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Suspension
D. Julian De Silva, MBBS, MD, FRCO, BSc, PGc, DICa,b, Amiya Prasad, MD, FACSc,d,*
KEYWORDS
Aesthetic canthal suspension Canthopexy Orbicularis sling Canthoplasty
KEY POINTS
OVERVIEW
Laxity of the lower eyelid is a common characteristic of facial aging, and correction of lower eyelid
laxity in conjunction with aesthetic blepharoplasty
is key to both an optimal cosmetic outcome and
avoidance of surgical complications. Laxity of the
lower eyelid is evaluated preoperatively with the
snap-back test.1 When lower eyelid blepharoplasty is completed with either a transcutaneous
or transconjunctival technique, consideration
must be given to the need for lower eyelid support
to avoid potential complications including lower
eyelid retraction and ectropion. With particular
relevance to transcutaneous lower blepharoplasty, excision of lower eyelid skin without
Oculo-Facial Plastic Surgery, London, UK; b Centre for London Facial Cosmetic & Plastic Surgery, London, UK;
Prasad Cosmetic Surgery, New York, NY, USA; d Division of Oculofacial Plastic & Reconstructive Surgery,
Winthrop 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.com
c
plasticsurgery.theclinics.com
Aesthetic canthal suspension is defined as a lateral elevation of the lower eyelid, which may be
completed as an independent procedure or more commonly in conjunction with aesthetic lower
blepharoplasty.
Indications for suspension of the lower eyelid include facial aging, laxity of the lower eyelid, and prevention of lower eyelid malposition.
Preoperative evaluation of the lower eyelid and its position with respect to the globe and the cheek
is key to optimal surgical management.
Anatomy of the lower eyelid and lateral canthus is both intricate and complex; thorough understanding of anatomy is required to avoid complications in aesthetic canthal suspension.
Canthopexy is defined as a procedure to elevate and support the lower eyelid to the lateral orbital
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.
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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ANATOMY
The lower eyelid is a mobile structure that protects
the eye from injury and enables the even distribution of the tears on blinking. The eyelid consists of
3 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. Beneath
the skin is loose subcutaneous tissue rich in elastic
fibers and with minimal fat. The orbicularis oculi is
a sphincteric muscle globe composed of elliptical
fibers that surround the globe. It is divided into 2
principal segments:
1. The palpebral part, which lies over the eyelids
proper and is further subdivided into pretarsal
and preseptal portions named after the
anatomic eyelid structures beneath
2. An orbital part whose fibers run concentrically
over the orbital rim
The orbicularis oculi is a protractor of the eyelids
whose function is to close the eyelids. The muscle
is innervated from its undersurface by the temporal (upper eyelids) and zygomatic (lower eyelids)
branches of the facial nerve.
Middle Lamella
The orbital septum is a fibrous structure beneath
the orbicularis muscle, which divides the anterior
lamella from the orbital cavity. It is a continuation
of the periosteum at the orbital rim. Vertically the
septum fuses with the lower eyelid retractors
5 mm below the tarsus, continuing as one layer
until inserting on the inferior edge of the tarsus.
Horizontally the septum lies posterior to the
medial palpebral ligament (canthal tendon) and
anterior to the lateral palpebral ligament. The
orbital septum provides an important functional
barrier in the eyelid that protects the spread of
infection from superficial skin tissues to the orbital
cavity.
Posterior Lamella
The tarsal plates form a dense fibrous tissue that
gives the eyelids a defined shape and structure.
The tarsus in the lower lid measures approximately
3 to 4 mm in height (compared with 10 mm in the
upper eyelid) and 20 mm in length, and is attached
medially via the medial palpebral ligament to the
lacrimal crest and laterally to the Whitnall ligament.
Finally, the lower eyelid retractors form a fibromuscular structure composed of the capsulopalpebral fascia and inferior tarsal muscle. The
retractors originate and are an extension of the
inferior rectus muscle, and provide 3 to 5 mm of
movement to the lower eyelid.
