Aesthetic CanthalSuspensionD. Julian De Silva, MBBS, MD, FRCO, BSc, PGc, DICa,b, Amiya Prasad, MD, FACSc,d,*

OVERVIEW

Laxity of the lower eyelid is a common character-istic of facial aging, and correction of lower eyelidlaxity in conjunction with aesthetic blepharoplastyis key to both an optimal cosmetic outcome andavoidance of surgical complications. Laxity of thelower eyelid is evaluated preoperatively with thesnap-back test.1 When lower eyelid blepharo-plasty is completed with either a transcutaneousor transconjunctival technique, considerationmust be given to the need for lower eyelid supportto avoid potential complications including lowereyelid retraction and ectropion. With particularrelevance to transcutaneous lower blepharo-plasty, excision of lower eyelid skin without

consideration of canthal suspension results in anincreased risk of lower eyelid retraction or malpo-sition. Aesthetic canthal suspension may involve asingle support suture to support the lower eyelidfrom the lateral orbital rim (canthopexy) or supportof the lateral canthal tendon (canthoplasty), ortightening of the orbicularis oculi (orbicularis sling).Care is required in support and alteration of thelateral canthus, as small differences can beapparent with asymmetry or functional discomfort.Oculoplastic surgeons have a good anatomic

knowledge of this area, as reconstructive surgeryon the lateral canthus is a common procedure. Bycontrast, other surgical specialties often find thisarea challenging because the anatomy is intricate

c Prasad Cosmetic Surgery, New York, NY, USA; d Division of Oculofacial Plastic & Reconstructive Surgery,

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Risk of major complications of lower eyelid surgery including lower eyelid retraction and ectropion,may be reduced with aesthetic canthal suspension.

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.comClin Plastic Surg 42 (2015) 7986Winthrop University Hospital, State University of New York College of Medicine, NY, USA* Corresponding author. Prasad Cosmetic Surgery, New York, NY.E-mail address: Amiya1Prasad@hotmail.coma Oculo-Facial Plastic Surgery, London, UK; b Centre for London Facial Cosmetic & Plastic Surgery, London, UK;rim with a plication suture without modification of the canthal tendon.

Canthoplasty is defined as a procedure that modifies, tightens, and can shorten the lower eyelid,and may involve surgery on the lateral canthal tendon, tarsus, and orbicularis oculi. Canthopexy is defined as a procedure to elevate and support the lower eyelid to the lateral orbitalKEYWORDS

Aesthetic canthal suspension Canthopexy O

KEY POINTS

Aesthetic canthal suspension is defined as a lacompleted as an independent procedure or mblepharoplasty.

Indications for suspension of the lower eyelid incvention of lower eyelid malposition.

Preoperative evaluation of the lower eyelid and iis key to optimal surgical management.

Anatomy of the lower eyelid and lateral canthustanding of anatomy is required to avoid comphttp://dx.doi.org/10.1016/j.cps.2014.08.0050094-1298/15/$ see front matter 2015 Elsevier Inc. Allicularis sling Canthoplasty

al elevation of the lower eyelid, which may becommonly in conjunction with aesthetic lower

e facial aging, laxity of the lower eyelid, and pre-

osition with respect to the globe and the cheek

s both intricate and complex; thorough under-tions in aesthetic canthal suspension.rights reserved. pla

De Silva & Prasad80The orbicularis oculi is a protractor of the eyelidswhose function is to close the eyelids. The muscleis innervated from its undersurface by the tempo-ral (upper eyelids) and zygomatic (lower eyelids)branches of the facial nerve.

Middle Lamella

The orbital septum is a fibrous structure beneaththe orbicularis muscle, which divides the anteriorlamella from the orbital cavity. It is a continuationof the periosteum at the orbital rim. Vertically theseptum fuses with the lower eyelid retractors5 mm below the tarsus, continuing as one layeruntil inserting on the inferior edge of the tarsus.Horizontally the septum lies posterior to themedial palpebral ligament (canthal tendon) andanterior to the lateral palpebral ligament. Theorbital septum provides an important functionalbarrier in the eyelid that protects the spread ofinfection from superficial skin tissues to the orbitaland less familiar. As a consequence, the orbicularissling technique, which avoids intricate surgery onthe lateral canthus while providing lateral canthalsuspension, is a technique preferred by somesurgeons. This article aims to provide a practicalapplication for surgeons in performing aestheticcanthal suspension.

