Operative Technique in Plastic Surgery – Kevin C.Chung

■ Digital imaging software may be an important adjunct to precisely evaluate
eyelid morphology and to detect asymmetries, which are common in the lower
eyelid.12
NONOPERATIVE MANAGEMENT
■ With the popularity and appeal of noninvasive procedures among cosmetic
surgery patients, a thorough and earnest discussion should be maintained
regarding the advantages and disadvantages of such techniques versus surgical
options by attending to the patient’s particular anatomic features and concerns.
■ Botulinum toxin may be employed to reduce skin wrinkles and expression
lines along the lateral portion of the lower eyelid, as well as to soften
orbicularis hypertrophy or protrusion.
■ Skin resurfacing techniques with either lasers or chemical peels such as
trichloroacetic acid or phenol/croton oil may be performed to improve skin
quality and dermatochalasis.
■ The use of fillers such as hyaluronic acid, collagen, or the patient’s own fat
may be infiltrated around the lower eyelid to correct an evident tear trough or
deep lid-cheek junction or to augment the inferior orbital rim and malar area to
provide better support and contour in a negative vector patient.
■ The use of nonsurgical procedures should not be discarded even if surgery is
indicated as they may be valuable adjuncts to improve and enhance the results
after lower blepharoplasty.
SURGICAL MANAGEMENT
■ The decision to proceed with surgery depends on the specific anatomic
concerns of the patient as well as on the degree and duration of the result
sought.13
■ Indications for surgery include herniated and prolapsed bags appearing
together with an evident tear trough deformity or deep lid-cheek junction.
■ Patients with poor skin quality or noticeable dermatochalasis are not good
candidates for transconjunctival fat removal and redraping in the lower eyelid.
They must be informed that this procedure alone will not improve and may
even worsen this specific condition.
■ Risks to the patient include hematoma, infection, and scarring
■ Determining the correct amount of fat to resect directly impacts the result of
the procedure. Excessive resection may result in insufficient tear trough
correction, whereas inadequate resection may leave a bulge that could require

revision.14
FIG 3 • A. Preoperative frontal. B. Preoperative three-
quarters views of a male patient with protruding eyelid
bags and marked nasojugal and palpebromalar
grooves.
FIG 4 • Preoperative markings.
T E C H N I Q U E S

Video p1-c033
■ Exposure
■ A 5/0 silk traction suture with a noncutting needle is placed through the
lower eyelid to expose the conjunctiva.
■ An incision with needle-tip electrocautery is performed just above the fornix
through the conjunctiva (TECH FIG 1A).
■ A traction suture is placed through the posterior conjunctival flap and held
with a mosquito clamp over the corneal protector (TECH FIG 1B). The
incision through the conjunctiva is then completed (TECH FIG 1C).
■ Vertical dissection with Stevens scissors divides the capsulopalpebral fascia,
and an insulated Desmarres retractor is used to elevate caudally the palpebral
edge of the divided conjunctiva (TECH FIG 1D).
00:00 / 00:00

TECH FIG 1 • A. An incision with needle-tip
electrocautery is performed just above the fornix
through the conjunctiva. B. A traction suture is placed
through the posterior conjunctival flap and held with a
mosquito clamp over the corneal protector. C. The
incision through the conjunctiva is then completed. D.
Vertical dissection with Stevens scissors divides the
capsulopalpebral fascia, and an insulated Desmarres
retractor is used to elevate caudally the palpebral
edge of divided conjunctiva.
■ Fat Pad Resection
■ The orbital septum is visualized and the fat compartments identified with the
help of sterile cotton tips (TECH FIG 2A).
■ The septum is incised and gentle, continuous pressure is applied to the globe
to allow the fat to herniate.
■ Fat is conservatively excised with electrocautery according to the
preoperative plan from the medial, central, and lateral fat compartments
(TECH FIG 2B).
■ The arcus marginalis is released and a 7- to 15-mm subperiosteal dissection

over the inferior orbital rim is performed and extended laterally by releasing
the orbicularis retaining ligament with cautery and a periosteal elevator3
(TECH FIG 2C).
■ Alternatively, the dissection can be carried out in the suborbicularis plane
supraperiostally, although more bleeding may be encountered.
■ Fat transposition is performed with the aid of two to three percutaneous
sutures by securing the medial and central fat pads over the inferior orbital
rim to ablating the tear trough deformity and blending the lid-cheek
junction14 (TECH FIG 2D).
■ Transposition of the lateral fat pad is seldom indicated although it may be
performed after releasing the lateral orbital thickening.
TECH FIG 2 • A. The orbital septum is visualized and
the fat compartments identified with the help of sterile
cotton tips. B. Fat is conservatively excised with
electrocautery according to the preoperative plan from
the medial, central, and lateral fat compartments. C.
The arcus marginalis is released and a 7- to 15-mm
subperiosteal dissection over the inferior orbital rim is
performed and extended laterally by releasing the
orbicularis retaining ligament with cautery and a

periosteal elevator. D. Fat transposition is performed
with the aid of two to three percutaneous sutures
securing the medial and central fat pads over the
inferior orbital rim ablating the tear trough deformity
and blending the lid-cheek junction.
■ Completion
■ A 4/0 fast resorbing suture on a noncutting needle is passed percutaneously
deep to the orbicularis, through the fat pads twice and back out through the
skin (TECH FIG 3A).
■ The sutures are secured over a Xeroform or cotton bolster or simply held in
place using Steri-Strips2 (TECH FIG 3B–D).
■ Hemostasis is revised and the wound is thoroughly cleansed with saline. The
traction suture and corneal protector are removed. It is not necessary to suture
the conjunctiva.
■ Secondary procedures such as a lower eyelid skin excision/resurfacing or
canthopexy may be performed at this stage.

TECH FIG 3 • A. A 4/0 fast resorbing suture on a
noncutting needle is passed percutaneously deep to
the orbicularis, through the fat pads twice and back
out through the skin. B. The sutures are secured over
a Xeroform or cotton bolster or simply held in place
using Steri-Strips. C,D. Illustration showing the lower
eyelid fat pads before being secured over the inferior
orbital rim through percutaneous sutures.

