C H A P T E R
14  
The Spectrum of Canthal Suspension
Techniques in Lower Blepharoplasty
Andrea Lora Kossler, MD and Guy G. Massry, MD
INTRODUCTION
Traditional lower blepharoplasty consists of an open
approach, transcutaneous procedure in which variable
amounts of skin, muscle, and fat are excised. Inherent
to this technique is a predilection for rounding of the
canthal angle and lower eyelid retraction [1–5], noted to
occur in 6% to 20% of such cases [4]. In the authors’
experience these are very difficult problems to address and
cause tremendous dissatisfaction in the aesthetic blepha-
roplasty population. Traditionally, postblepharoplasty
lower eyelid retraction has been thought to be primarily
related to unaddressed lower eyelid laxity, anterior lamel-
lar shortage, and the development of a middle lamellar
scar [2,6]. More recently, it has been shown that weak-
ness of the orbicularis oculi muscle and negative orbito-
facial vector eyelid configuration also play an important
role in postblepharoplasty eyelid malposition [7]. Irre-
spective of the primary cause, canthal suspension, as a
means of addressing preexistent lower eyelid laxity, has
become an integral part of lower blepharoplasty and
reduces the incidence of postoperative eyelid malposition
and aesthetic deficit [8–12]. In addition to maintaining
aesthetics, when canthal suspension is added to surgery,
eyelid function is preserved. Unaddressed eyelid laxity
can biomechanically weaken orbicularis oculi function
[13] and lead to an inadequate blink, ocular surface expo-
sure, altered tear clearance, foreign body sensation, and
tearing [13–16].
In 1969 Tenzel [17] was the first to suggest lateral
canthal suspension as a method to correct lower lid mal-
position. He described a lateral canthotomy (open pro-
cedure) and inferior cantholysis to gain access to the
lower tarsus for suspension to the lateral orbital rim
[17]. Webster then described canthal suspension as an
adjunct to blepharoplasty to prevent lid malposition [18].
As it became clear that the incidence of lower lid mal-
position could be reduced with adjunctive canthal sus-
pension during blepharoplasty, this addition to surgery
became commonplace [6,18]. In 1979, Anderson et al.
[19] described the lateral tarsal strip (LTS), which gained
favor as a standard canthal suspension technique. In this
procedure the lateral canthal tendon (LCT) is accessed
through a canthotomy, and horizontal eyelid shorten-
ing is a common step. While the LTS and its variations
[20–26] are a landmark development in the manage-
ment of reconstructive eyelid procedures, its invasiveness
and disruption of canthal architecture and anatomy have
152
limited its integration into contemporary aesthetic bleph-
aroplasty. Some of the limits of this procedure include the
potential development of horizontal eyelid length dispar-
ity between the upper and lower lid, alteration of the
canthal angle and commissure, lateral canthal dystopia,
and poor overall cosmesis [27–30]. In the setting of ectro-
pion or entropion, patients are often accepting of these
issues as their premorbid condition has been improved
significantly. The aesthetic patient is much less forgiv-
ing. As such, open canthopexy procedures [10,18,31–35],
in which the canthal tendon is plicated to the orbital
rim, gained favor as they better preserve lateral canthal
anatomy and are less disruptive. In an effort to further
preserve canthal integrity and maintain canthal aesthet-
ics, closed canthal suspension techniques have evolved
[30,36–39]. In this setting the canthus is accessed from
a distant site without a canthal incision (hence a closed
procedure). This better preserves native canthal anatomy
and avoids the aforementioned complications of the
LTS procedure, as well as the development of canthal
webs and scars, which can occur when canthal incisions
are made.
In this chapter the authors attempt to simplify canthal
suspension surgery by detailing a spectrum of procedures,
including: (1) traditional open canthoplasty [17,19–26]
and open canthopexy [10,18,31–35]; and (2) more
contemporary closed canthoplasty [30,36] and closed
canthopexy [38]. The authors will also review canthal
nomenclature, relevant canthal anatomy, discuss canthal
aging changes, highlight key preoperative examination
pearls, and review postoperative care and complications.
CANTHAL NOMENCLATURE
The description of canthal surgery in the literature can be
confusing for both the novice and/or experienced surgeon
as numerous procedures are reported, most being simple
modifications of one another. What makes this even more
complex is the naming of these surgical variations and the
anatomic structures modified during surgery. For simpli-
fication and clarity, the authors prefer the general term
“canthal suspension,” as all canthal procedures have a
common goal of “supporting or tightening” the lower
lid at the canthus. In addition, to develop a proper foun-
dation and framework for understanding and planning
these procedures, a mental flowchart of the options avail-
able is often helpful. To this vein, the authors subdivide
canthal suspension techniques into two broad categories:
 14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty 153