Lateral Canthus
The lateral canthus anatomically is where the upper and lower lids meet laterally. The point where
the lids meet is called the commissure. The lateral
canthal tendon, which bolsters the eyelids to the
orbital rim, is formed by the pretarsal and preseptal portions of the orbicularis, which taper to form
the superior and inferior limb of the lateral canthal
tendon, which inserts onto the Whitnall tubercle
2 mm posterior to the lateral orbital rim. In most
people the height of the lateral canthus is several
millimeters above the medial canthus (see Fig. 1).
EVALUATION
The preoperative evaluation of the lower eyelid is
essential in guiding surgical management of the
canthal support. The presence of lower eyelid
laxity and the position of the lower eyelid in relation
to the medial canthus should be evaluated in all
patients.
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. (Reprinted
from Gray H. Grays anatomy. Philadelphia: Lea and Febiger; 1918.)
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Table 1
Lower eyelid distraction test
Grade of Laxity
Description
Grade
Grade
Grade
Grade
Grade
Normal
24 mm
46 mm
>6 mm
Fails to return to normal
position
0
I
II
III
IV
Description
Grade 0
Grade I
Grade II
Grade III
Grade IV
SURGICAL PROCEDURE
The surgical procedures for aesthetic canthal suspension can be categorized into 4 principal types:
1.
2.
3.
4.
Canthopexy
Orbicularis oculi sling
Canthoplasty
Modified canthoplasty
Canthopexy
For those patients undergoing aesthetic lower
blepharoplasty who have mild but clinically significant lower eyelid laxity, a canthopexy should provide a reduced risk of lower eyelid retraction or
ectropion. The advantage of this technique is
that it is a relatively noninvasive means of suspending the lower eyelid to the lateral orbital rim
with a single suture (Fig. 2).
Lateral Canthoplasty
Three to 5 mL of local anesthesia (1% lidocaine
and 1:100,000 epinephrine) is infiltrated. A single suture of 5-0 absorbable or nonabsorbable
suture (eg, Prolene, Vicryl, or Monocryl) is used.
If upper blepharoplasty is performed at the
same time as the lower blepharoplasty, the
lateral upper blepharoplasty incision can be
used and a buttonhole dissection performed
to the lateral orbital rim. The suture is then inserted to be taken from the periosteum of the
inner aspect of the lateral orbital rim toward to
the lateral canthus.
If transcutaneous lower blepharoplasty is
performed, the suture can exit the skin and
be repassed to the lateral orbital rim.
With transconjunctival blepharoplasty the suture can be passed out of the eyelid through
the lateral angle at the Gray line (immediately
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AFTERCARE
Postoperative care is identical to the management
of lower blepharoplasty.
Patients are advised on the use of prophylactic
topical and oral antibiotics for the first week.
The use of ice compresses for the first 2 to
3 days for 10 to 15 minutes over every hour
during the day are recommended to reduce
eyelid swelling.
Fig. 3. Lateral canthal release and fixation of the lateral canthus to the periosteum.
COMPLICATIONS
Complications from aesthetic canthal suspension
can be divided into early and late postoperative
Fig. 4. Preoperative and postoperative views of patients who have undergone aesthetic lateral canthoplasty
surgery.
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SUMMARY
Support of the lower eyelid with canthal suspension is a useful tool in the prevention of complications of lower blepharoplasty with particular
relevance to eyelids with increased lower lid laxity,
relatively prominent globes, and negative vector
configuration of the eyelid-cheek junction. Caution
is required in surgical management of this highly
delicate anatomic area, as relatively small adjustments can result in relatively large changes that
can alter the shape and appearance of the lower
eyelids. Management options include canthopexy,
orbicularis sling, and modified canthoplasty. The
most conservative surgical management option
is canthopexy, which supports the lower eyelid
over either the short or long term. The use of the
orbicularis sling technique avoids surgery around
the relatively complex lateral canthus, but may
not be suitable for cases without a need for a
skin incision or a history of dry eye. Canthoplasty
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