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Presentation

Medial Canthal Reconstruction: Anatomy, Defects, and Repair Techniques

Description

The talk reviewed medial canthal anatomy and why reconstruction is challenging: the area contains the lacrimal drainage system, has very thin skin, is highly sensitive to tension and vector forces, and relies on limited vascular supply. Key anatomy included the medial canthal tendon’s anterior and posterior limbs, their relationship to the lacrimal crests, and the importance of preserving or reanchoring the tendon to prevent ectropion and maintain eyelid function. Reconstruction was organized by defect size and depth, emphasizing restoration of support, contour, and lacrimal function while matching tissue thickness and color. For small superficial defects, secondary intention, conical grafts, bilobed flaps, or glabellar flaps may be used; larger or deeper defects may require forehead or paramedian forehead flaps, though these can be bulky and often need staged debulking. Full-thickness defects require layered repair: posterior lamella support with options such as a Hughes flap, sliding tarsoconjunctival flap, free tarsal graft, cartilage, hard palate, or periosteal tissue; anterior lamella replacement with skin grafts or advancement flaps; and lacrimal system intubation or later Jones tube/DCR if preservation is not possible. The speaker stressed avoiding vertical tension, thinking in subunits and layers, protecting the globe, and prioritizing function, form, aesthetics, and eye safety in every repair.

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Conclusions

Successful medial canthal reconstruction depends on restoring the natural concavity, structural support, and contour of the inner eyelid region while preserving eye function.
Because the medial canthus has thin skin, complex lamellar anatomy, lacrimal structures, and limited vascularity, defects in this area are especially unforgiving and require careful planning.
Reconstruction should be based on a layered assessment of the defect, including size, depth, periosteal or tendon involvement, and whether the lacrimal system is affected.
Small superficial medial canthal defects may heal well by secondary intention if they are centrally located and do not expose tendon, bone, or lacrimal structures.
For small skin-only defects, conical grafts, bilobed flaps, or glabellar flaps can provide good color and texture match while preserving the medial canthal hollow.
Large or deep defects often require staged, subunit-based reconstruction rather than a single large flap, with separate replacement of anterior and posterior lamellae.
Canthal stability is critical, and the medial canthal tendon should be reanchored to the posterior lacrimal crest whenever it is disrupted to prevent ectropion and poor lid position.
When the lacrimal system is involved, the best chance of preserving drainage is early identification and intubation, with secondary procedures reserved for irreparable damage.
Full-thickness lower lid defects can be effectively reconstructed with posterior lamellar replacement techniques such as the Hughes flap, followed by anterior lamellar skin grafting or advancement.
For extensive medial canthal and lower eyelid defects, forehead flaps are useful because they provide reliable vascularized coverage, but they are bulky and often require second-stage refinement.
The key principle across all techniques is to avoid vertical tension on the lower lid and instead direct closure forces horizontally or superomedially to reduce cicatricial ectropion.
Overall, medial canthal reconstruction is best approached as a controlled, layered restoration of form, function, and aesthetics that respects facial subunits and protects the eye.

Harvey J. 1998 article on conical skin grafts in medial canthal reconstruction.
Jeffrey A. Nerad, Techniques in Ophthalmic Plastic Surgery (Second Edition).