History

The history of lateral canthal suspension techniques parallels the development of surgical procedures that tighten the lower eyelid to correct existing or potential lower eyelid malpositions. These techniques are therefore separated into those which address existing lower eyelid malpositions and those which prevent the development of such. Numerous surgical procedures directed to the lateral canthus have been developed to correct: (1) cicatricial, atonic or paralytic lower eyelid malpositions; (2) lateral canthal dystopia (lateral canthus lower than medial canthus); (3) epiphora; and (4) corneal exposure. Modifications of lateral canthoplasty has found wide acceptance in cosmetic surgery of the lower eyelid.

In 1826 Von Walther designed the simple lateral tarsorrhaphy procedure to connect the upper and lower eyelids laterally. This had the disadvantage of distorting the lid margins and decreasing the functional fields of vision. In 1950 and 1953 McLaughlin described a lateral tarsorrhaphy procedure that produces a more aesthetic result for non-cicatricial, paralytic lower eyelid malposition with lagophthalmos.

Lateral canthorrhaphies were developed to avoid the deformities associated with the tarsorrhaphies. These procedures were various flap transpositions with skin removal to support the lower eyelid to the upper eyelid at the lateral canthus. Denonvilliers (1856, 1863); Kuhnt-Szymanowski (1870, 1912, 1916) and Meller (1953) described procedures which were widely accepted. Modifications of these procedures were described by Smith (1959) and Kazanjian and Converse (1959) with a tarsoconjunctival wedge excised medially. Bick (1966) reported a technique removing the full thickness temporal aspect of the lower eyelid to correct laxity. Edgerton and Wolfert (1969) described a de-epithelialized dermal pennant of lateral canthal tissue that was passed through a drill hole in the lateral orbital wall to correct lower eyelid malposition. Montandon (1978) modified this procedure to include a lateral tarsorrhaphy. Lateral canthal suspensions have also been described by Whitaker (1984) via the facelift; Whitaker (1984), Ortiz-Monastario and Rodriguez (1985) from the coronal and Paterson, Munro and Farkas (1987) from the conjunctival approach. Jelks (1990, 1991, 1993, 1995) and Hinderer (1993) and Flowers (1993) described variations in bony fixation of the lower eyelid.

Many surgeons developed their own methods of creating the lateral canthal angle by various lateral canthal tendon suture techniques. The most effective methods isolated the lower lid contribution to the lateral retinaculum by a lateral canthotomy and cantholysis of the inferior limb of the lateral canthus at the bony orbital rim. The lower eyelid was thus released from the upper eyelid and retinacular structures to allow more selective repositioning. Tenzel (1969); Marsh and Edgerton (1979); Bachelor and Jobe (1980); Holt, Holt and van Kirk (1984); and Leone (1987), described the use of periosteal flaps and temporalis fascia and palmaris longus tendons for lateral canthal reconstructions.

Anderson and Gordy (1979); Hamako and Baylis (1980); Wesley and Collins (1983); Lisman and associates (1987); Jelks and associates (1997); Patipa (1999); Fagien (2002); McCord (2002); Hester (2004); and Codner (2006) have described various methods of tarsal and or inferior retinacular attachment to the bony orbital tissues that selectively tighten and reposition the lower eyelid.

Physical evaluation

Anatomy

To facilitate a thorough anatomical analysis, the eyelids and surrounding structures are divided into zones (Fig. 30.1).

Fig. 30.1 Surgical zones of the eyelids and periocular structures: Zone 0 (not labeled) includes the ocular globe and orbital structures behind the orbital septum, orbital retaining ligaments, arcus marginalis, posterior lacrimal crest and lateral retinaculum. Zone I and Zone II include the upper and lower eyelids, respectively from the lateral commissure to the canalicular puncti. Zone III is the medial canthus with the upper and lower eyelid lacrimal drainage system. Zone IV is the lateral canthal area with the lateral retinaculum. Zone V includes the contiguous periorbital structures of nasal, glabellar, brow, forehead, temple, malar and nasojugal regions that merge with Zones I–IV. Zones I–IV are further subdivided into structures that are anterior (preseptal) and posterior (postseptal to the orbital septum.

From Jelks GW, Jelks EB, Chiu E. Secondary blepharoplasty: Current techniques. In: Mathes SJ, ed. Plastic surgery. Philadelphia: Saunders, 2006, Vol. II.

The lower eyelid (Zone II) extends from the lid margin to the inferior orbital bony rim and is separated into the anterior lamella of skin and orbicularis oculi muscle, the middle lamella consisting of tarsus, orbital septum and retroseptal fat and the posterior lamella with the capsulopalpebral fascia or lower eyelid retractors and the conjunctiva (Fig. 30.2A).

Fig. 30.2 A, The lower eyelid is best represented anatomically as consisting of three lamellae. The anterior lamella is composed of skin and orbicularis oculi muscle. The posterior lamella is the conjunctiva and the capsulopalpebral fascia, an extension of the inferior rectus muscle. The middle lamella is composed of the orbital septum and fat which abuts the inferior border of the tarsus. B, The arcus marginalis is the line of fusion between the periorbita, periosteum and orbital septum. C, The origin of the orbital portion of the orbicularis oculi from the inferior medial orbit. D, The orbicularis oculi muscle is divided into palpebral (pretarsal and preseptal) and orbital portions. Orbital retaining ligaments provide muscle attachment.

