralytic lagopthalmos (the inability of bringing the eyelids together) is a very challenging surgical problem. In your case, it SOUNDS as if both the upper and lower lids are compromised.
Since tucking the side corner of the eyelid tighter to the side of the eye socket (ie canthopexy) did not seem to work well to bring the lower lid higher, your surgeons may feel that you need more of an upward and inward pull of the lower lid against the eyeball.
There are several methods of performing canthoplasties. At the core, they all divide the lateral eyelid ligament and then reattach it 2-3 mm higher than it normally is within the eye socket to enable full eyelid excursion over the eye, allow tears to continue to lubricate the surface of the eye and prevent dryness and ulceration.
In such cases, the suspension (canthopexy) WOULD have to be undone, divided and done again in a tighter fashion (canthoplasty).
If you have reasonable medical insurance and had it continuously since your brain surgery, I see NO reason why they should not pay for this procedure. This is NOT cosmetic surgery. This is 100% reconstructive plastic surgery in which the surgeon attempts to restore an abnormal condition back to normal function and appearance. I would fight this all the way.

I had a lateral canthal suspension of both eyes for Lagopthalmos that didn't help. Will a canthoplasty fix it?

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