ANATOMY

The lower eyelid is a mobile structure that protectsthe eye from injury and enables the even distribu-tion of the tears on blinking. The eyelid consists of3 principal layers (Fig. 1):

1. Anterior lamella (skin, subcutaneous tissue,orbicularis oculi muscle)

2. Middle lamella (orbital septum)3. Posterior lamellar (tarsal plates, striated and

smooth muscle, and conjunctiva)

Anterior Lamella

The eyelid skin is the thinnest in the body. Beneaththe skin is loose subcutaneous tissue rich in elasticfibers and with minimal fat. The orbicularis oculi isa sphincteric muscle globe composed of ellipticalfibers that surround the globe. It is divided into 2principal segments:

1. The palpebral part, which lies over the eyelidsproper and is further subdivided into pretarsaland preseptal portions named after theanatomic eyelid structures beneath

2. An orbital part whose fibers run concentricallyover the orbital rimcavity.Posterior Lamella

The tarsal plates form a dense fibrous tissue thatgives the eyelids a defined shape and structure.The tarsus in the lower lid measures approximately3 to 4 mm in height (compared with 10 mm in theupper eyelid) and 20 mm in length, and is attachedmedially via the medial palpebral ligament to thelacrimal crest and laterally to theWhitnall ligament.Finally, the lower eyelid retractors form a fibro-

muscular structure composed of the capsulopal-pebral fascia and inferior tarsal muscle. Theretractors originate and are an extension of theinferior rectus muscle, and provide 3 to 5 mm ofmovement to the lower eyelid.

Lateral Canthus

The lateral canthus anatomically is where the up-per and lower lids meet laterally. The point wherethe lids meet is called the commissure. The lateralcanthal tendon, which bolsters the eyelids to theorbital rim, is formed by the pretarsal and presep-tal portions of the orbicularis, which taper to formthe superior and inferior limb of the lateral canthaltendon, which inserts onto the Whitnall tubercle2 mm posterior to the lateral orbital rim. In mostpeople the height of the lateral canthus is severalmillimeters above the medial canthus (see Fig. 1).

Blood Supply of the Lower Eyelids

The eyelids have a profuse blood supply fromthe lateral and medial palpebral arteries thatform a marginal and peripheral arterial archin the upper and lower eyelids. The lateralpalpebral arteries are derived from thelacrimal artery and the medical palpebral ar-teries from the ophthalmic artery. The venousdrainage is to the superior orbital vein and thefacial vein.

The lymphatic drainage of the medial two-thirds of the lower eyelid is to the submandibu-lar lymph nodes, and from the lateral one-thirdto the superficial parotid lymph nodes.

EVALUATION

The preoperative evaluation of the lower eyelid isessential in guiding surgical management of thecanthal support. The presence of lower eyelidlaxity and the position of the lower eyelid in relationto the medial canthus should be evaluated in allpatients.Lower eyelid evaluation should include the

following:

Lower eyelid distraction testing (Table 1). The

lower eyelid is pulled away from the globe

Fig. 1. Anatomy of the lower eyelid. Sagittal section and support of the lower eyelid: coronal section. (Reprintedfrom Gray H. Grays anatomy. Philadelphia: Lea and Febiger; 1918.)

Aesthetic Canthal Suspension 81

(termed lower eyelid distraction). If the eyelid

scleral show without lower eyelid laxity, whichis a consequence of prominent eyes or a

and supraplacement of the lower lid) to avoid

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Table 1Lower eyelid distraction test

Grade of Laxity Description

Grade 0 Normal

Grade I 24 mm

Grade II 46 mm

Grade III >6 mm

Grade IV Fails to return to normalposition

De Silva & Prasad82can be pulled 8 mm or more away from theglobe this is defined as a positive test, whichidentifies loss of canthal tendon integrity andthe presence of clinically significant lowereyelid laxity.