PEARLS AND PITFALLS
Patient
evaluation
■ Failure to identify adequate candidates for the procedure will
inevitably lead to suboptimal results.
■ A tear trough deformity caused by a sagging orbicularis muscle or
excessive skin will not be corrected by transconjunctival fat pad
redraping alone.
Hemostasis
■ Bleeding should be avoided from beginning to end of the
procedure through adequate infiltration and use of needle-tip
cautery for dissection and fat excision.
Exposure
■ Inadequate exposure of the surgical field should be avoided. The
length of the transconjunctival incision should be long enough to
ensure correct visualization.
■ Alternatively, the lateral fat pad may be approached through the
upper eyelid incision if an upper blepharoplasty is planned
concomitantly.
Fat resection
■ Fat pad resection should be performed cautiously on the medial
and central compartments to avoid ending up with too little fat to
transpose.
■ Excision of the lateral fat pad is often more ample because
correction of a deep lid-cheek junction laterally is usually
insufficient through transposition alone.
Orbital rim
dissection
■ Dissection over the inferior orbital rim should be generous to
accommodate for the transposed fat pads and allow them to
adequately redrape caudally. Care should be taken to avoid injury
to the inferior orbital nerve.
Percutaneous
sutures
■ Placement of the percutaneous sutures should be performed far
enough caudally to provide sufficient tension to the transposed fat
pads to avoid their retraction back to their original position.
■ A de la Plaza retractor or a small Langenbeck-type retractor may
be employed instead of a Desmarres to aid in the placement of the
sutures.
■ A blunt tip needle should be employed and passed twice through
the fat pads to avoid cheese wiring of the sutures.
■ Caution should be taken not to tie the sutures excessively tight
over the bolsters to avoid dents or injury to the skin over the
inferior orbital rim due to postoperative facial swelling.
■ Alternatively, Steri-Strips may be employed to hold the sutures in
place.

FIG 5 • A. Postoperative frontal. B. Postoperative three-
quarters views of the patient.
Preoperative Planning
■ The complete eyelid photographic series of the patient should be carefully
reviewed before surgery and should be available in the operating room.
■ Markings on the patient should be performed in the upright position. The tear
trough and lid-cheek junction should be outlined, as well as the areas of
maximal protrusion of the fat pads (FIG 4).
■ The patient should be inquired as to whether having taken aspirin in the days
prior to surgery and the procedure suspended if aspirin is still taken.
■ The surgeon must be familiar with techniques for canthal support and
tarsorrhaphy should they be necessary at the end of the procedure.
Positioning
■ The patient is positioned supine on the operating table.
■ Prepping is performed with a low concentration chlorhexidine solution without
alcohol, avoiding penetration into the eyes.
■ Intravenous sedation is started and corneal protectors are placed.
■ Oxygen is administered through a nasal catheter at a low flow and
concentration. Instructions should be given to the anesthetist to momentarily
interrupt flow when using electrocautery to avoid accidental fires in the
operating room.
■ The conjunctiva, lower eyelid, and tear trough are infiltrated with a 1%
lidocaine with 1:100,000 epinephrine solution.
Approach
■ Approach to the lower eyelid bags and tear trough is achieved preseptally

through a transconjunctival incision made midway between the tarsal plate and
fornix.
■ Alternatively, the transconjunctival incision may be shortened and the lateral
bag may be approached through an upper blepharoplasty incision if performed
concomitantly.15
■ Dissection over the orbital rim to create a pocket for the fat pads to be
transposed may be performed in a supra- or subperiosteal plane.
POSTOPERATIVE CARE
■ The bolsters or Steri-strips are removed after 6 days.
■ Patients are instructed to apply cold packs and slight compression for 48
hours.
■ Artificial tear drops are prescribed as well as oral antibiotics and pain
medication.
■ Patients should be carefully followed the evening and day after surgery. Any
suspicion of retrobulbar hematoma such as excessive pain, pressure, or nausea
and vomiting should be managed urgently through canthotomy with
cantholysis and hematoma drainage.
■ Patients should start early with massage if lower lid retraction or hardness
appears.
■ Patients are advised to sleep for 5 days with their head elevated and to avoid
activity, medication, or food, which may increase blood pressure or swelling.
OUTCOMES
■ Patients with protruding fat pads and an evident tear trough deformity should
expect good outcomes when no skin excess is present preoperatively (FIGS
5–7).
■ Hidalgo performed transconjunctival fat transposition in 61% of 248
consecutive lower blepharoplasties in which an integrated approach was
employed. Only 2.4% required revision to remove excess fat or skin.14
■ Goldberg reviewed the results of 24 consecutive patients who underwent
subperiosteal transconjunctival fat repositioning and noted hardening of the
transposed fat that resolved by 6 months. Four patients required revision for
undercorrection of the tear trough deformity.3
■ A recurrence of the initial deformity may appear if fixation of the extruded fat
pads over the inferior orbital rim is insufficient or if excess fat was not
adequately removed.

COMPLICATIONS
■ Apart from prolonging postoperative downtime, a hematoma may constitute a
true surgical emergency if the bleeding accumulates in the retrobulbar space,
which may lead to optic nerve compression and blindness.16
■ Although an infrequent complication, an infection should be treated promptly
with topical or systemic antibiotics if necessary.
■ Patients should be informed of the possibility of lid margin malposition or
retraction despite avoiding an external incision. Excessive or inadequate
scarring in the middle or posterior lamella may be responsible for this
complication. Surgical revision may be required to correct it, although early
management with vertical massage and taping may be sufficient to avoid
surgery.
FIG 6 • Female patient with protruding eyelid bags and
marked nasojugal and palpebromalar grooves. A.
Preoperative frontal view. B. Postoperative frontal view.
C. Preoperative view in upward gaze. D. Postoperative
view in upward gaze.

FIG 7 • Female patient with protruding eyelid bags and
marked nasojugal and palpebromalar grooves. A.
Preoperative frontal view. B. Postoperative frontal view.
C. Preoperative view in upward gaze. D. Postoperative
view in upward gaze.
■ Prolonged edema may be seen more frequently when fat transposition is
performed, due to the more extensive infraorbital dissection required, which
produces more disruption of lymphatic channels draining the orbit.
■ Patients may also experience various degrees of hardening and fibrosis around
the infraorbital rim where the fat is transposed, especially in the first 3
months.3
■ Inclusion cysts or granulomas may occur after a transconjunctival approach,
especially if a long incision was employed and topical ointment was prescribed
postoperatively.
■ Chemosis is less common through the transconjunctival approach but may
occur more frequently if canthal support techniques were added to the
procedure.

