Aesth Plast Surg (2013) 37:892895

DOI 10.1007/s00266-013-0181-6

CASE REPORT

AESTHETIC

Lacrimal Ductule Fistula: A New Complication of Cosmetic

Lateral Canthoplasty
Kanjana Leelapatranurak Jung Hoon Kim
Kyung In Woo Yoon-Duck Kim

Received: 14 June 2012 / Accepted: 12 June 2013 / Published online: 9 July 2013
Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2013

Abstract
Background Lateral canthal reconstruction performed to
lengthen the horizontal palpebral fissure for aesthetic purposes is becoming more prevalent in Far East Asian
countries. The lacrimal ductule fistula has become a complication of this procedure.
Methods A retrospective medical record review was
performed to analyze four patients (one man and three
women) who presented with tearing from a lacrimal ductule fistula after cosmetic lateral canthoplasty for lengthening of a horizontal palpebral fissure. The average age of
the patients was 27.3 years (range 2132 years). The
review analyzed patient data from previous surgeries, eye
examinations, photographs, operative records, and pathology records.
Results All the patients experienced tearing from a lacrimal ductule fistula after cosmetic lateral canthoplasty
performed by four different plastic surgeons. Eye examination demonstrated tearing through one or more lacrimal
ductule fistulas in scar tissue of the lateral canthal area. To
relieve this symptom, two patients underwent excision of
the lacrimal ductule and lateral canthal reconstruction. The

symptom subsided postoperatively without recurrence.

Pathologic examination performed for one patient showed
the lacrimal ductule in the surgical specimen.
Conclusions Lacrimal ductule fistula or exteriorization of
the lacrimal ductule can complicate cosmetic lateral canthoplasty if precautions are not taken in the assessment of
the patient or in the performance of the procedure. Excision
is required to reconcile the symptomatic lacrimal fistula,
whereas canthal reconstruction is needed to remedy the
disfiguring lateral canthus to achieve appropriate canthal
shape and position.
Level of Evidence V This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Lacrimal ductule fistula
Lateral canthoplasty

Cosmetic canthoplasty
Aesthetic canthoplasty
Tearing

Complication

Introduction
K. Leelapatranurak (&)
Mettapracharak Hospital, 52 Moo 2, Raikhing, Sampran,
Nakorn Pathom, Thailand
e-mail: Kanjana_nue@yahoo.com
J. H. Kim
K. I. Woo
Y.-D. Kim
Samsung Medical Center, 50 Irwon-Dong, Gangnam-Gu,
Seoul, South Korea
e-mail: hearts75@hanmail.net
K. I. Woo
e-mail: eyeminded@skku.edu
Y.-D. Kim
e-mail: yoonduck.kim@samsung.com

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Many techniques for lateral canthal reconstruction have

been performed for both aesthetic and curative purposes.
Indications mainly include horizontal lid laxity, eyelid
malpositioning, and lateral canthal dystopia. In Western
countries, aesthetic reconstruction of the lateral canthus
emphasizes restoration of proper lateral canthal support
and position [14]. In various Far East Asian countries,
including South Korea, the cosmetic reasons for performing this procedure (i.e., to make Oriental eyes appear
larger and wider) have grown more prevalent in recent
years.

Aesth Plast Surg (2013) 37:892895

Cosmetic lateral canthoplasty is a popular surgical

procedure performed to lengthen the horizontal palpebral
fissure. Many surgical techniques have been introduced,
but complications associated with the procedure have not
been well addressed [59].
We report on four patients with tears draining from a
lacrimal ductule fistula that developed after cosmetic lateral
canthoplasty for lengthening of the horizontal palpebral
fissure. Various published canthoplasty techniques were
reviewed, but none indicated tearing as a complication.
The current report aims to point out the lacrimal ductule
fistula as a new complication of cosmetic lateral canthoplasty. We retrospectively reviewed the medical records of
four patients (one man and three women) who showed
tearing through a lacrimal ductule fistula after cosmetic
lateral canthoplasty performed by four different surgeons
in four different local plastic clinics. These patients were
later referred to the oculoplastics division of Samsung
Medical Center for tearing evaluation, from 2002 to 2012.
The average age of the patients was 27.3 years (range
2132 years). The objective of lateral canthoplasty in each
case was to lengthen the horizontal palpebral fissure to
make the eyes larger and wider. The review analyzed
patient data from previous surgeries, complete eye examinations, ophthalmic photographs, operative records, and
pathology records.

