Cicatricial canthal webs

Cicatricial canthal webs present a complex reconstructive challenge for the eyelid surgeon. A combination of vertical skin deficiency, cutaneous and subcutaneous scar, and altered anatomy and blood supply can make surgical correction difficult and unpredictable. Patients typically are seen after blepharoplasty surgery or trauma with both cosmetic and functional (visual-field obstruction in lateral gaze) deficits. This is often a significant frustration to both the patient and the surgeon. A combination of a Y-to-V advancement flap, adjacent tissue rearrangement with Z-plasties centered on the arms of the Y (five-flap technique), and scar excision, when necessary, can be a useful procedure for revision of these webs.

The charts of patients who underwent cicatricial canthal web revision in the solo private practice of the author over a 5-year period (2006-2010) were retrospectively reviewed. Each patient had a history of previous eyelid surgery or trauma that led to the development of the web. No patient had previous surgery to address the web. Each patient's presenting complaints were aesthetic, functional, or both, and each was previously told to avoid revision, as surgery to correct the web would make the condition worse. Patient's pre- and postrevision digital photographs, and patient and physician assessments, were reviewed to evaluate the results of surgery. Postoperative injections of subcutaneous steroid (Kenalog) and/or 5-fluorouracil (5-FU) were given as a treatment adjunct to modulate wound healing and prevent scarring when deemed appropriate.

Eight patients were included in the study. Seven (88%) patients are women, and 1 (12%) patient is a man. The mean patient age is 46 years (range, 18-56 years), and the mean follow-up is 17 months (range, 9-30 months). Seven (88%) of the patients had lateral canthal webs after surgery, and 1 (12%) patient had a medial canthal web after a motor vehicle accident. Every patient voiced aesthetic concerns with the web, and 4 (57%) of the 7 patients with lateral canthal webs reported a visual deficit related to the defect. Six (75%) patients received 3 separate injections of Kenalog postoperatively, and 2 (25%) patients received the same number of injections composed primarily of 5-FU admixed with steroid. Each patient was satisfied with the aesthetic and functional result of surgery.

Cicatricial canthal webs are an uncommonly reported finding that has received little attention in the literature. The condition has both aesthetic and functional implications, can be very bothersome and frustrating to patients, and can be intimidating to the treating surgeon. Although surgical revision carries risks of flap necrosis, scar, and worsened appearance, it can also significantly improve appearance and function. If the patient is realistic, understands the limitation of surgery, and will be happy with a moderate improvement, surgery should be strongly considered. The author found that revision of cicatricial canthal webs with the technique described in this article yields excellent results, given the limitations of the presenting problem.