REFERENCES
1. Barton FE, Ha R, Awada M. Fat extrusion and septal reset in patients with the
tear trough triad: a critical appraisal. Plast Reconstr Surg. 2004;113(7):2115-
2121.
2. Davison SP, Irio M, Oh C. Transconjunctival lower lid blepharoplasty with
and without fat repositioning. Clin Plast Surg. 2015;42(1):51-56.
3. Goldberg RA. Transconjunctival orbital fat repositioning: transposition of
orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg.
2000;105(2):743-748.
4. Hamra ST. The role of the septal reset in creating a youthful eyelid-cheek
complex in facial rejuvenation. Plast Reconstr Surg. 2004;113(7):2124-2141.
5. Kakizaki H, Malhotra R, Madge SN, Selva D. Lower eyelid anatomy: an
update. Ann Plast Surg. 2009;63(3):344-351.
6. Haddock NT, Saadeh PB, Boutros S, Thorne CH. The tear trough and
lid/cheek junction: anatomy and implications for surgical correction. Plast
Reconstr Surg. 2009;123(4):1332-1340.
7. Jindal K, Sarcia M, Codner MA. Functional considerations in aesthetic eyelid
surgery. Plast Reconstr Surg. 2014;134(6):1154-1170.
8. Tepper OM, Steinbrech D, Howell MH, et al. A retrospective review of
patients undergoing lateral canthoplasty techniques to manage existing or
potential lower eyelid malposition: identification of seven key preoperative
findings. Plast Reconstr Surg. 2015;136(1):40-49.
9. Friedmann DP, Goldman MP. Dark circles: etiology and management options.
Clin Plast Surg. 2015;42(1):33-50.
10. Goldberg RA, McCann JD, Fiaschetti D, Simon GJB. What causes eyelid
bags? Analysis of 114 consecutive patients. Plast Reconstr Surg.
2005;115(5):1395-1402.
11. Archibald DJ, Carlson ML, Friedman O. Pitfalls of nonstandardized
photography. Facial Plast Surg Clin North Am. 2010;18(2):253-266.
12. Bravo FG, Kufeke M & Pascual D. Incidence of lower eyelid asymmetry: an
anthropometric analysis of 204 patients. Aesthet Surg J. 2013;33(6):783-788.
13. Bravo FG. The aesthetic-health pyramid: a tool for patient education. Plast
Reconstr Surg. 2010;126(2):112e-113e.
14. Hidalgo DA. An integrated approach to lower blepharoplasty. Plast Reconstr
Surg. 2011;127(1):386-395.
15. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the
palpebral aperture. Clin Plast Surg. 1991;18(1):183.

16. Mejia JD, Egro FM, Ergo FM, Nahai F. Visual loss after blepharoplasty:
incidence, management, and preventive measures. Aesthet Surg J.
2011;31(1):21-29.

34
CHAPTER
Indications and Technique
for Lower Blepharoplasty via
Subciliary Incision
Francisco G. Bravo
DEFINITION
■ Patients concerned with the aesthetic appearance of their lower eyelids may be
managed surgically through a direct external approach bellow the lid margin.
■ Patients with poor skin quality or dermatochalasis associated with prominent
bags and orbicularis laxity are good candidates for this approach.
■ Canthal support techniques as well as orbicularis suspension maneuvers are
usually required and are frequently performed routinely to avoid postoperative
lid malposition.
ANATOMY
■ The lower eyelid consists of an anterior, middle, and posterior lamella1 (FIG
1A).
■ The skin and the orbicularis oculi muscle form the anterior lamella.
■ The orbital septum, orbital fat, and suborbicularis adipose tissue form the
middle lamella.
■ The tarsal plate, lower eyelid retractors (capsulopalpebral head and fascia),
and the conjunctiva form the posterior lamella.
■ The orbicularis oculi muscle is subdivided into the pretarsal, preseptal, and
orbital components.
■ There are three postseptal fat compartments in the lower eyelid (FIG 1B).
■ Nasal and central fat pads are separated by the inferior oblique muscle.
■ Central and lateral fat pads are separated by the arcuate expansion of the
Lockwood ligament (FIG 1C).
■ The orbicularis retaining ligament or orbitomalar ligament attaches the

palpebral orbicularis oculi muscle to the underlying maxilla (FIG 2A).
■ The tear trough or nasojugal groove and the lid-cheek junction or
palpebromalar groove extend below the orbital rim and are explained by
anatomical features in the subcutaneous plane2 (FIG 2B).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The preoperative evaluation for patients seeking lower eyelid surgery includes
a detailed assessment of the patient’s medical history and a thorough physical
examination.3
■ Medical history
■ Special attention should be paid to risk factors that may predispose to
postoperative complications.
■ Thyroid pathology, diabetes, hypertension, heart disease, coagulopathy, and
any previous periorbital surgery or trauma should be documented.
■ Vision disorders such as impaired visual acuity or the need to use corrective
glasses or contact lenses should be noted before surgery.
■ The use of medications such as aspirin and other nonsteroidal anti-
inflammatory drugs, anticoagulants, and certain vitamins and herbal
supplements such as vitamin E and ginkgo should be recorded and suspended
2 weeks prior to surgery.
■ Smoking history should also be documented and interrupted preferably for 4
weeks prior and 2 weeks after surgery.
■ A history suggestive of dry eye syndrome should be clarified, and if present,
the decision to proceed should be discussed carefully with the patient.
■ Physical examination
■ Evaluation should be performed with three goals in mind:
■ Document preoperative eye function
■ Identify anatomic features that may predispose patients to developing
postoperative complications.
■ Identify the specific anatomical features that are causing the patient’s
concern in order to customize the procedure.
■ Functional evaluation should include an examination and documentation of
visual acuity, extraocular muscular movements, Bell phenomenon, pupillary
response, and adequate tear production through a Schirmer or tear break-apart
time test.3
■ Anatomic features that may predispose to postoperative complications such as
lower eyelid retraction, ectropion, or malposition include the following:

■ A negative vector caused by a prominent eye or a retruded maxilla, which
may be measured by a Hertel exophthalmometer.
■ Tarsoligamentous or horizontal lid margin laxity with a measurable lag in the
snap-back test and a greater than 6 mm distraction test.
■ A negative canthal tilt in which the lateral canthus lies at a lower position in
relationship to the medial canthus.
■ Scleral show in which the lid margin rests below the corneoscleral limbus.
■ Specific anatomic features that need to be identified as possible causes of the
morphological concerns the patient might wish to address include4,5

Arcuate expansion Preaponeurotic fat pad Lacrimal gland Temporal fat pad Interpad septum (arcuate expansion of Lockwood ligament) Posterior lamella Anterior lamella Orbital septum - Middle lamella Upper orbital septum (reinforced with capsulopalpebral fascia) Capsulopalpebral fascia Lower orbital septun (transparent, unreinforced) Arcus maginalis Interpad septum > Nasal fat pad - Path of inferior oblique muscle Central fat pal

FIG 1 • A. The lower eyelid consists of an anterior,
middle, and posterior lamella. B. There are three
postseptal fat compartments in the lower eyelid. C.
Central and lateral fat pads are separated by the
arcuate expansion of the Lockwood ligament.
FIG 2 • A. The orbicularis retaining ligament or
orbitomalar ligament attaches the palpebral orbicularis

oculi muscle to the underlying maxilla. B,C. The tear
trough or nasojugal groove and the lid-cheek junction or
palpebromalar groove extend below the orbital rim and
are explained by anatomical features in the
subcutaneous plane.
■ Orbital fat herniation or prolapse due to fat pad hypertrophy or caused by
excessive laxity of the orbital septum and orbicularis oculi muscle
■ Tear trough deformity and a deep lid-cheek junction
■ Dark circles due to skin pigmentation or prominent intramuscular vasculature
in patients with thin, translucent skin and subcutaneous fat atrophy
■ Dermatochalasis or skin excess and rhytides
■ Orbicularis prominence or hypertrophy
■ Malar bags and festoons
IMAGING
■ The use of high-quality preoperative photography is a key element to plan and
carry out eyelid surgery, as well as to document and serve as reference for
clinical examination.
■ Standardization in patient positioning, lighting, lens focal length, and
background is crucial to avoid misinterpretation and distortion of the patient’s
anatomic features.6
■ The photographic series should include frontal, oblique, and profile views, as
well as frontal views while smiling, rising the eyebrows, frowning, gazing
upward, and closing the eyes, and also with slight posterior and anterior head
tilts while looking into the lens.
■ High-quality video capture should also be considered to appropriately
document ocular and eyelid function preoperatively.
■ Digital imaging software may be an important adjunct to precisely evaluate
eyelid morphology and to detect asymmetries, which are common in the lower
eyelid.7
NONOPERATIVE MANAGEMENT
■ With the popularity and appeal of noninvasive procedures among cosmetic
surgery patients, a thorough and earnest discussion should be maintained
regarding the advantages and disadvantages of such techniques vs surgical

options attending to the patient’s particular anatomic features and concerns.
■ Botulinum toxin may be employed to reduce skin wrinkles and expression
lines along the lateral portion of the lower eyelid, as well as to soften
orbicularis hypertrophy or protrusion.
■ Skin resurfacing techniques with either lasers or chemical peels such as
trichloroacetic acid or phenol-croton oil may be performed to improve skin
quality and dermatochalasis.
■ The use of fillers such as hyaluronic acid, collagen, or the patient’s own fat
may be infiltrated around the lower eyelid to correct an evident tear trough or
deep lid-cheek junction or to augment the inferior orbital rim and malar area to
provide better support and contour in a negative vector patient.
■ The use of nonsurgical procedures should not be discarded even if surgery is
indicated as they may be valuable adjuncts to improve and enhance the results
after lower blepharoplasty.
SURGICAL MANAGEMENT
■ The decision to proceed with surgery depends on the specific anatomic
concerns of the patient as well as on the degree and duration of the result
sought.8
■ Indications for surgery include herniated and prolapsed bags, an evident tear
trough deformity or deep lid-cheek junction and orbicularis muscle laxity or
excess skin.
■ Patients with good skin quality might be better candidates for a
transconjunctival approach.
■ Risks to the patient include hematoma, infection, and lower eyelid retraction
or malposition.
■ The main steps include access to the eyelid bags through a subciliary incision,
release of the arcus marginalis and orbitomalar ligament, removal of lower
eyelid fat, lateral canthopexy, and resuspension or tightening of the orbicularis
muscle.
■ The skin should be excised conservatively in most cases, and canthal support
techniques should be employed routinely to decrease the incidence of lower lid
retraction or scleral show.
Preoperative Planning
■ The complete eyelid photographic series of the patient should be carefully
reviewed before surgery and should be available in the operating room.

■ Markings on the patient should be performed in the upright position. The tear
trough and lid-cheek junction should be outlined, as well as the areas of
maximal protrusion of the fat pads.
■ The patient should be inquired as to whether having taken aspirin in the days
prior to surgery and the procedure suspended if a positive response was given.
■ The surgeon must be familiar with techniques for canthal support and
tarsorrhaphy as they are often necessary at the end of the procedure.
Positioning
■ The patient is positioned supine on the operating table.
■ Prepping is performed with a low concentration chlorhexidine solution without
alcohol, avoiding penetration into the eyes.
■ Intravenous sedation is started, and corneal protectors are placed.
■ Oxygen is administered through a nasal catheter at a low flow and
concentration. Instructions should be given to the anesthetist to momentarily
interrupt flow when using electrocautery to avoid accidental fires in the
operating room.
■ The lower eyelid and inferior orbital rim are infiltrated with a 1% lidocaine
with 1:100 000 epinephrine solution.
Approach
■ Skin-muscle flap approach with orbicularis oculi resuspension:
■ Exposure to the lower eyelid bags and orbital septum is achieved through the
subciliary incision, dividing the muscle in a stair-step fashion to preserve the
pretarsal segment.
■ Undermining of the skin-muscle flap is performed to achieve adequate
exposure of the orbital septum and inferior orbital rim for fat reduction.
■ A strong resuspension of the orbicularis to the periosteum is required after
skin excision, so as to avoid lid malposition or retraction postoperatively.
■ Skin-only flap approach with reverse orbicularis oculi tightening (ROOT):
■ Exposure of the pretarsal and preseptal segments of the orbicularis is
achieved through the subciliary incision by undermining a skin-only flap
extending to the infraorbital rim.
■ The orbital septum and fat pads are exposed through an incision in the caudal
aspect of the preseptal orbicularis taking care to avoid the medial portion that
provides innervation through buccal branches to the pretarsal segment.