Case Report
Case 1
A 21-year-old woman patient presented with abnormal
tearing that had persisted for two consecutive months. She
had undergone cosmetic lateral canthoplasty by a local
plastic surgeon 3 months before the onset of her symptom.
The patients eye examination showed a corrected visual
acuity of 20/20 in both eyes. No abnormalities were
observed in the examination of the anterior and posterior
segments. Two small orifices oozing a clear fluid were
found in the left lateral canthal area (Fig. 1a). The upper
and lower eyelid margins at the lateral canthal angle were
separated, with noticeable erythematous conjunctival tissue. Shallowness of the lateral fornix also was detected
(Fig. 1b).
To relieve the patients tearing symptom, fistulectomy
was performed by preoperative injection of methylene blue
solution through the orifices followed by removal of soft
tissues around the fistula tract. Subcutaneous tissue and skin
then were meticulously sutured. The lateral canthus also
was reconstructed to create a sharp canthal angle (Fig. 1c).
The pathologic examination showed a trace of a lacrimal

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ductule structure on the removed tissue (Fig. 1d). The

patients symptoms subsided without recurrence.
Case 2
A 26-year-old woman presented with deviant tearing in her
right lateral canthus. She had undergone cosmetic lateral
canthoplasty by a local plastic surgeon 3 months before the
onset of her symptom. A cystic lesion had developed in the
scar tissue of her right lateral canthus, which was later
needle-punctured, resulting in a permanent fistula.
The patients eye examination showed a visual acuity of
20/20 in both eyes and an intraocular pressure of 16 and
17 mmHg in each eye. No specific findings resulted from
examination of the anterior and posterior segments. A
small orifice draining clear fluid was found in her right
lateral canthal area (Fig. 2).
The patient underwent elliptical skin excision with fistulectomy assisted by methylene blue injection for fistula
tract identification. Lateral canthal reconstruction also was
performed, with no postoperative recurrence.
Case 3
A 32-year-old woman presented with unusual tearing from
her right eye. She had undergone double-eyelid formation
and cosmetic lateral canthoplasty by a local plastic surgeon
6 months before the onset of her symptom.
The patients eye examination showed an uncorrected
visual acuity of 20/20 in both eyes. Punctate corneal erosion due to dry eye was observed in both eyes. A small
orifice was noted in the right lateral canthal area (Fig. 3).
Clear fluid was continuously draining from the orifice
without evidence of inflammation. Treatment options were
discussed, but the patient refused corrective surgery for her
condition.
Case 4
A 30-year-old man presented with a tear-filled cyst on his
right lateral canthus 4 months after lateral canthoplasty and
nasal augmentation by a local plastic surgeon. He
recounted that the cyst continued to refill after the fluid had
been drained.
The patients eye examination showed an uncorrected
visual acuity of 20/20 in both eyes. Examination of the
anterior and posterior segments resulted in no specific
findings. A 3.5-mm cyst was present on the patients right
lateral canthus, and both of his lateral fornices were significantly shallow (Fig. 4). We recommended cyst excision, but the patient opted against surgical correction.

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Aesth Plast Surg (2013) 37:892895

Fig. 1 Case 1. (a) Two small

cutaneous orifices in the left
lateral canthus after cosmetic
lateral canthoplasty (arrow).
(b) Discontinuity of the lateral
canthal angle with outward
migration of palpebral
conjunctiva and a shallow
lateral fornix. (c) View 1 month
after lacrimal fistula excision
and revision lateral canthoplasty
showing natural look, sharp
lateral canthal angle.
(d) Pathologic slide showing a
duct-like structure within the
dermis

Fig. 2 Case 2. Clear fluid drained from a cutaneous fistula (arrow) in

the right lateral canthal area 3 months after cosmetic lateral
canthoplasty

Fig. 3 Case 3. Tear oozing from a lacrimal fistula (arrow) in the right
lateral canthal area after cosmetic lateral canthoplasty

Discussion
Lateral canthoplasty for cosmetic reasons is commonly
performed in Far East countries and is especially prevalent
in South Korea. The operation aims to increase the horizontal palpebral fissure, making Oriental eyes appear larger

