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

Canthoplasty techniques	Indications
IRLCx	LME I, B-STD <1 cm
IRLC	LME I and II, B-STD <1 cm LME I and II, B-STD >1 cm

TSLC

LME I

Lateral canthal laxity

Lateral canthal asymmetry

TSLC + HLS
TSLC + HLS + VSG

LME II-IV with HLL

LME II-IV with HLL and MLR

DOPLC LME II-IV, B-STD >1 cm DOP + TSLC + HLS

LME II-IV with HILL, B-STD <1 cm

LME II-IV with HLL, B-STD >1 cm

DOP + TSLC + HLS + VSG

LME III-IV with HLL and MLR, B-STD <1 cm

LME III-IV with HLL and MLR, B-STD >1 cm

DOP + TSLC HLS + VSG + midface elevation/titanium screw fixation

LME III-IV with HLL and MLR, midface descent, B-STD <1 cm

LME III-IV with HLL and MLR, midface descent, B-STD >1 cm

Technique abbreviations: IRLCx, inferior retinacular lateral canthopexy; IRLC, inferior retinacular lateral canthoplasty; TSLC, tarsal strip lateral canthoplasty; HLS, horizontal lid shortening; VSG, vertical spacer graft; DOPLC, dermal-orbicular pennant lateral canthoplasty; DOP, dermal-orbicular pennant.

Indications abbreviations: LME, lid margin eversion; B-STD, bone to soft tissue distance; HLL, horizontal lid laxity; MLR, midlamellar retraction.

From Jelks GW, Jelks EB, Chiu ES. Secondary Blepharoplasty: Current Techniques. In: Mathes, ed. Plastic Surgery, Vol II, Philadelphia, Saunders 2006.

Table 30.2 Ancillary lower eyelid: reconstructive techniques

Technique	Indication
Upper eyelid myocutaneous flap to lower eyelid. Full-thickness skin graft to lower eyelid Buccal mucosal graft Palatal mucosal graft	Lower eyelid anterior lamellar deficiency Lower eyelid conjunctival deficiency

From Jelks GW, Jelks EB, Chiu ES. Secondary Blepharoplasty: Current Techniques. In: Mathes, ed. Plastic Surgery, Vol II, Philadelphia, Saunders 2006.

Fig. 30.6 A, The lower eyelid lateral fat and the inferior retinacular lateral canthal procedures are performed through the lateral aspect of the upper eyelid blepharoplasty incision. The skin and muscle are elevated from the lateral orbit to expose the lower eyelid lateral fat. The inferior aspect of the lateral retinacular structures lies immediately superior to this fat. The lower eyelid lateral fat is removed which exposes the lateral retinaculum. Inset, after removal of the lower eyelid lateral fat, a “cave” is created inferior to the lateral retinacular structures. The illustration reveals this area as it would be visualized from inside the orbit. B, Canthoplasty procedure with lysis of the lower eyelid attachments to the lateral retinaculum. Inset, canthopexy in which the lower eyelid component of the lateral retinaculum is plicated and anchored to the lateral orbital rim periosteum. C, Both needles of a double-armed permanent suture are passed with a hitching stitch into the released inferior retinacular component of the lower eyelid and then into the periosteum of the inner aspect of the orbital rim. D, The suture is tied after the transconjunctival lower eyelid procedures are completed. The position of the suture is adjusted and tightened so the lower eyelid level covers one to two millimeters of the inferior corneal limbus.

Modified from Jelks GW, Glat PM, Jelks EB, Longaker MT. The inferior retinacular lateral canthoplasty: a new technique. Plast Reconstr Surg 1997;100:1262.

Inferior retinacular lateral canthal procedure

The inferior retinacular lateral canthopexy or canthoplasty was developed for use in the primary blepharoplasty patient to help prevent lower eyelid malposition. It is helpful in correction of lower eyelid malposition associated with a negative vector relationship and mild to moderate lid margin eversion. The main advantage of the inferior retinacular canthal procedure is that it does not separate the lower eyelid from the lateral palpebral commissure. The inferior retinacular lateral canthoplasty procedure is performed through a horizontal lateral canthal incision (Fig. 30.7A) or an upper lateral eyelid incision (Fig. 30.6A).