TABLE 14.1  Canthal Nomenclature and Definitions

Nomenclature Definition
Open canthal suspension Requires a canthal incision (canthotomy) to access the LCT or terminal tarsus
Closed canthal suspension Requires no canthotomy to access the LCT or terminal tarsus. These structures are accessed from a
distant site (i.e., upper lid crease)
Canthoplasty The terminal tarsus or LCT is modified and secured to the lateral orbital rim
Canthopexy The terminal tarsus, orbicularis muscle, or LCT are not modified, but are suspended to the lateral
orbital rim with a plication suture
Canthotomy Lateral canthal incision
Cantholysis Dynamic release of the LCT from the lateral orbital rim
Lateral canthus The general area where the upper and lower lids meet laterally
Lateral commissure The point of union of the upper and lower lids at the lateral canthus
LCT Connective tissue structure that secures the upper and lower terminal eyelid to the lateral orbital rim
Lateral retinaculum Another name used to describe the LCT. The confluence of several of the soft-tissue structures of the
lateral upper and lower eyelid that have connections with the LCT
LPL Another synonymous name for the LCT
Lateral raphe The area of fine fibrous bands where the terminal orbicularis muscle of the upper and lower lids meet
Orbitofacial vector The relationship of globe projection to the lower lid and midface. When the globe and midface are
aligned in a horizontal plane the vector is neutral. When the globe projects more anterior than the
midface, the vector is negative; when the globe sits posterior to the midface the vector is positive
Ab-externo Suture passage starts outside the wound (outside in) to secure the LCT to the lateral orbital rim
Ab-interno Suture passage starts inside the wound (inside out) to secure the LCT to the lateral orbital rim
LCT, Lateral canthal tendon; LPL, lateral palpebral ligament.

(1) open, and (2) closed, with each category further sub-
divided into either a canthoplasty or canthopexy variant.
An open canthal procedure involves a canthal incision,
or canthotomy, while a closed procedure does not. In
open surgery, as anatomy is obvious, precise placement
of the lower eyelid is enhanced. However, because the
canthus is disarticulated and reformed, canthal deformity
can occur. A closed canthal suspension, on the other
hand, accesses and suspends the canthal tendon or termi-
nal tarsus through a distant site (typically the upper lid
crease). In this technique, exposure is limited, anatomy is
better preserved, but placement of the canthus can be less
precise. Its main advantages are that it is less traumatic
and avoids lateral canthal deformity. A canthoplasty is
a procedure in which the LCT or temporal lower lid is
incised, plus/minus shortened, and secured to the lateral
orbital rim. Conversely, a canthopexy is a procedure in
which the lower eyelid is suspended to the lateral orbital
rim with a plication suture without modification of the
LCT or terminal tarsus.
Attaining clarity of anatomic terminology of the
canthus is also important to understanding canthal sus-
pension surgery. The connective tissue structure that
secures the terminal eyelid to the orbit is called the LCT.
It is derived/originates from distal fibers of the palpebral
orbicularis muscle and inserts onto the lateral orbital rim.
A synonymous name for the LCT is the lateral palpebral
ligament. This is actually a better description of the struc-
ture, as a tendon connects a muscle to bone to move the
bone, while a ligament attaches bones to bone to secure
their alignment, which is more descriptive of what is
occurring here. The lateral retinaculum is another name
used to describe the LCT. A retinaculum, by definition, is
a band around tendons to stabilize them and hold them
in place. As the LCT has contributions or connections
with many other structures (lateral horn of levator apo-
neurosis, check ligament of lateral rectus, orbital septum,
etc.), the confluence of these structures can be considered
a retinaculum. Finally, the lateral canthus is the general
area where the upper and lower lids meet, whereas the
commissure is the point of this union. The lateral raphe is
an area of fine fibrous bands where the terminal orbicu-
laris muscle of the upper and lower lids meet. Additional
nomenclature specific to lateral canthal surgery includes
the terms ab-interno (originating from the inside) and
ab-externo (originating from the outside). Refer to Table
14.1 for a simplified naming and description of relevant
canthal surgical concepts and anatomic structures.
CANTHAL ANATOMY
The lower eyelid is suspended medially and laterally at
the respective canthi by the medial canthal tendons and
LCTs. As stated, the LCT is a connective tissue structure
derived from the terminal pretarsal and preseptal orbi-
cularis fibers that inset onto the lateral orbital rim. It is
a three-dimensional structure anchored horizontally, but
with a vertical component, as the lateral canthus is typi-
cally 2 mm higher than its medial counterpart (normal
canthal tilt) [40,41]. In addition, it has an anterior and
154 MASTER TECHNIQUES IN FACIAL REJUVENATION