■ After fat reduction is performed, tightening of the lax orbicularis muscle is
performed in a reverse fashion by excising a segment of the muscle caudally
and repairing the orbicularis without tension.
■ Skin excision and muscle tightening are performed independently through
this approach, which may be useful in patients with evident muscular laxity
and excess skin.
T E C H N I Q U E S
■ Skin-Muscle Flap Approach With Orbicularis
Oculi Resuspension
■ The skin is incised 5 mm from the canthal angle with a slight downward
slant to run parallel or within and existing crow’s foot.
■ Straight scissors are employed to undermine the skin from the pretarsal
muscle through careful spreading, pointing the tips of the scissors to the
medial canthus (TECH FIG 1A).
■ A 5-0 silk traction suture with a noncutting needle is placed through the
lower eyelid, and the lid margin is retracted upward covering the eye (TECH
FIG 1B).
■ The subciliary incision is performed through skin only with straight
scissors, 2 to 3 mm below the lid margin.
■ The muscle is divided in a stair-step fashion9 2 to 3 mm below the skin
incision to preserve at least 5 mm of pretarsal orbicularis muscle (TECH FIG
1C).
■ The skin-muscle flap is elevated inferiorly in a preseptal plane to the inferior
orbital rim.
■ The orbital septum is visualized and the fat compartments identified with the
help of sterile cotton tips.
■ The septum is incised and gentle, continuous pressure is applied to the globe
to allow the fat to herniate.
■ Fat is conservatively excised with electrocautery according to the
preoperative plan (TECH FIG 1D).
■ The arcus marginalis is released, and dissection over the inferior orbital rim
is performed and extended laterally by releasing the orbicularis retaining

ligament with cautery and a periosteal elevator.
■ Alternatively, the dissection can be carried out in the suborbicularis plane
supraperiostally, although more bleeding may be encountered.
■ Excess fat may be transposed or grafted over the inferior orbital rim to blend
the lid-cheek junction or improve a tear trough deformity.
■ Canthopexy is performed to correct lid laxity and prevent scleral show
postoperatively. Care is taken to maintain the lid margin against the globe at
the lateral canthus and to remove the corneal protector before tightening the
canthopexy suture9 (TECH FIG 1E–G).
■ Hemostasis is revised, and the wound is thoroughly cleansed with saline.
■ The skin-muscle flap is redraped in a superior lateral vector, and excess skin
and muscle are excised conservatively (TECH FIG 1H,I).
■ Remaining excess muscle is excised with cautery.

TECH FIG 1 • A. After the skin is incised, straight
scissors are used to undermine the skin from the
pretarsal muscle. B. A 5-0 Silk traction suture with a
noncutting needle is placed through the lower eyelid,
and the lid margin is retracted upward covering the
eye. C. The muscle is divided in a stair-step fashion9 2
to 3 mm below the skin incision to preserve at least 5
mm of pretarsal orbicularis muscle. D. Fat is
conservatively excised with electrocautery according
to the preoperative plan from the lateral, central
(shown), and medial fat compartments. E. A 4-0 white
Ethibond or Mersilene suture is placed on the tarsal
plate and lateral retinaculum. F. Right angle scissors
are employed to connect the lateral orbital rim to the

inferior incision. G. The needle is passed through the
periosteum in the lateral orbital rim. H. The skin-
muscle flap is redraped, and excess skin is marked for
removal. I. Excess skin and muscle are excised. J.
Resuspension of the orbicularis muscle: the needle is
passed through the orbicularis muscle. K. The needle
is passed through the periosteum of the lateral orbital
rim.
■ Resuspension of the orbicularis muscle is performed with direct periosteal
fixation of the muscle to the lateral orbital rim using a 4-0 resorbable suture
(TECH FIG 1J,K).
■ A 6-0 fast resorbing or a 7-0 Prolene suture is employed to close the
subciliary incision.
■ The initial traction suture may be employed as a temporary Frost suture in
patients who might be prone to lower lid retraction or scleral show and left in
place for 24 to 72 hours.
■ A temporary lateral tarsorrhaphy using a 5-0 Prolene suture is performed in
patients who develop chemosis intraoperatively or in those that required more
extensive canthal support and left in place for 3 days.
■ Skin-Only Flap Approach With Reverse
Orbicularis Oculi Tightening (ROOT)
■ A 5-0 silk traction suture with a noncutting needle is placed through the
lower eyelid, and the lid margin is retracted upward to cover the eye.
■ The skin is incised 5 mm from the canthal angle with a slight downward
slant to run parallel or within and existing crow’s foot and continued medially
toward the medial canthus 2 to 3 mm below the lid margin (TECH FIG 2A).
■ A skin-only flap is elevated to the level of the orbital rim exposing the
pretarsal and preseptal portions of the orbicularis muscle. Countertraction
with sterile cotton tips and transillumination are helpful in this dissection
(TECH FIG 2B).
■ Orbicularis muscle laxity is assessed, and a small strip of muscle is marked
for removal near the inferior orbital rim.

■ The muscle is incised along the markings, and a small strip of orbicularis is
elevated as a flap from lateral to medial (TECH FIG 2C).
■ Care is taken to avoid extending the incision too far medially in order to
preserve buccal branches that provide innervation to the pretarsal
orbicularis.
■ Through the resulting gap in the muscle, the orbicularis is undermined in a
preseptal plane cranially to expose the fat compartments and caudally to
access the inferior orbital rim.
■ The orbital septum is visualized, and the fat compartments are identified
with the help of sterile cotton tips.
■ The septum is incised, and gentle, continuous pressure is applied to the globe
to allow the fat to herniate.
■ Fat is conservatively excised with electrocautery according to the
preoperative plan from the medial, central, and lateral fat compartments
(TECH FIG 2D).