Fig. 30.7 Key points to achieve symmetric lateral canthal repositioning. A, The lateral canthal and lower eyelid incision should be horizontal. B, The lid is elevated to cover 1 to 2 mm of the inferior limbus. C, The level of fixation to the lateral orbital periosteum is at a level corresponding to the superior aspect of the pupil in primary position. D, On closure of the lateral canthal skin incisions, the angle of divergence from the original horizontal orientation must be equal and symmetric to ensure lateral canthal and lower eyelid symmetry.

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

When the upper lid blepharoplasty is performed in conjunction with lower lid blepharoplasty, the inferior edge of the lateral aspect of the upper eyelid incision is grasped and a submuscular, supraperiosteal skin and muscle flap is elevated 1–2 cm around the lateral canthus and lower eyelid. This is accomplished with a combination of fine point electrosurgical needles and blunt scissor dissection.

An insulated coated Desmarres retractor is inserted as the skin and muscle flap is elevated to expose the lateral canthal retinacular and lateral lower eyelid area. Gentle pressure on the globe produces a bulge in this area which is the excess lateral lower eyelid fat covered by orbital septum. Sharp scissors puncture the orbital septum and expose the fat. The fat is gently removed with forceps and electrocautery to the proper contour (Fig. 30.6A). In our experience, the lower eyelid lateral fat needs to be judiciously removed rather than repositioned.

When the lower eyelid lateral fat is removed, a distinct circular area is created which resembles a “hole” or “cave” from the surgeon’s perspective. The superior aspect or roof of the cave corresponds to the lateral retinacular structures of the lower eyelid inserting into the orbital tubercle of Whitnall (Fig. 30.6A, inset). This tissue is grasped with forceps and a hitching suture is passed through it. Fine point electrocautery is used to release the tissue from the lateral retinacular attachments to the orbital tubercle so the lower eyelid is easily moved superiorly and laterally. The needles are passed into the inner aspect of the orbital rim periosteum at a point corresponding to the upper level of the pupil when the eye is in primary gaze. This procedure is termed a lateral canthoplasty because it releases and repositions the lateral canthus and lower eyelid to a different position (Fig. 30.6B). The inferior retinacular tissue (roof of the “cave”) can be sutured to the lateral orbital rim periosteum without releasing it from the orbital tubercle when the clinical situation does not require significant lower eyelid and lateral canthus repositioning. This is termed a lateral canthopexy (Fig. 30.6B, inset). In both the canthopexy and the canthoplasty, the point of suture fixation is the periorbita of the inner aspect of the orbital rim at the level of the upper pupil in primary gaze (Fig. 30.6D).

The suture is a 5-0 nylon (Ethibond P-3 needle) for cosmetic blepharoplasty cases and 4-0 Polydek (Deknatel ME-2 needle) for reconstructive cases. The lateral canthoplasty is completed by tightening the suture and securing the lower lid lateral retinaculum to an elevated position inside the lateral orbital rim (Fig. 30.6D). The lower eyelid level should cover 1–2 mm of the inferior cornea and appear overcorrected. The lower eyelid settles into a lower position in 2 to 6 weeks. Symmetry of the eyelids at the completion of surgery is imperative (Fig. 30.7D).

If the fixation of the lateral retinacular tissue to the orbital periosteum is inadequate due to scarring or trauma, a local periosteal flap or fascial graft is used. Occasionally, a drill hole in the lateral orbital bone may be required for secure fixation (Fig. 30.8).