Pretarsal Tarsus
orbicularis
Lateral canthal tendon Levator Tarsus
(anterior part) aponeurosis Orbital
septum
Lateral canthal
tendon Lacrimal gland
(posterior part) Levator, Preseptal
lateral horn orbicularis

Lateral Pretarsal
canthal orbicularis
tendon
Lockwood’s
Preseptal
ligament
orbicularis
Whitnall’s
tubercle Orbital
Capsulopalpebral
septum
fascia

A B
Figure 14.1   (A) Axial section of the lateral canthus and lateral orbital rim demonstrating the anterior and posterior components of the lateral

canthal tendon (lateral palpebral ligament), with the posterior portion (deep head) attaching to Whitnall’s tubercle. (B) Lateral canthal anatomy,
and association with other eyelid structures.

A B
Figure 14.2  (A) Laxity and dehiscence of the LCT can result in a (B) “fishmouthing” phenomenon with medialization of the lateral canthus and
deficient and weakened eyelid closure (arrows show direction of closure as horizontal rather than vertical with resultant lagophthalmos). LCT,
Lateral canthal tendon.

posterior component. The posterior portion attaches
3 mm posterior to the orbital rim at Whitnall’s tuber-
cle 10 mm below the frontozygomatic suture [40]. It is
important to recreate this attachment during canthal sus-
pension surgery, as it assures the lower lid’s appropriate
apposition to the globe (Fig. 14.1A). The anterior portion
of the tendon inserts at the anterior edge of the orbital
rim. This lends support to canthal integrity, but plays a
secondary role to the more critical posterior attachment.
Traditionally, the lateral canthus has been considered
a support structure only; however, it has other functions
and many moving parts. It is associated with the orbital
septum, the lateral horn of the levator aponeurosis, and
plays a role in native upper lid tension (Fig. 14.1B). For
this reason, on occasion, surgery has led to temporary
or permanent ptosis (when the upper limb of the tendon
is imbricated). The canthus is also intimately associated
with the check ligament of the lateral rectus muscle, and
in the normal state moves laterally a few millimeters
with abduction. Finally, the orbicularis muscle (eyelid
protractor) is oriented circumferentially around the eye.
This normally would allow a circular contraction pattern
of the muscle. As the canthal tendons secure the orbicu-
laris laterally and medially, this biomechanically imparts
a vertical contraction pattern of the palpebral aperture.
When canthal integrity is lost with senescence or from
eyelid surgery, this contraction pattern becomes deficient,
leading to an altered blink, poor eyelid closure, and “fish-
mouthing” (Fig. 14.2) [13], or a medialization of the
lateral canthus with a shortened horizontal fissure and
impaired eyelid dynamics.
CANTHAL AGING CHANGES
With aging, tissue descent, deflation (bone and fat), and
cutaneous degeneration contribute to an alteration of
 14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty 155

A B
Figure 14.3   Snap-back test. (A) The lower eyelid is pulled inferiorly and away from the globe, (B) the lid returns without blink. Note that the

lower lid demonstrates decreased orbicularis tone as it does not return to normal position without blink (compared with opposite side). (Reprinted
with permission from Massry GG. Managing the lateral canthus in the aesthetic patient. Master techniques in blepharoplasty and periorbital reju-
venation. New York, NY: Springer New York; 2011. p. 187.)