TECH FIG 2 • A. The skin is incised. B. A skin-only
flap is elevated. C. The muscle is incised where it has
been marked for removal, and a small strip of
orbicularis is elevated as a flap from lateral to medial.
D. Fat is excised with electrocautery. E,F. The
orbicularis muscle is tightened by directly suturing the

edges of excised preseptal orbicularis with a running
6-0 Vicryl suture. G. Excess muscle is excised, but a
portion is maintained and turned over medially to
provide volume in order to improve a tear trough
deformity if present.
■ The arcus marginalis is released, and dissection over the inferior orbital rim
is performed and extended laterally by releasing the orbicularis retaining
ligament with cautery and a periosteal elevator.
■ Alternatively, the dissection may be carried out in the suborbicularis plane
supraperiostally, although more bleeding may be encountered.
■ Excess fat may be transposed or grafted over the inferior orbital rim to blend
the lid-cheek junction or improve a tear trough deformity.
■ Canthopexy is performed to correct lid laxity and prevent scleral show
postoperatively. A white Ethibond or Mersilene suture is employed to fix the
tarsal plate and lateral retinaculum to the periosteum in the lateral orbital rim.
Care is taken to maintain the lid margin against the globe at the lateral
canthus and to remove the corneal protector before tightening the canthopexy
suture.
■ Hemostasis is achieved, and the wound is thoroughly cleansed with saline.
■ The orbicularis muscle is tightened by directly suturing the edges of excised
preseptal orbicularis with a running 6-0 Vicryl suture. Excess muscle is
excised, and a portion is maintained and turned over medially to provide
volume to improve a tear trough deformity if present (TECH FIG 2E–G).
■ The skin-only flap is redraped in a superior lateral vector, and excess skin is
excised conservatively.
■ A 6-0 fast resorbing or a 7-0 Prolene suture is employed to close the
subciliary incision.
■ The initial traction suture may be employed as a temporary Frost suture in
patients who may be prone to lower lid retraction or scleral show.
■ A temporary lateral tarsorrhaphy using a 5-0 Prolene suture is performed in
patients who develop chemosis intraoperatively or in those who required
more extensive canthal support. The suture is left in place for 3 days.

PEARLS AND PITFALLS
Patient
evaluation
■ Failure to identify adequate candidates for the procedure will
inevitably lead to suboptimal results.
■ Patients with good skin quality and minimal orbicularis laxity may
benefit more from a transconjunctival approach.
Hemostasis
■ Bleeding should be avoided from the beginning to the end of the
procedure through adequate infiltration and use of needle-tip
cautery for dissection and fat excision.
Canthopexy
■ Although the standard position of the lateral canthopexy suture is
at the lower level of the pupil, patients with prominent eyes or
negative vectors require a higher fixation at the upper level of the
pupil, whereas patients with deep set eyes will require positioning
at a lower level.
■ Patients with asymmetric lower eyelids, as is often the case, will
also require a higher fixation on the side in which the lateral
canthus is initially lower.
■ Special attention must be paid to maintaining the lid margin
against the globe when tightening the canthopexy suture. The
anchoring point in the periosteum should be well inside the lateral
orbit at the depth of Whitnall tubercle.
Orbicularis
muscle
incision
■ Care must be taken to leave a segment of at least 5 mm of
pretarsal orbicularis when incising the muscle through the
subciliary skin-muscle approach.
■ The incision should not extend excessively past the medial corneal
limbus to avoid injury to the buccal nerve branches that are
responsible for pretarsal orbicularis innervation.
Orbicularis
muscle
tightening
■ A strong canthal support and a secure orbicularis resuspension to
periosteum are imperative to avoid lower lid malposition and
retraction when the skin-muscle flap approach is employed.
■ Muscle resection must be conservative and not extended medially
when performing a reverse orbicularis oculi tightening procedure
through a skin-only flap.
Skin excision
■ The skin should be removed very conservatively.
■ A slight upward pull should be applied on the lid margin until it
lies above the inferior corneal limbus before assessing the skin that
should be excised.
Postoperative
care
■ Frost and tarsorrhaphy sutures must be employed readily in
patients morphologically prone to develop postoperative lid

malposition or retraction.
■ Slight compression with a loose elastic head band applied over the
eyes may prove useful to control swelling during the initial
postoperative period. Adequate padding over the eyelids and
midface is essential.
POSTOPERATIVE CARE
■ Patients are instructed to apply cold packs and slight compression for 48
hours.
■ Artificial tear drops are prescribed as well as oral antibiotics and pain
medication.
■ Patients are advised to sleep for 5 days with their head elevated and to avoid
activity, medication, or food that may increase blood pressure or swelling.
■ Sutures are removed at the 6th postoperative day.
OUTCOMES
■ Patients with protruding fat pads and an evident tear trough deformity, who
also have excess skin in the lower eyelid and a lax orbicularis muscle, should
expect good outcomes (FIG 3A–D).
■ Although excellent results may be obtained, patients should be well informed
of the risks associated with the procedure that may require surgical revision as
well as of the prolonged swelling that may occur.
■ Codner reviewed the results of 264 patients who underwent transcutaneous
lower lid blepharoplasty.9
■ Chemosis was the most common complication occurring in over 12% of the
patients.
■ Blepharitis developed in 10 patients (3.8%) and required antimicrobial eye
ointment in combination with steroids.
■ Temporary lid malposition was encountered in 16 patients (6.1%) and
resolved completely with conservative lid massage.
■ Lower lid retraction requiring surgical correction occurred seven patients
(2.7%), whereas frank bilateral ectropion with symptoms of corneal exposure
occurred in two patients (0.8%) who also required revision of the lateral
canthoplasty.
■ Another 11.7% of the patients required revision for minor complications
such as cysts or granulomas developing from the incision line, inadequate
scars, canthal suture palpability, or inflammation and canthal webbing.