Snap-back testing (Table 2). The lower eyelidis pulled inferiorly with the examiners finger.When released, the eyelid should snap backto normal position without blink immediately.If this is delayed the test is positive, andgenerally signifies orbicularis deficit. Any pa-tient who shows unilateral evidence of poororbicularis tone should undergo evaluation toexclude VII nerve abnormality. Clinical signsof facial nerve paralysis, including orbicularisoculi weakness, should be discussed withthe patient and fully evaluated before surgicaltreatment.24

The position of the lateral canthus in relation tothe medial canthus. The normal position oflateral canthus is several millimeters above themedial canthus. A minority of patients have alateral canthus at the same level or below themedial canthus. The position of the lateralcanthus should be evaluated preoperatively,as postoperative changes in its position willchange the appearance of the eyes; this issueshould be discussed with the patient beforesurgery to avoid patient dissatisfaction.3.4.

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Table 2Lower eyelid snap-back test

Grade of Laxity Description

Grade 0 Lid that returns to normalposition immediately onrelease

Grade I 23 s

Grade II 45 s

Grade III >5 s but does return toposition with blinking

Grade IV Fails to return to normalposition (eg, ectropion)bowstringing (pseudoretraction) of theglobe. A volume-deficient midface (soft tissue orbone) results in relative globe prominence.Caution is required in canthal suspension forthese patients to avoid the aforementionedbowstringing effect.

An important consideration in the evaluationof the lower eyelid is an understanding of thecharacter of patients and how the appearanceof the eyes affects their view of themselves.The position of the lateral canthus and howthis is perceived has significant psychologicalimpact. Careful attention should be paid todiscussing lateral canthal suspension withthe patient before surgery so as to avoid unex-pected changes in appearance that may bebothersome to the patient.

URGICAL PROCEDURE

he surgical procedures for aesthetic canthal sus-ension can be categorized into 4 principal types:

CanthopexyOrbicularis oculi slingCanthoplastyModified canthoplasty

anthopexy

or those patients undergoing aesthetic lowerlepharoplasty who have mild but clinically signif-ant lower eyelid laxity, a canthopexy should pro-de a reduced risk of lower eyelid retraction ortropion. The advantage of this technique isat it is a relatively noninvasive means of sus-ending the lower eyelid to the lateral orbital rimnormal anatomic variant. The relative prominence of the globe is of crit-ical importance in evaluation of the lowereyelid, to avoid potential complications ofaesthetic canthal suspension. Prominent eyes(whether due to shallow orbits, large globes,or orbital pathology) require alternative canthalsuspension techniques (hang-back sutures The position of the lower eyelid in relation tothe iris. In most of the population the lowereyelid rests just above the lower limbus (ie,covering the inferior 12 mm of the iris). Pa-tients with marked laxity may have inferiorscleral show (defined as visible sclera be-tween the iris and the lower eyelid margin). Asmall proportion of patients may have inferiorith a single suture (Fig. 2).

FiManLotuth

Aesthetic Canthal Suspension 83 Three to 5mLof local anesthesia (1% lidocaineand 1:100,000 epinephrine) is infiltrated. A sin-gle suture of 5-0 absorbable or nonabsorbablesuture (eg,Prolene, Vicryl, orMonocryl) is used.

If upper blepharoplasty is performed at thesame time as the lower blepharoplasty, thelateral upper blepharoplasty incision can beused and a buttonhole dissection performedto the lateral orbital rim. The suture is then in-serted to be taken from the periosteum of theinner aspect of the lateral orbital rim toward tothe lateral canthus.

If transcutaneous lower blepharoplasty isperformed, the suture can exit the skin andbe repassed to the lateral orbital rim.

With transconjunctival blepharoplasty the su-ture can be passed out of the eyelid throughthe lateral angle at the Gray line (immediately

used by facial plastic and general plastic sur-

commonly when severe lower eyelid laxity is pre-sestisisreThofwotca

g. 2. Lateral canthopexy suture. (A) Shows 5-0onocryl suture from lateral orbital rim to Gray lined returning from Gray line to lateral orbital rim.wer eyelid position is without tension along the su-re. (B) Shows elevation of lower eyelid position withe suture tied.nt (resulting in eyelid malposition) or for recon-ruction following tumor excision. The procedureonly indicated if severe laxity of the lower eyelidpresent or if the position of the lower eyelid inlation to the medial canthus is to be modified.e procedure is effective in changing the positionthe lower eyelid; however, it may be associatedith an increased risk of asymmetry, scarring, andher complications, and is relatively rarely indi-ted for aesthetic canthal suspension.