the dimensions of the palpebral aperture and the associ-
ated position, tone, and function of the lower eyelid. In
general, the eyelid aperture changes from one that is a
horizontal oval (longer in this dimension) to one that is
more vertical as the lateral canthus migrates medially
[42]. Canthal alterations resulting from tissue involution
is a multifactorial process that occurs in three dimen-
sions. It is very difficult to recreate a youthful appearance
and function when the sole intervention is tissue excision
and suspension in one plane. This is especially true of the
canthus, whose purpose is so much more than maintain-
ing appropriate lid position (i.e., blink, check ligament
to the lateral rectus, eyelid excursion, lacrimal pump
function, etc.). For this reason, the “belt and suspend-
ers” procedures we often employ in this setting can cause
havoc among the aesthetic patient population, even in the
presence of what appears to be a nice result [7,43]. This is
also why, in this particular patient population, less tissue
disruption is better and consideration should be given
to the more contemporary closed suspension techniques
elaborated on later.
PREOPERATIVE ASSESSMENT
A careful analysis of the lower lid position and func-
tion in patients undergoing blepharoplasty is essential
to determine the need for canthal suspension. In addi-
tion, identification of patients at high risk of postopera-
tive eyelid malposition is critical. For example, patients
with a history of thyroid disorder, facial nerve paresis,
previous blepharoplasty, or trauma require special atten-
tion on examination to assure surgical feasibility. The
physical examination should include both a static and
dynamic examination of the lower eyelid and canthus.
The clinical features evaluated include: eyelid position,
tone, and an assessment of laxity. Also, eyelid fissure
dimensions, lateral canthal angle configuration, direc-
tion of movement of the lateral commissure with blink,
adequacy of eyelid closure, and the morphologic relation-
ship of the globe to the cheek (orbitofacial vector) should
be assessed. In the following paragraphs the authors
will focus on the essential elements of the physical
assessment.
The lower eyelid margin normally rests just above
the inferior limbus in neutral gaze. The margin reflex
distance-2 (MRD-2), which is the distance between the
corneal light reflex and the lower eyelid margin with
the patient staring at a light in primary gaze, is used
to measure the lower lid position [44]. It is normally
6 mm and can increase in patients with lower lid laxity.
When lower lid retraction is present the lid rests below
the limbus, scleral show is manifest, and the MRD-2
increases. The horizontal palpebral fissure normally mea-
sures 30 mm and the canthus lies 2 mm higher tempo-
rally than nasally. Documenting these measurements is
important for assessment, surgical decision-making, and
photographic reference after surgery if needed.
The eyelid snap-back and distraction tests are per-
formed to evaluate the integrity of the lower eyelid canthal
complex. The snap-back test is performed by pulling the
lower eyelid down and away from the globe. The eyelid
should return to its normal resting position in less than 1
second without blink. If this is delayed the test is positive
and generally signifies orbicularis weakness (Fig. 14.3).
In the eyelid distraction test, the distance that the lower
eyelid can be pulled away from the globe is measured (Fig.
14.4). A distance of 8 mm or more is defined as a posi-
tive test and indicates clinically significant eyelid laxity.
In the setting of aesthetic blepharoplasty, the examination
modalities described may miss subtle degrees of eyelid
laxity that can still predispose to postoperative compli-
cations. Therefore, for the purposes of preserving eyelid
appearance and function after surgery, canthal suspen-
sion should be considered even when small deficiencies
of canthal tendon integrity are present.
Another critical factor on examination is the relation-
ship of globe projection to the lower lid and midface.
This relationship is referred to as the orbitofacial vector.
When the globe and midface are aligned in a vertical
plane the vector is neutral. When the globe projects more
anterior than the midface, the vector is negative; when
the globe sits posterior to the midface the vector is posi-
tive (Fig. 14.5). A negative vector configuration places
the eyelid at a mechanical disadvantage, as the lower
lid must work against a gradient to maintain normal
resting position. This is a delicate equilibrium that can
156 MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 14.4   Eyelid distraction test. The lower eyelid is pulled away
from the globe and the distance is measured. Eight mm or more signifies
eyelid laxity. (Reprinted with permission from Massry GG. Manag-
ing the lateral canthus in the aesthetic patient. Master techniques in
blepharoplasty and periorbital rejuvenation. New York, NY: Springer
New York; 2011. p. 187.)
be negatively impacted by even a small manipulation of
the lower lid/canthal complex. In fact, it has recently
been shown that negative vector globe/lid topography can
be a significant contributor to postblepharoplasty eyelid
retraction [7]. Special care and attention must be given
to patients presenting with negative vector topography,
which is typically seen in the setting of shallow orbits,
long eyes (myopia), proptosis, or a hypoplastic midface.
Finally, as with any aesthetic evaluation, it is impor-
tant to discuss the postoperative goals and expectations
of the lateral canthal surgery. The position of the lateral
canthus, and how patients perceive this, has significant
psychological impact. Careful attention should be paid
to discussing the suggested procedure at length so as to
avoid an unexpected change in appearance that may be
bothersome to the patient.
SURGERY
Open Canthal Suspension
Lateral Tarsal Strip
The workhorse of open canthoplasty has been the LTS
procedure. The LTS [19], and its variants [20–26], remains
one of the most common reconstructive canthal suspen-
sions performed today. It would be remiss not to describe
it, as it requires undoing and redoing all aspects of the
canthus. Once this is mastered, clarity is developed with
all forms of canthal suspension, and surgery becomes
easier to perform. As mentioned previously, disadvan-
tages of the technique can include any combination of
(1) shortening of the horizontal palpebral fissure; (2) lid
length disparity between the upper and lower lids, with
or without symptoms of eyelid imbrication; (3) misalign-
ment, distortion, or dystopia of the lateral canthal angle;
(4) prolonged chemosis; and (5) lateral canthal scarring,
webbing, or unacceptable aesthetic appearance [27–30].
As a result of these potential issues, and the fact that there
are now less invasive options available for the aesthetic
Figure 14.5  A negative orbitofacial vector is diagnosed if a straight
line drawn from the cornea falls anterior to the inferior orbital rim in
the lateral view.
patient population, the LTS is less commonly used in this
setting. However, in patients (typically older) who mani-
fest profound eyelid laxity in which horizontal eyelid
shortening is a necessary step, it is an excellent option.
The procedure begins with an 8-mm lateral canthot-
omy (Fig. 14.6A). The terminal lower lid is elevated,
putting the LCT on stretch. The tendon is released (infe-
rior cantholysis; Fig. 14.6B), allowing dynamic release of
the eyelid from the orbital rim (Fig. 14.6C). The inferior
border of the tarsus is released from its underlying attach-
ments to the conjunctiva and lower eyelid retractors (Fig.
14.6D). The anterior and posterior lamella are divided
(Fig. 14.7A), the mucocutaneous junction is trimmed
(Fig. 14.7B), and the excess skin is excised (Fig. 14.7C).
The lateral edge of the tarsus is drawn to its normal
anatomic insertion at the lateral orbital rim with a slight
overcorrection. Special attention is placed on assuring a
normal lower lid relation to the limbus and avoidance
of bowstringing of the eye by the lower lid (clothesline
effect). When an appropriate lid length is identified, the
terminal tarsus is shortened conservatively (Fig. 14.8A).
The posterior tarsus is deepithelialized, and a double-
armed 4-0 Mersilene or other such suture (Vicryl) on a
half-circle needle is passed through the terminal tarsus
(newly formed tarsal strip; Fig. 14.8B). The suture enters
the suborbicularis side of the tarsus and exists the epi-
thelial side (anterior to posterior). The suture engages
the periosteum, approximately 3 mm posterior to the
lateral orbital rim, so as to attain appropriate apposi-
tion of the lid to the globe, at the level of Whitnall’s
tubercle (Fig. 14.8C). The suture is tied, securing the
tarsus to the lateral rim (Fig. 14.8D). The commissure is
reformed with a 6-0 plain gut (or other) gray-line suture
from upper to lower lid (Fig. 14.9A and B). This suture
can also be passed through the underlying periosteum
between the lids to further secure the commissure to the
rim. The incision is closed (Fig. 14.9C).
 14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty 157