COMPLICATIONS
■ Apart from prolonging postoperative downtime, a hematoma may constitute a
true surgical emergency if the bleeding accumulates in the retrobulbar space,
which may lead to optic nerve compression and blindness.
■ Although an infrequent complication, an infection should be treated promptly
with topical or systemic antibiotics if necessary.
■ Patients should be informed of the possibility of lid margin malposition.
Surgical revision may be required to correct this complication, although early
management with vertical massage and taping may be sufficient to avoid
surgery.10
■ Prolonged edema may be seen more frequently when the transcutaneous
approach is performed, due to the more extensive dissection required that
produces more disruption of lymphatic channels draining the orbit.
FIG 3 • A. Patient shown preoperatively and
postoperatively (B) after lower blepharoplasty through a
subciliary incision with a skin-muscle flap and
orbicularis resuspension. C. Patient shown
preoperatively and postoperatively (D) after lower

blepharoplasty through a subciliary incision with a skin-
only flap and reverse orbicularis oculi tightening
(ROOT).
■ Patients may also experience various degrees of hardening and fibrosis around
the infraorbital rim if fat was transposed or grafted, which normally resolves by
3 months.
■ Chemosis may occur frequently when canthal support techniques are used, due
to postoperative edema with poor lymphatic drainage. Treatment includes
prescription of mild topical steroid eye drops or short-term eye patching. A
temporal lateral tarsorrhaphy may prevent corneal exposure and avoid
chemosis in selected patients. Conjunctival incision and drainage may be
required in recalcitrant cases.9
REFERENCES
1. Kakizaki H, Malhotra R, Madge SN, Selva D. Lower eyelid anatomy: an
update. Ann Plast Surg. 2009;63(3):344-351.
2. Haddock NT, Saadeh PB, Boutros S, Thorne CH. The tear trough and
lid/cheek junction: anatomy and implications for surgical correction. Plast
Reconstr Surg. 2009;123(4):1332-1340.
3. Jindal K, Sarcia M, Codner MA. Functional considerations in aesthetic eyelid
surgery. Plast Reconstr Surg. 2014;134(6):1154-1170.
4. Friedmann DP, Goldman MP. Dark circles: etiology and management options.
Clin Plast Surg. 2015;42(1):33-50.
5. Goldberg RA, McCann JD, Fiaschetti D, Simon GJB. What causes eyelid
bags? Analysis of 114 consecutive patients. Plast Reconstr Surg.
2005;115(5):1395-1402.
6. Archibald DJ, Carlson ML, Friedman O. Pitfalls of nonstandardized
photography. Facial Plast Surg Clin North Am. 2010;18(2):253-266.
7. Bravo FG, Kufeke M, Pascual D. Incidence of lower eyelid asymmetry: an
anthropometric analysis of 204 patients. Aesthet Surg J. 2013;33(6):783-788.
8. Bravo FG. The aesthetic-health pyramid: a tool for patient education. Plast
Reconstr Surg. 2010;126(2):112e-113e.
9. Codner MA, Wolfli JN, Anzarut A. Primary transcutaneous lower
blepharoplasty with routine lateral canthal support: a comprehensive 10-year
review. Plast Reconstr Surg. 2008;121(1):241-250.
10. Pepper JP, Baker SR. Transcutaneous lower blepharoplasty with fat

transposition. Clin Plast Surg. 2015;42(1):57-62.

35
CHAPTER
Lateral Canthal
Manipulation With
Canthopexy or Canthoplasty
George N. Kamel, Glenn W. Jelks, and Oren M. Tepper
DEFINITION
■ The lateral canthus or lateral retinaculum is a continuation of the preseptal and
pretarsal orbicularis muscle and receives contributions from the following
anatomic structures: the lateral horn of the levator aponeurosis, the lateral
extension of the preseptal and pretarsal orbicularis oculi muscle (lateral canthal
tendon), the Lockwood ligament, and the check ligament of the lateral rectus
muscle.
■ The inferior retinaculum refers to the lower eyelid’s contribution to the lateral
retinaculum.
■ Lateral canthopexy refers to repositioning of the lateral canthus without
disinsertion from the orbital tubercle, whereas in a lateral canthoplasty, the
lateral canthus is disinserted and repositioned.
ANATOMY
■ A thorough understanding of the periorbital anatomy is necessary to achieve
optimal aesthetic surgical results while avoiding potential complications.
■ The eyelids and surrounding structures can be divided into five anatomical
zones (FIG 1).1,2 Zone I and zone II represent the upper and lower eyelid,
respectively. Zone III represents the medial canthus and lacrimal drainage
system. Zone IV includes the lateral canthal region and lateral retinaculum.
Zone V represents the surrounding periorbital structures and includes the
forehead, brow, glabellar, temple, malar, and nasal regions.
■ Lower eyelid procedures including lower eyelid blepharoplasty and lateral
canthopexy or canthoplasty focus on zones II and IV. The lower eyelid or zone

II can be thought of as a trilamellar structure that consists of an anterior,
middle, and posterior lamella. The anterior lamella consists of skin and
orbicularis oculi muscle that is further divided into pretarsal, preseptal, and
orbital components. The pretarsal and preseptal components are often referred
to as palpebral portions. The middle lamella includes the tarsus, orbital septum,
and retroseptal fat, while the posterior lamella denotes the capsulopalpebral
fascia and conjunctiva.
FIG 1 • The five zones of the periorbital region.
■ The tarsal plate of the lower eyelid on average measures 25 mm wide, 4 mm in
height, and 1 mm in thickness and provides structural integrity to the eyelid.
■ The lateral canthus or lateral retinaculum (zone IV) is a three-dimensional
fibrous structure that connects the upper and lower tarsal plates to the Whitnall
tubercle, located 8 mm posterior to the lateral orbital rim (FIG 2). These
structures converge at the lateral canthal angle, typically approximately 1.5 to
2.0 mm above the medial canthal angle. This aesthetically pleasing and
favorable relationship of the lateral canthus above the medial canthus is often
referred to as a positive canthal tilt. When the lateral canthus is at the level of
or below the medial canthus, this is referred to as neutral or negative canthal
tilt, respectively. It is the lower eyelid portion of the lateral retinaculum or the
“inferior retinaculum” that is the focus of the lateral canthopexy or
canthoplasty techniques that will be described in this chapter.
PATHOGENESIS