Fig. 30.8 Drill hole fixation of a lateral canthoplasty. After determination of the proper point of fixation, a single drill hole is made no less than 1 mm and generally approximately 4 mm posterior to the lateral orbital rim. A double-armed 4-0 Teflon-coated Dacron or Polydek (ME-2) suture is used for fixation. In a canthopexy procedure (no lysis of the lateral canthus), the suture is double looped into the canthal tissue, and both suture arms are brought through the single hole.

From Jelks GW, Jelks EB, Chiu ES. Secondary blepharoplasty: Current techniques in Mathes, ed. Plastic surgery, Vol II, Philadelphia: WB Saunders, 2006

Tarsal strip lateral canthoplasty

See Fig. 30.8; Chapter 32.

The procedure divides the lateral palpebral commissure (canthotomy) and selectively releases the lower eyelid (cantholysis) from the orbital tubercle. The amount of horizontal lid shortening can be varied with the amount of temporal lower lid tarsal baring, suture placement and fixation into the orbital periosteum. The tarsal strip procedure, with its many variations, is useful for correction of moderate to severe lid margin eversion, paralytic ectropion and secondary correction of unrecognized horizontal lid laxity after blepharoplasty. It is contraindicated when the lateral canthal position is lower than the medial canthal position (negative canthal tilt, prominent globe, negative vector relationship).The technique produces a decrease in the horizontal dimension of the palpebral aperture, giving the appearance of a “beady eye”. Deformity of the lateral lower eyelid at the lateral commissure with lack of contact with the globe, webbing and trichiasis may also occur.

Dermal orbicular pemart lateral canthoplasty

Dermal orbicular pennant lateral canthoplasty was developed for patients with more than 1 cm distance from the lateral canthus and the bony orbit (Fig. 30.10B) and to reduce the incidence of the “beady eye” appearance and lower eyelid contour deformities caused by the tarsal strip technique. This procedure uses an extension of the lower eyelid in the form of a de-epithelialized pennant of skin and orbicularis oculi muscle (Fig. 30.9A–C). A lateral canthotomy may or may not be performed; therefore, lateral palpebral commissure deformities are reduced and shortening of the horizontal palpebral aperture does not occur (Fig. 30.12). A horizontally oriented dermal orbicular pennant of de-epithelialized skin and muscle, 0.5 cm by 1.0 cm, is incised in such a way to add an extension to the lower eyelid without cutting the lateral commissure. The pennant is completely separated from the upper eyelid pretarsal, preseptal and orbital orbicularis oculi muscle. The pennant is separated from the lower eyelid orbital and preseptal orbicularis oculi muscle, but left attached to the pretarsal orbicularis oculi muscle (Fig. 30.9C). Release of the lower eyelid by lysis of the inferior retinaculum (Fig. 30.9D) allows the lower eyelid to be elevated and tightened.

Fig. 30.10 Lateral bone to canthus relationship. A, This patient exhibits less than 1 cm of distance and a neutral vector. B, This patient exhibits more than 1 cm and a negative vector.

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

Fig. 30.9 Dermal-orbucular pennant lateral canthoplasty. A, The patient is illustrated with a protective, colored contact lens in place. The dermal-orbicular flap is outlined at the lateral canthus. Note the horizontal alignment and the maintenance of the external commissure. An incision is made through the superficial layers. B, The flap is de-epithelialized, preserving the underlying dermis. The superficial border of the flap is incised to the suborbicularis muscle plane. C, the inferior border of the dermal-orbicular pennant is elevated to maintain the attachment of the pretarsal orbicularis muscle. D, The lower lid component of the lateral retinaculum is divided by “strumming” the structure with a Colorado needle. The fixation of the suture is to the lateral orbital rim, corresponding to the upper level of the pupil with the patient in primary gaze. E, A vertical graft of autogenous auricular cartilage or palatal mucosa is used to correct vertical defects caused by midlamellar cicatricial retraction.

A–D modified from Jelks GW, Jelks EB, Chiu ES. Secondary blepharoplasty: Current techniques. In Mattes, ed. Plastic surgery. Vol II, Philadelphia, Saunders, 2006.