A B

C D
Figure 14.6   Lateral tarsal strip. (A) A canthotomy initiates the procedure. (B) The inferior crus of the LCT is lysed (inferior cantholysis).

(C) Dynamic release of the lower lid after cantholysis. (D) The inferior border of the tarsus is separated from the conjunctiva and lower eyelid
retractors. LCT, Lateral canthus tendon. (Reprinted with permission from Managing the lateral canthus in the aesthetic patient. Master techniques
in blepharoplasty and periorbital rejuvenation. New York, NY: Springer New York; 2011. p. 188.)

A B
Figure 14.7   (A) The anterior and posterior lamellae are divided, (B) the lid margin (mucocutaneous junction) is trimmed,.
158 MASTER TECHNIQUES IN FACIAL REJUVENATION

Commissure-Sparing Open Canthal Suspension

C this bridge of tissue from the commissure intact. The
Figure 14.7, cont’d  (C) Tthe excess skin is excised. (Managing the
lateral canthus in the aesthetic patient. Master techniques in blepha-
roplasty and periorbital rejuvenation. New York, NY: Springer New
York; 2011. p. 190.)
There is a subset of aesthetic patients who need more
than the typical canthal suspension attained with an
open canthopexy or the closed procedures that will be
described, but do not require the invasiveness of an LTS
procedure. Also, some patients benefit from a degree
of positional change in the canthus, which is often not
predictably attained without total canthal reconstruction
(such as LTS). In these cases the authors have used what
they call a commissure-sparing open canthal suspension
(CSOCS). The results have been predictable, reliable, and
have resulted in less of the potential aesthetic deficits
mentioned for the more aggressive LTS procedure.
A canthotomy is performed starting 2 to 3 mm lateral
to the commissure (Fig. 14.10A). It is important to leave
lower lid or commissure is elevated, putting the canthal
tendon on stretch (Fig. 14.10B). The canthal tendon is
then internally lysed in a graded fashion (Fig. 14.10C).