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Fig. 4 Case 4. A tear-filled cyst on the right lateral canthus (arrow)

with discontinuity of the lateral canthal angle after cosmetic lateral
canthoplasty

and wider. This procedure may be performed alone or in

combination with double-eyelid formation surgery, medial
canthoplasty, or epicanthal fold correction.
Several surgical techniques of cosmetic lateral canthoplasty have been introduced, but no standard surgical
procedure exists [69]. Moreover, those cosmetic outcomes
are not satisfactory due to disruption of the normal canthal
anatomy and scar formation. Nonetheless, Shins cosmetic
lateral canthoplasty is used, in which a rotational flap
technique is deployed to increase the horizontal palpebral
fissure without disrupting the continuity of the lower eyelid
margin at the lateral canthal angle [5].
With Shins technique, the upper eyelid crus flap, which
is destined to lengthen the lower eyelid margin, requires
posterior back-cutting of the palpebral conjunctiva to
reduce tension during the flap closure [5]. The authors have

Aesth Plast Surg (2013) 37:892895

noted that the posterior depth should be less than half the
transverse length of the palpebral conjunctiva and that the
surgery should be considered for patients with a sufficient
lateral fornix [5]. However, if this technique is inadvertently performed for a patient with a shallow lateral fornix
or if the back-cutting is too deep into the lateral conjunctival fornix, redirection or damage of the lacrimal ductule
may result.
The patients in the current study experienced tearing
through a lacrimal fistula after cosmetic lateral canthoplasty for lengthening of the horizontal palpebral fissure.
Cases 1 and 4 showed a disfigured lateral canthal angle and
noticeable scar tissue of the conjunctiva and skin in the
lateral canthus area, which had troublesome lacrimal fistulas. Poor surgical technique or excessive tissue reaction
may have caused lacrimal fistula and cyst formation. Cases
2 and 3 showed an exteriorized ductule in the upper part of
the newly formed lateral canthus several months after
surgery.
The postoperative tearing experienced by the reported
patients may have resulted from the surgical technique
itself or from direct intraoperative injury to the lacrimal
ductule. Such improper surgical technique of cosmetic
lateral canthoplasty may cause outward redirection of
normal lacrimal ductule orifices by externalization of
conjunctival tissue with excessive manipulation or scar
formation. The externalized palpebral conjunctiva may
contain a number of normal lacrimal duct openings that
usually are located on the superolateral fornix. Another
possible cause is direct injury to the lacrimal ductules
during surgery, resulting in formation of a lacrimal fistula.
Surgical correction is needed if tearing from the fistula
becomes troublesome. Our patients displayed single or
multiple small cutaneous orifices in the lateral canthus with
continuous drainage of clear fluid but no signs of inflammation. In one patient, a fluid-filled cyst was found. To
relieve the symptoms completely, two of our patients
underwent removal of the fistula tract as well as meticulous
skin suturing. The patients experienced no recurrence after
the fistulectomy.
Intraoperative injection of methylene blue solution is
very helpful in identifying the fistula tract by staining the
inside of the lumen. Lateral canthal reconstruction to
recreate an almond-shaped lateral canthus may be performed in combination with fistulectomy and should be
performed if examination shows an unnatural appearance
of the lateral canthal angle due to discontinuity of the upper
and lower eyelid margins or disfigured conjunctival tissue
in the lateral canthal angle.
Notably, one of the most common remedial procedures
for lateral canthoplasty is the lateral tarsal strip procedure

895

[10], which requires an intact orbital periosteum to reattach

the lateral canthal tendon. Such a procedure is challenging
if the canthal tendon or the periosteum is inadequate, as in
the reported cases. These patients may need more sophisticated procedures for canthal support, for instance, a suspension suture through drilled holes on the lateral orbital
rim.
Spinelli and colleagues [11] introduced a more effective
and less invasive technique for revision canthoplasty using
the Mitek anchoring system for suture fixation.

Conclusions
The cosmetic lateral canthoplasty is a popular procedure in
the Far East, especially in South Korea. The procedure can
cause outward redirection of the lacrimal ductule or direct
lacrimal ductule injury if precautions are not taken in the
assessment of the patient or in the performance of the
procedure. A number of conditions may lead to formation
of an exteriorized lacrimal ductule, which requires excision
and lateral canthal reconstruction. Further studies investigating the lacrimal ductule fistula complication after cosmetic lateral canthoplasty are required to minimize
complications and improve the surgical outcome.

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