Fig. 30.12 A, Patient with bilateral lower eyelid malposition after blepharoplasty. B, The patient is seen 9 months after bilateral dermal-orbicular pennant lateral canthoplasties.

From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing, 1992, p. 5.

This technique is useful in postblepharoplasty patients with lower eyelid malposition, especially when there is a negative vector relationship and the soft tissue to bone distance is greater than 1 cm (see Fig. 30.10). The variable amount of orbital rim to lateral palpebral aperture distance can be managed by varying the suture placement for the canthal tightening (Fig. 30.11B).

Fig. 30.11 Dermal-orbicular pennant lateral canthoplasty fixation and closure. A, Both arms of ME-e 4-0 Polydek suture are passed through periosteum from the inner to the outer aspect of the orbital rim. The needles are passed through the loop and cinched tightly down, hugging the inner aspect of the orbital rim. B, Most commonly, periosteal fixation if to the lateral edge of the tarsus. Fixation of the lower lid covers 1–2 mm of the inferior cornea. C, On closure, elevation causes inferior angulation of the original horizontal incision. D, When bilateral procedures are performed, care is taken to obtain symmetry of closure.

Modified from Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg 1993;20:417.

Dermal-orbicular pennant with tarsal strip horizontal lid shortening and midface suspension

The dermal-orbicular pennant flap with or without horizontal lid shortening or vertical spacer grafts with midfacial suspension has become the preferred method of surgical correction for complex lower eyelid malpositions. This combination of techniques allows the surgeon to selectively release the lower eyelid lateral canthal attachment, correct midlamellar retractions, perform horizontal lid shortening and redrape the orbicularis oculi muscle with a midface and cheek suspension.

Patients with severe lower eyelid malposition associated with cheek and midfacial descent have often had multiple procedures resulting in deficient lower eyelid muscle and skin. The lower eyelid malposition is due to a combination of vertical restriction and horizontal laxity. The dermal orbicular pennant technique provides access for correction of the midfacial descent and lower eyelid cicatricial retraction. The tarsal strip technique provides management of the horizontal lid laxity. A tension-free lateral canthoplasty is assured by midfacial suspension with or without a titanium screw. The combined techniques do require separation of the lateral palpebral commissure (lateral canthotomy).

After elevation of the dermal-orbicular pennant (see Fig. 30.9), if horizontal lid shortening is necessary, a lateral canthotomy and inferior lid cantholysis is performed. The temporal tarsus is bared of conjunctiva, cilia, skin and muscle creating a tarsal strip which is attached to the dermal orbicular pennant. The amount of tarsal strip developed corresponds to the amount of horizontal lid shortening required. The cheek and midface is elevated from a supraperiosteal or subperiosteal plane by extending the dermal orbicular pennant incision. A titanium fixation screw with attached sutures suspends the cheek and midfacial tissue (Fig. 30.13). The place for screw insertion varies from the lateral orbital rim to the zygoma prominence (Fig. 30.14). Correction of midlamellar cicatricial vertical retraction is performed with a vertical spacer graft (auricular cartilage) that is inserted through the same incision. A separate lower eyelid incision is avoided (Fig. 30.9E).

Fig. 30.13 A, Patient with lower eyelid malposition and midfacial cheek descent. B, Postoperative view at 6 weeks after midfacial suspension with titanium screw fixation and extended dermal-orbicular pennant lateral canthoplasty.

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

Fig. 30.14 Mitek screw fixation in subperiosteal midface elevation. After elevation of the subperiosteal midface flap, fixation is achieved by suspending the flap with two 4-0 Vicryl sutures on half-circle cutting needles. The sutures are then tied to a titanium screw placed on the anterior surface of the lateral orbital bone (zygomatic bone). The screw is tightened until the head is flush with the bone surface. The elevated and stabilized structures support the reposition lower lid and the recruited and elevated cheek skin and tissue help replace deficient posterior lamella.

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