A B

C D
Figure 14.8  (A) The tarsus is shortened, (B) a single- or double-armed suture, passed anterior to posterior, engages the newly formed lateral tarsal
strip, (C) which is secured to the periosteum at the level of Whitnall’s tubercle, and (D) and is tied securing the tarsal strip to the lateral orbital rim.
(Managing the lateral canthus in the aesthetic patient. Master techniques in blepharoplasty and periorbital rejuvenation. New York, NY: Springer
New York; 2011. p. 190.)
 14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty 159

A B

C
Figure 14.9   (A, B) The commissure is reformed with a gray-line suture from upper to lower lid. The underlying periosteum can be incorporated

in this pass to secure the commissure to the orbital rim. (C) The canthus is closed. (Courtesy Guy Massry, MD.)

The canthus will dynamically release, allowing expo-
sure for periosteal suture placement (Fig. 14.10D). A
5-0 polydioxanone (PDS) suture is passed through the
open wound to engage the lateral orbital rim periosteum
(same location as with the LTS) and then fed internal to
external (ab-interno; Fig. 14.11A) and external to inter-
nal (ab-externo; Fig. 14.11B) through the same hole in
the commissure and again through the periosteum (Fig.
14.11C), before tying the suture and securing the canthus
(Fig. 14.11D). An alternative suture pass is to place both
ends of a double-armed similar suture through the same
entry point in the commissure (ab-externo only) and then
engage the periosteum internally with both ends of the
suture. In either scenario, the canthus can be raised with a
more aggressive cantholysis, and the direct view attained
for positioning. Also, if orbicularis plication is desired,
a subcutaneous dissection frees the terminal preseptal
orbicularis muscle for direct plication. The authors con-
sider this an intermediate canthal suspension procedure.
It avoids the disadvantages of a LTS and preserves the
commissure and canthal angle, yet in their experience
is more powerful than an open canthopexy and more
accurate in canthal positioning than the closed proce-
dures described later.
Open Canthopexy
There is a subset of patients who require only mild lower
lid support during blepharoplasty. It is best to always
err on the side of caution when deciding on adding lid
support in these cases, so as to avoid the difficulties of
dealing with postoperative lower eyelid malposition. As
a general rule, if the thought of canthal suspension arises
during surgery, the surgeon should trust his/her instincts
and add the procedure. In cases that need mild support
with minimal canthal distortion, a canthopexy can be
added. In most of these scenarios, the authors prefer a
closed procedure (described later), as the canthus is less
disturbed. However, in cases when a skin pinch is added
(i.e., already an infraciliary incision), or in isolated lower
blepharoplasty when an upper lid crease incision is not
planned, an open canthal tendon plication (canthopexy)
is an option. A 4- to 5-mm canthal incision is also made
to or through the commissure (Fig. 14.12A). A suture
(4-0 Vicryl, PDS, or similar type on half-circle needle)
160 MASTER TECHNIQUES IN FACIAL REJUVENATION

A B

C D
Figure 14.10   Commissure-sparing open canthal suspension. (A) A canthotomy is performed 3 mm lateral to the commissure. (B) Elevation of

the lateral lid puts the canthal tendon on stretch. (C) Internal lysis of the lateral canthal tendon in a graded fashion. (D) The periosteum engaged
with forceps. (Courtesy Guy Massry, MD.)

A B
Figure 14.11   (A) A 5-0 polydioxanone suture is passed through the lateral rim periosteum and then through the commissure (ab-interno internal

to external), and (B) the same suture returns through the same hole in the commissure (ab-externo external to internal),.
 14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty 161

C D
Figure 14.11, cont’d  (C) Aagain engages the periosteum, (D) secures the canthus to the lateral rim. (Courtesy Guy Massry, MD.)