The procedure is performed with the use of 3to 5 mL local anesthesia (1% lidocaine andgeons, and offers the advantage of avoiding sur-gery on the complex anatomy of the lateralcanthus itself. Although this technique is relativelystraightforward to perform, it does result in dam-age to the orbicularis oculi (which may be relevantin patients with, or at risk of, dry eye).

With the use of 3 to 5 mL local anesthesia (1%lidocaine and 1:100,000 epinephrine) a lowereyelid skin incision is made as part of thetranscutaneous blepharoplasty or in conjunc-tion with transconjunctival blepharoplasty.

A lateral orbicularis oculi rectangular strip isfashioned at the lateral canthus. A 5-0 absorb-able or nonabsorbable suture is the used toattach the orbicularis strip to the lateral orbitalrim, providing a support to the position of thelower eyelid.

Lateral Canthoplasty

Lower eyelid canthoplasty, or lateral tarsal sling, is acommon procedure used in reconstructive surgeryto restore the functional position of the lower eyelid,posterior to the eyelashes at the junction be-tween the anterior and posterior lamellae ofthe eyelid). The suture is then looped backthrough the Gray line to the lateral orbital rim.

The suture is then tied at the lateral orbital rimand the skin checked for puckering and, ifnecessary, subcutaneously released.

The procedure is then repeated on the secondside, taking care to maintain similar elevationand position on the lateral orbital rim to avoidcreating asymmetry in the position of thelateral canthus.

Orbicularis Oculi Sling

In conjunction with lower blepharoplasty, an orbi-cularis sling is fashioned that provides support tothe lower eyelid. This technique is more commonly1:100,000 epinephrine).

A horizontal skin incision is made from thelateral canthus approximately 10mm in length.

The orbicularis oculi is divided and the lateralaspect of the lower tarsal plate cleaned.

The lower eyelid is detached from the tarsusby dividing the lateral canthal tendon and de-taching orbicular attachments to the lowereyelid, releasing the lower eyelid to movelaterally (Fig. 3).

The lower eyelid is the shortened in relation tothe degree of laxity by reshaping the lateralaspect of the lower lateral tarsus.

A 5-0 absorbable or nonabsorbable suture isused to reattach the lateral canthal tarsus tothe lateral orbital rim.

Surgical note: In most patients the position of thelateral orbital rim is severalmillimeters above thepo-sition of the medial canthus; care must be taken inpositioning this suture toavoidchanging theappear-ance of the eyelids and inducing asymmetries.

Additional sutures are then placed by sur-

procedure; however, there is shortening of thelower eyelid. As a less invasive procedure thanlateral canthoplasty, it is more useful in aestheticcanthal suspension.

The procedure is performed with the use of 3to 5 mL local anesthesia (1% lidocaine and1:100,000 epinephrine).

A buttonhole incision is made through the skinand orbicularis to identify the lateral aspect ofthe tarsal plate.

A 5-0 absorbable or nonabsorbable suture isused to support the terminal tarsus and/orlateral canthal ligament to the lateral orbitalrim periosteum.

The canthal angle is then recreated with a 6-0or 7-0 absorbable suture from the upper tolower eyelid (either Gray line to Gray line orlash line to lash line). This suture preventsblunting of the lateral canthal angle that is acommon occurrence with periorbital aging.

De Silva & Prasad84geons with considerable variation in surgicaltechnique. Options include orbicularis oculisuture, Gray line suture, lash line suture, andclosure of the lateral canthal skin (see Fig. 3).

Modified Lateral Canthoplasty

Modified lateral canthoplasty is a hybrid techniqueinvolving elements of the lateral canthopexy andlateral canthoplasty techniques. The lower eyelidis divided from the upper eyelid with a canthotomyFig. 3. Lateral canthal release and fixation of the lateral cAFTERCARE

Postoperative care is identical to the managementof lower blepharoplasty.

Patients are advised on the use of prophylactictopical and oral antibiotics for the first week.

The use of ice compresses for the first 2 to3 days for 10 to 15 minutes over every hourduring the day are recommended to reduceeyelid swelling.anthus to the periosteum.

Patients are commonly reviewed at 1 weekafter surgery for the removal of skin sutures.

