A e s t h e t i c Ca n t h a l

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

consideration of canthal suspension results in an

increased risk of lower eyelid retraction or malposition. Aesthetic canthal suspension may involve a
single support suture to support the lower eyelid
from the lateral orbital rim (canthopexy) or support
of the lateral canthal tendon (canthoplasty), or
tightening of the orbicularis oculi (orbicularis sling).
Care is required in support and alteration of the
lateral canthus, as small differences can be
apparent with asymmetry or functional discomfort.
Oculoplastic surgeons have a good anatomic
knowledge of this area, as reconstructive surgery
on the lateral canthus is a common procedure. By
contrast, other surgical specialties often find this
area challenging because the anatomy is intricate

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

Clin Plastic Surg 42 (2015) 7986

http://dx.doi.org/10.1016/j.cps.2014.08.005
0094-1298/15/$ see front matter 2015 Elsevier Inc. All rights reserved.

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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and less familiar. As a consequence, the orbicularis
sling technique, which avoids intricate surgery on
the lateral canthus while providing lateral canthal
suspension, is a technique preferred by some
surgeons. This article aims to provide a practical
application for surgeons in performing aesthetic
canthal suspension.

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).

Blood Supply of the Lower Eyelids

 The eyelids have a profuse blood supply from
the lateral and medial palpebral arteries that
form a marginal and peripheral arterial arch
in the upper and lower eyelids. The lateral
palpebral arteries are derived from the
lacrimal artery and the medical palpebral arteries from the ophthalmic artery. The venous
drainage is to the superior orbital vein and the
facial vein.
 The lymphatic drainage of the medial twothirds of the lower eyelid is to the submandibular lymph nodes, and from the lateral one-third
to the superficial parotid lymph nodes.

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

Aesthetic Canthal Suspension

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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 The position of the lower eyelid in relation to
the iris. In most of the population the lower
eyelid rests just above the lower limbus (ie,
covering the inferior 12 mm of the iris). Patients with marked laxity may have inferior
scleral show (defined as visible sclera between the iris and the lower eyelid margin). A
small proportion of patients may have inferior
scleral show without lower eyelid laxity, which
is a consequence of prominent eyes or a
normal anatomic variant.
 The relative prominence of the globe is of critical importance in evaluation of the lower
eyelid, to avoid potential complications of
aesthetic canthal suspension. Prominent eyes
(whether due to shallow orbits, large globes,
or orbital pathology) require alternative canthal
suspension techniques (hang-back sutures
and supraplacement of the lower lid) to avoid
bowstringing (pseudoretraction) of the globe.
 A volume-deficient midface (soft tissue or
bone) results in relative globe prominence.
Caution is required in canthal suspension for
these patients to avoid the aforementioned
bowstringing effect.
 An important consideration in the evaluation
of the lower eyelid is an understanding of the
character of patients and how the appearance
of the eyes affects their view of themselves.
The position of the lateral canthus and how
this is perceived has significant psychological
impact. Careful attention should be paid to
discussing lateral canthal suspension with
the patient before surgery so as to avoid unexpected changes in appearance that may be
bothersome to the patient.

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

(termed lower eyelid distraction). If the eyelid

can be pulled 8 mm or more away from the
globe this is defined as a positive test, which
identifies loss of canthal tendon integrity and
the presence of clinically significant lower
eyelid laxity.
 Snap-back testing (Table 2). The lower eyelid
is pulled inferiorly with the examiners finger.
When released, the eyelid should snap back
to normal position without blink immediately.
If this is delayed the test is positive, and
generally signifies orbicularis deficit. Any patient who shows unilateral evidence of poor
orbicularis tone should undergo evaluation to
exclude VII nerve abnormality. Clinical signs
of facial nerve paralysis, including orbicularis
oculi weakness, should be discussed with
the patient and fully evaluated before surgical
treatment.24
 The position of the lateral canthus in relation to
the medial canthus. The normal position of
lateral canthus is several millimeters above the
medial canthus. A minority of patients have a
lateral canthus at the same level or below the
medial canthus. The position of the lateral
canthus should be evaluated preoperatively,
as postoperative changes in its position will
change the appearance of the eyes; this issue
should be discussed with the patient before
surgery to avoid patient dissatisfaction.
Table 2
Lower eyelid snap-back test
Grade of Laxity

Description

Grade 0

Lid that returns to normal

position immediately on
release
23 s
45 s
>5 s but does return to
position with blinking
Fails to return to normal
position (eg, ectropion)

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).

Aesthetic Canthal Suspension

posterior to the eyelashes at the junction between the anterior and posterior lamellae of
the eyelid). The suture is then looped back
through the Gray line to the lateral orbital rim.
 The suture is then tied at the lateral orbital rim
and the skin checked for puckering and, if
necessary, subcutaneously released.
 The procedure is then repeated on the second
side, taking care to maintain similar elevation
and position on the lateral orbital rim to avoid
creating asymmetry in the position of the
lateral canthus.

Orbicularis Oculi Sling

In conjunction with lower blepharoplasty, an orbicularis sling is fashioned that provides support to
the lower eyelid. This technique is more commonly
used by facial plastic and general plastic surgeons, and offers the advantage of avoiding surgery on the complex anatomy of the lateral
canthus itself. Although this technique is relatively
straightforward to perform, it does result in damage to the orbicularis oculi (which may be relevant
in patients with, or at risk of, dry eye).

Fig. 2. Lateral canthopexy suture. (A) Shows 5-0

Monocryl suture from lateral orbital rim to Gray line
and returning from Gray line to lateral orbital rim.
Lower eyelid position is without tension along the suture. (B) Shows elevation of lower eyelid position with
the suture tied.