A B

C
D
Figure 14.12   Open canthopexy. (A) A canthal incision is made to or through the commissure. (B) A semi-circle needle engages the lateral canthal

tendon and is secured to the lateral orbital rim. (C, D) Optional terminal preseptal orbicularis suspension suture.
162 MASTER TECHNIQUES IN FACIAL REJUVENATION

A B
Figure 14.13  Closed canthal suspension. (A) Temporal eyelid crease incision and dissection in a submuscular, preperiosteal plane to the lateral
canthus. (B) Forceps tent up the lateral canthus and the lateral canthal tendon is strummed from the temporal upper eyelid incision. (Courtesy
Guy Massry, MD.)

A B
Figure 14.14  (A) The lateral canthal tendon (LCT) left undisturbed and plicated/suspended to lateral orbital rim (canthopexy). (B) The LCT is
lysed (canthoplasty) and the cut end is then secured to the lateral orbital rim.

engages the LCT and is secured to the lateral orbital rim
periosteum as previously described (Fig. 14.12B). As an
aside, some surgeons prefer to only suspend the terminal
preseptal orbicularis with a similar suture bite, or to add
such suspension to the LCT plication (Fig. 14.12C). The
authors often add an orbicularis suture, but never in iso-
lation, as they feel this is a weak suspension at best. If the
commissure is preserved, an alternative suture placement
is the full-thickness commissure approach described in the
CSOCS technique. If the commissure has been divided, a
gray-line suture is placed to recreate an aesthetic canthal
angle. The canthus is closed with interrupted absorbable
or permanent suture.
Closed Canthal Suspension
What the authors refer to as closed canthal suspension is a
relatively contemporary means of providing lower eyelid
support and preserving canthal appearance and integ-
rity. As stated, in these procedures the canthal tendon
or terminal tarsus is accessed from a distant site as to
avoid canthal incisions, division of the commissure, and
the potential for eyelid imbrication, scars, webs, and the
other myriad of complications that can arise from tradi-
tional canthal surgery. This option is especially useful for
the typical aesthetic patient who requires only minimal
lower eyelid suspension. The senior author has found this
an invaluable tool in reducing complications and patient
complaints after lower blepharoplasty surgery.
A variety of such procedures have been described
[30,36–39]. The authors will focus on a temporal upper
lid crease as the entry location for surgery. An 8-mm
incision is made. The orbicularis muscle is divided and
a submuscular, preperiosteal dissection ensues to the
canthus (Fig. 14.13A). The canthus is tented up with
forceps and the LCT is strummed with scissors or other
cutting device from the temporal upper eyelid incision
(Fig. 14.13B). At this point surgical planning and intra-
operative findings dictate the next step. Depending on
the degree of laxity present (dictated by clinical experi-
ence), the tendon can be left undisturbed (canthopexy;
Fig. 14.14A), scored in a graded fashion, or lysed (can-
thoplasty; Fig. 14.14B). If the tendon is manipulated at
 14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty 163

all, there will be a degree of release from its bony attach-
ments. The authors feel that even if only minimal lower
lid support is desired, the tendon should be scored as to
create a raw surface for readhesion. Once the appropriate
release is attained, the canthus is secured with various
suture options. The authors prefer a double-armed 5-0
PDS suture on an RB-1 needle. The canthal tendon can
be grasped internally through the wound (ab-interno)
and directly secured to the periosteum at the appropri-
ate location (Fig. 14.15A). Alternatively, after engaging
the canthal tendon, the suture can be passed internal to
external through the commissure and then back the other
direction (ab-interno/ab-externo) prior to securing the
periosteum (Fig. 14.15B). Finally, both ends of the suture
can be passed through the same location in the commis-
sure external to internal (ab-externo) prior to securing the
canthus to the periosteum (Fig. 14.15C). The preference
for technique is surgeon dependent and all lead to similar
results. As an aside, if “pseudo-eyelid shortening” or
lower lid tension is desired, the canthal suspension suture
can engage the terminal tarsus in lieu of the LCT. As a
matter of caution, it is possible to imbricate the terminal
upper lid fibers of the LCT in this technique. This can
lead to temporary and rarely permanent postoperative
ptosis. This can be avoided by careful suture placement
and, when needed, a graded release of these upper LCT
fibers prior to tying the suspension suture. The temporal
wound can be closed in layers or skin only.
Hang-Back Canthal Suspension
Surgical modifications are necessary for negative vector
eyelids to prevent “bowstringing” of the globe by the

A B

C D
Figure 14.15   Suture techniques for lateral canthal suspension. (A, B) Ab-interno: the lateral canthal tendon (LCT) is grasped internally through

the wound and secured to the periosteum. (C, D) Ab-interno/ab-externo: the LCT is grasped internally, the suture exits the commissure (external)
then back through the commissure to engage the periosteum,. Continued
164 MASTER TECHNIQUES IN FACIAL REJUVENATION

E F
Figure 14.15, cont’d  (E, F) Aab-externo both suture arms are passed through the commissure, external to internal, and are then secured to the
periosteum.