The final results of canthal suspension tech-niques are apparent at 6 months after surgery;the position of the eyelids is often higher immedi-ately after surgery and drops 1 to 2 mm duringthe following months (Fig. 4).

COMPLICATIONS

Complications from aesthetic canthal suspensioncan be divided into early and late postoperative

complications. Common complications are similarto those of lower blepharoplasty, including ecchy-mosis, swelling, and hematoma formation.

Early Postoperative Complications

Early postoperative complications include excessbleeding and hematoma formation, which arecommon and mostly resolve without intervention.A rare complication is orbital hemorrhage thatmay compress the optic nerve, resulting inimpaired visual acuity. Orbital hemorrhage re-quires urgent treatment with a lateral canthotomy

nts

Aesthetic Canthal Suspension 85Fig. 4. Preoperative and postoperative views of patie

surgery.who have undergone aesthetic lateral canthoplasty

to prevent compartment syndrome compression is generally reserved for more marked laxity, which

Korn BS, Kikkawa DO, Cohen SR. Transcutaneous lower

Shorr N, Goldberg RA, Eshaghian B, et al. Lateral can-

De Silva & Prasad86of the optic nerve.Patients may describe tightness at the lateral

orbital rim, which usually subsides over the first6 weeks as the support suture loosens. Occasion-ally this may persist as a result of low-level inflam-mation, requiring injection of low-dose steroid(0.10.2 mL Kenalog 10 mg/mL).

Late Postoperative Complications

Late postoperative complications have the poten-tial to be the most troublesome, and include asym-metries in the position of the lateral canthus,undercorrection, and overcorrection. Relativelyminor changes in the lateral canthus can changethe appearance of the eyes and change theapparent openness of the eyes, with elevation ofthe lower eyelid reducing the surface area of whitesclera. Care is required in altering the apparentopenness of eyes, as patients are often comfort-able with the preexisting openness of their eyesand may be unhappy if such changes are notdiscussed with them preoperatively.These complications may require further revi-

sion surgery for correction. Granuloma formationand suture abscess formation at the suspensionof the lower eyelid at the lateral orbital rim maypresent with swelling and discomfort; this mayresolve spontaneously or require injection of low-dose steroid (0.10.2 mL Kenalog 10 mg/mL).Occasionally surgical excision of the suture maybe indicated.

SUMMARY

Support of the lower eyelid with canthal suspen-sion is a useful tool in the prevention of complica-tions of lower blepharoplasty with particularrelevance to eyelids with increased lower lid laxity,relatively prominent globes, and negative vectorconfiguration of the eyelid-cheek junction. Cautionis required in surgical management of this highlydelicate anatomic area, as relatively small adjust-ments can result in relatively large changes thatcan alter the shape and appearance of the lowereyelids. Management options include canthopexy,orbicularis sling, and modified canthoplasty. Themost conservative surgical management optionis canthopexy, which supports the lower eyelidover either the short or long term. The use of theorbicularis sling technique avoids surgery aroundthe relatively complex lateral canthus, but maynot be suitable for cases without a need for askin incision or a history of dry eye. Canthoplastythoplasty. Ophthal Plast Reconstr Surg 2003;19(5):

34552.eyelid blepharoplasty with orbitomalar suspension:

retrospective review of 212 consecutive cases.

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SUGGESTED READINGS

Anderson RL, Gordy DD. The tarsal strip procedure.

Arch Ophthalmol 1979;97(11):21926.

De Silva DJ, Ramkissoon YD, Ismail AR, et al. Modified

lateral tarsorrhaphy. Ophthal Plast Reconstr Surg

2011;27(3):2168.

Hamra ST. Repositioning the orbicularis oculi muscle in

the composite rhytidectomy. Plast Reconstr Surg

1992;90:1422.

Aesthetic Canthal SuspensionKey pointsOverviewAnatomyAnterior LamellaMiddle LamellaPosterior LamellaLateral CanthusBlood Supply of the Lower Eyelids

EvaluationSurgical procedureCanthopexyOrbicularis Oculi SlingLateral CanthoplastyModified Lateral Canthoplasty

AftercareComplicationsEarly Postoperative ComplicationsLate Postoperative Complications

SummaryReferencesSuggested readings