The confluence of the orbital septum, orbital floor periorbita and maxillary periosteum at the inferior bony margin is termed the arcus marginalis (Fig. 30.2B). The arcus marginalis in the inferior medial orbit corresponds to the origin of the orbital portion of the orbicularis oculi muscle (Fig. 30.2C).

The orbicularis oculi muscle is innervated by the seventh cranial nerve and acts as an antagonist to the levator palpebrae superioris muscle innervated by the third cranial nerve. The orbicularis oculi muscle is divided into palpebral and orbital portions. The palpebral portion is further subdivided into pretarsal and preseptal portions. The orbital portion of the orbicularis oculi arises medially from the superiormedial orbital margin, the maxillary process of the frontal bone, the medial canthal tendon, the frontal process of the maxilla, and the inferiormedial orbital margin (Fig. 30.2C, D). The peripheral fibers sweep across the eyelid over the orbital margin in a series of concentric loops, the more central ones forming almost complete rings. In the lower eyelid, the orbital portion covers the origins of the elevator muscles of the upper lip and nasal ala and continues temporally to cover part of the origin of the masseter muscle. Occasionally, the lower orbital portion may actually continue as low as the corner of the mouth. The inferior orbital orbicularis oculi constitutes the nasojugal, cheek and malar area of the facial anatomy.

The preseptal portion diverges from its origin on the medial canthal tendon and posterior lacrimal diaphragm and passes across the lid as a series of half ellipses to meet at the lateral palpebral raphe (Fig. 30.3A). The muscle bundles are not interrupted and do not interdigitate at the raphe. The pretarsal muscles form a more superficial common lateral canthal tendon 7 mm from the lateral orbital tubercle where it inserts (Fig. 30.3B).

Fig. 30.3 A, The lateral palpebral raphe. B, The lateral canthal tendon and the anatomy of the structures of the lateral canthus.

From Jelks, GW, Smith, BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders, 1990, p. 1671.

The medial canthus (Zone III) is a complex region containing the origins of the orbicularis oculi muscle (and the lacrimal collecting system (Fig. 30.4).

Fig. 30.4 The nose has been cut away to show the origins of the orbicularis oculi muscle fibers and their relation to the lacrimal collecting system. The anterior component of the medial canthal tendon extends forward to the anterior lacrimal crest to the frontal process of the maxilla. The palpebral portion of the orbicularis oculi muscle can be separated into pretarsal and preseptal components. Furthermore, these components possess deep and superficial heads as they pass medially. The deeper fibers pass posteriorly to the lacrimal sac and fascia and to the posterior lacrimal crest. These fibers are vital to the lacrimal pump mechanism.

From Zide, BM and Jelks, GW. Surgical anatomy of the orbit. New York: Raven Press, 1985, p. 43.

The lateral canthus (Zone IV) is an integral anatomic unit of the temporal aspects of the eyelids. The lateral canthus is more correctly termed a lateral retinaculum which consists of the lateral horn of the levator palpebrae superioris muscle, the continuation of the preseptal and pretarsal orbicularis oculi muscle as the lateral canthal tendon, the inferior suspensory ligament of the globe (Lockwood’s ligament) and the check ligaments of the lateral rectus muscle (Fig. 30.5). The lateral retinaculum structural components attach to a confluent region of the lateral orbital rim known as Whitnall’s tubercle. It is important to note that the lower eyelid lateral fat is immediately inferior to the lower eyelid contribution to the lateral canthal tendon as it inserts into the orbital tubercle confluence of the lateral retinacular structures. This portion of the lateral canthal mechanism is termed the inferior retinacular component and is the anatomical basis for the inferior retinacular lateral canthoplasty.

Fig. 30.5 The lateral canthus is really a lateral retinaculum of several structures which converge at the orbital tubercle of Whitnall. The lateral retinacular structures which insert into the orbital tubercle are the lateral horn of the levator aponeurosis, the lateral canthal tendon, the inferior suspensory ligament of the globe (Lockwood) and the check ligament of the lateral rectus muscle.

From Jelks, GW, Smith, BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders, 1990, p. 1671.

Technical steps

The lateral canthal procedures are performed with the surgeon at the head of the patient looking toward the feet. A focused headlight and 4× loop magnification is recommended.

Careful evaluation of the specific anatomic deformities enables the surgeon to choose the optimal lateral canthal procedure and if necessary, ancillary procedures (Tables 30.1, 30.2). The distance from the bony orbital rim to the palpebral commissure is the single most important measurement in choosing between a canthopexy or canthoplasty (Fig. 30.6B) and a dermal orbicular pennant. If the bone to soft tissue distance is less than 1 cm, tarsal strip, inferior retinacular canthopexy, or canthoplasty procedures are preferred. If the distance is greater than 1 cm (prominent globes, high myopia, thyroid orbitopathy, malar hypoplasia and negative vector relationship), a dermal orbicular pennant lateral canthoplasty is recommended.

Table 30.1 Canthoplasty techniques and indications