 With the use of 3 to 5 mL local anesthesia (1%

lidocaine and 1:100,000 epinephrine) a lower
eyelid skin incision is made as part of the
transcutaneous blepharoplasty or in conjunction with transconjunctival blepharoplasty.
 A lateral orbicularis oculi rectangular strip is
fashioned at the lateral canthus. A 5-0 absorbable or nonabsorbable suture is the used to
attach the orbicularis strip to the lateral orbital
rim, providing a support to the position of the
lower eyelid.

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

Lower eyelid canthoplasty, or lateral tarsal sling, is a

common procedure used in reconstructive surgery
to restore the functional position of the lower eyelid,
commonly when severe lower eyelid laxity is present (resulting in eyelid malposition) or for reconstruction following tumor excision. The procedure
is only indicated if severe laxity of the lower eyelid
is present or if the position of the lower eyelid in
relation to the medial canthus is to be modified.
The procedure is effective in changing the position
of the lower eyelid; however, it may be associated
with an increased risk of asymmetry, scarring, and
other complications, and is relatively rarely indicated for aesthetic canthal suspension.
 The procedure is performed with the use of 3
to 5 mL local anesthesia (1% lidocaine and
1:100,000 epinephrine).

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 A horizontal skin incision is made from the
lateral canthus approximately 10 mm in length.
 The orbicularis oculi is divided and the lateral
aspect of the lower tarsal plate cleaned.
 The lower eyelid is detached from the tarsus
by dividing the lateral canthal tendon and detaching orbicular attachments to the lower
eyelid, releasing the lower eyelid to move
laterally (Fig. 3).
 The lower eyelid is the shortened in relation to
the degree of laxity by reshaping the lateral
aspect of the lower lateral tarsus.
 A 5-0 absorbable or nonabsorbable suture is
used to reattach the lateral canthal tarsus to
the lateral orbital rim.
Surgical note: In most patients the position of the
lateral orbital rim is several millimeters above the position of the medial canthus; care must be taken in
positioning this suture to avoid changing the appearance of the eyelids and inducing asymmetries.
 Additional sutures are then placed by surgeons with considerable variation in surgical
technique. Options include orbicularis oculi
suture, Gray line suture, lash line suture, and
closure of the lateral canthal skin (see Fig. 3).

Modified Lateral Canthoplasty

Modified lateral canthoplasty is a hybrid technique
involving elements of the lateral canthopexy and
lateral canthoplasty techniques. The lower eyelid
is divided from the upper eyelid with a canthotomy

procedure; however, there is shortening of the

lower eyelid. As a less invasive procedure than
lateral canthoplasty, it is more useful in aesthetic
canthal suspension.
 The procedure is performed with the use of 3
to 5 mL local anesthesia (1% lidocaine and
1:100,000 epinephrine).
 A buttonhole incision is made through the skin
and orbicularis to identify the lateral aspect of
the tarsal plate.
 A 5-0 absorbable or nonabsorbable suture is
used to support the terminal tarsus and/or
lateral canthal ligament to the lateral orbital
rim periosteum.
 The canthal angle is then recreated with a 6-0
or 7-0 absorbable suture from the upper to
lower eyelid (either Gray line to Gray line or
lash line to lash line). This suture prevents
blunting of the lateral canthal angle that is a
common occurrence with periorbital aging.

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.

Aesthetic Canthal Suspension

 Patients are commonly reviewed at 1 week
after surgery for the removal of skin sutures.
The final results of canthal suspension techniques are apparent at 6 months after surgery;
the position of the eyelids is often higher immediately after surgery and drops 1 to 2 mm during
the following months (Fig. 4).

COMPLICATIONS
Complications from aesthetic canthal suspension
can be divided into early and late postoperative

complications. Common complications are similar

to those of lower blepharoplasty, including ecchymosis, swelling, and hematoma formation.

Early Postoperative Complications

Early postoperative complications include excess
bleeding and hematoma formation, which are
common and mostly resolve without intervention.
A rare complication is orbital hemorrhage that
may compress the optic nerve, resulting in
impaired visual acuity. Orbital hemorrhage requires urgent treatment with a lateral canthotomy

Fig. 4. Preoperative and postoperative views of patients who have undergone aesthetic lateral canthoplasty
surgery.

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to prevent compartment syndrome compression
of the optic nerve.
Patients may describe tightness at the lateral
orbital rim, which usually subsides over the first
6 weeks as the support suture loosens. Occasionally this may persist as a result of low-level inflammation, requiring injection of low-dose steroid
(0.10.2 mL Kenalog 10 mg/mL).

Late Postoperative Complications

Late postoperative complications have the potential to be the most troublesome, and include asymmetries in the position of the lateral canthus,
undercorrection, and overcorrection. Relatively
minor changes in the lateral canthus can change
the appearance of the eyes and change the
apparent openness of the eyes, with elevation of
the lower eyelid reducing the surface area of white
sclera. Care is required in altering the apparent
openness of eyes, as patients are often comfortable with the preexisting openness of their eyes
and may be unhappy if such changes are not
discussed with them preoperatively.
These complications may require further revision surgery for correction. Granuloma formation
and suture abscess formation at the suspension
of the lower eyelid at the lateral orbital rim may
present with swelling and discomfort; this may
resolve spontaneously or require injection of lowdose steroid (0.10.2 mL Kenalog 10 mg/mL).
Occasionally surgical excision of the suture may
be indicated.

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

is generally reserved for more marked laxity, which

is less common in the group of patients seeking
aesthetic blepharoplasty.

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4. Fagien S. Algorithm for canthoplasty: the lateral retinacular suspension: a simplified suture canthopexy.
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