Hyperfixation

Fixation point Suture allowed

too low to hang back

A B
Figure 14.16   Hang-back canthal suspension. (A) Bowstringing of a prominent eye with lid tightening. Note scleral show and lid retraction (arrow)

created by lid tightening. (B) Hang-back canthal suspension with supra-placement of periosteal fixation suture. Note elevation of lower lid and
reduction of scleral show. (Adapted from Managing the lateral canthus in the aesthetic patient. Master techniques in blepharoplasty and periorbital
rejuvenation. New York, NY: Springer New York; 2011. p. 194.)

lid (Fig. 14.16A) [3]. In this setting there is a relative
deficiency of horizontal lower eyelid length in relation to
globe projection. A normal suspension of the lower lid
will cause it to retract inferiorly along the globe, leading
to both eyelid retraction and scleral show.
In this scenario, the authors recommend a hang-back
modification to canthal suspension. This modification can
be added using any of the techniques previously described;
closed or open approach with a canthopexy or cantho-
plasty. When the lateral canthal suture is secured to the
lateral orbital rim, the suture is left loose or allowed to
hang back. The amount of hang back is tailored to each
case depending on the amount of pseudo-lid lengthening
desired. This maneuver artificially lengthens the eyelid
and prevents bowstringing. Additionally, the suture can
be supraplaced along the orbital rim, providing a greater
elevating effect (Fig. 14.16B) [3].
POSTOPERATIVE CARE AND COMPLICATIONS
Postoperative care is identical to the management of
lower blepharoplasty. Ophthalmic antibiotic ointment is
used on the incision three times a day for 1 week. Ice
compresses are encouraged for the first 2 to 3 days for
10 to 15 minutes over every hour during the day. Patients
are instructed to avoid exercise or strenuous activity for
the first week after surgery and are typically seen 1 week
after surgery for the removal of skin sutures.
 14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty 165
Early postoperative complications include: chemosis,
granuloma formation, epithelial lined cysts, suture abscess,
and wound infection. Chemosis typically resolves over a
few weeks with or without added topical or oral steroid
preparations. If persistent, superiorly directed eyelid
massage, a temporary tarsorrhaphy, or rarely conjunc-
tival cut down or cautery is needed. Cysts, granulomas,
and abscesses often require minor in-office surgical inter-
ventions and typically resolve without sequelae. Infec-
tion is treated with oral antibiotics and an incision and
drainage is added for localized abscess when appropriate.
Late postoperative complications, including alterations in
the canthal position (dystopia), lateral canthal scarring,
and web formation, are more troublesome. Relatively
minor changes in canthal appearance and position can
significantly alter the appearance of the eyes and result
in an unhappy patient. Asymmetries often resolve over 4
to 6 weeks but may require revision surgery if persistent.
Canthal scars and webs are especially problematic as revi-
sions are not predictable. Injectable wound modulators,
such as Kenalog 5 mg/mL or 5-fluorouracil 50 mg/mL,
can be helpful [45–47]. The authors inject 0.2 to 0.3 cc
of either medication, beginning as early as 2 weeks after
surgery. Injections can be repeated every 2 weeks until
no further improvement is noted (usually four injections
maximum). Two to four units of Botulinum toxin A can
also be given, and the authors have anecdotally noted an
improvement is scar or web flattening [46]. Finally, even
in the face of what appears as otherwise good surgery,
patients may complain of canthal pain, tight eyelids,
eyelids that “feel” different, and that they just don’t look
like themselves. These can be very difficult issues that
often never resolve. Reassurance, acknowledgment of the
problem, and time are the best medicines here.
CONCLUSION
Canthal suspension is an essential component of lower
eyelid surgery. Familiarization with the spectrum of both
open and closed canthal suspension procedures (cantho-
plasty and canthopexy) is essential to the aesthetic eyelid
surgeon. Traditional open canthal suspension techniques
are powerful and effective for correcting eyelid malposi-
tion. However, these techniques are less commonly used
in aesthetic blepharoplasty due to alterations in canthal
appearance. Closed canthal suspension techniques are
less invasive and disruptive to the canthus. While they are
less powerful than traditional canthal suspension proce-
dures, they may be appropriate for the typical aesthetic
patient who requires only minimal suspension.
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