■ Despite distinct ethnic and cultural differences, the youthful eye resembles an
almond shape, which has a long and narrow palpebral fissure and an upward
inclination of approximately four degrees laterally. In patients with loss of
lateral canthal support, the lateral palpebral fissure takes on a more rounded
appearance with concomitant laxity of the lower eyelid margin. The
pathophysiology of lateral canthal disorders is attributed to the loss of canthal
support from gravitational, mechanical, or involutional factors.
FIG 2 • Supporting structures of the upper and lower
eyelid. Note the lateral retinaculum receives
contributions from both the upper and lower eyelids.
FIG 3 • Key seven-step preoperative checklist.
■ A subset of patients are at increased risk for lower eyelid malposition resulting
from lower blepharoplasty. In such patients, lateral canthal tightening may be
indicated to help prevent these sequelae.
PATIENT HISTORY AND PHYSICAL FINDINGS

■ The preoperative assessment begins with a detailed medical history with
emphasis on risk factors that may lead to postoperative complications. A past
medical history of hypertension, diabetes, thyroid disease, bleeding diathesis,
glaucoma, dry eyes, trauma, and periorbital and facial operations, including
refractive surgery, is of particular significance and should be documented.
Furthermore, the use of medications that include nonsteroidal anti-
inflammatory, anticoagulants, and aspirin should be recorded and held for a
minimum of 2 weeks prior to surgery.
■ The physical exam should be performed with the patient sitting in an upright,
relaxed position and should begin with an assessment of visual acuity,
pupillary reflexes, extraocular muscle movement, and an intact Bell
phenomenon.3 A focused lower eyelid exam should document the presence of
malar bags, fat herniation, dermatochalasis, tear trough deformities, and skin
pigmentation. In addition, the senior authors have previously identified seven
key features that should be assessed in patients undergoing lower eyelid
procedures and include the following: canthal tilt, vector analysis, scleral show,
tarsoligamentous integrity, lateral canthal-orbital rim distance, midface
position, and vertical restriction.2 This standard preoperative checklist is
provided in FIG 3.
■ Canthal tilt assesses the relationship of the medial and lateral canthus (FIG 4).
The average position of the lateral canthus is approximately 1.5 to 2 mm
cephalad to the medial canthus thus resulting in a positive tilt. Canthal tilt can
be described as positive, negative, or neutral.

FIG 4 • Canthal tilt: The canthal tilt defines the
relationship between the medial and lateral canthus.
FIG 5 • A comparison of normal malar position as

shown on the reader’s right to descent.
■ Vector analysis describes the relationship of the anterior cornea of the globe to
the malar eminence and can be neutral, positive, or negative. A positive vector
is defined by a posterior relationship of the anterior cornea to the malar
eminence, whereas in a negative vector, the anterior cornea projects in front of
the malar eminence. It is negative vector anatomy that is associated with
prominent fat pads, midface descent, and greater risk of lower eyelid
malposition post blepharoplasty.
■ Scleral show defines the relationship between the lower eyelid margin and the
inferior limbus of the cornea, which is normally present at the same level
precluding visualization of the sclera. Scleral show below the level of the
inferior limbus suggests tarsoligamentous laxity.
■ Tarsoligamentous integrity defines the tone of the lower eyelid and is
examined with a snapback test and lid distraction test. The snapback test is
performed by having the patient in primary gaze without blinking, displacing
the lower eyelid inferiorly, and measuring the time required for the lower
eyelid to return to its normal position. Measurements greater than 1 second are
considered abnormal and can be associated with loss of orbicularis oculi
muscle tone. The lid distraction test involves anterior traction on the lower
eyelid away from the globe and measuring the distance between the globe and
lower eyelid. Measurements less than 4 mm are considered normal, whereas
distraction greater than 8 mm indicates tarsoligamentous laxity and the
possible need for horizontal lower eyelid shortening.
■ Lateral canthal-orbital rim distance (LC-OR) is a clinically valuable
measurement and can be categorized as either being greater than or less than 1
cm. This measurement becomes important when determining which procedure
to use for patients requiring correction of significant lower eyelid malposition.
■ Midface position is an important consideration of the lower eyelid-cheek
junction. Patients with midface descent may benefit from a cheek suspension to
support the lower eyelid and relieve tension on the lateral canthus (FIG 5).
■ This 7-step analysis helps to determine the proper procedures for the patient
undergoing primary blepharoplasty or correcting pre-existing lower eyelid
malposition. As shown (see FIG 3), patients with anatomic features on the left
side have favorable conditions as compared to those with findings that line up
on the right side.

■ During the preoperative exam, one must assess for vertical restriction, which is
measured by elevating the lower eyelid and ensuring that the eyelid margin
reaches a level above the pupil. In cases of vertical restriction, one must
decipher the origin as resulting from the anterior, middle, or posterior lamella.
When restriction is present, additional corrective procedures may include
release of cicatrix, placement of spacer graft, cheek suspension, or Mitek
anchor fixation.
IMAGING
■ Radiographic imaging is generally not indicated in the preoperative workup in
patients undergoing procedures that include lower eyelid rejuvenation with
lateral canthopexy or canthoplasty.
SURGICAL MANAGEMENT
■ The inferior retinacular canthopexy was designed to improve eyelid aesthetics
and prevent lower eyelid malposition in patients undergoing a primary
blepharoplasty without separating the lower eyelid from the lateral palpebral
commissure. Furthermore, its utility can be seen in correcting lower eyelid
malposition in patients with a negative vector relationship. The lateral tension
and pull achieved from the inferior retinacular canthopexy may provide
significant improvement to lower eyelid aesthetics by smoothing the lower
eyelid skin and diminishing or obviating the need for lower eyelid skin
resection. Patients with more severe laxity or retraction may require
canthoplasty in place of canthopexy.
Preoperative Planning
■ The 7-step checklist previously described can aid the surgeon in stratifying
patients into an appropriate surgical treatment plan.
Positioning
■ Lower eyelid blepharoplasty with or without canthal manipulation is
performed with the surgeon standing at the head of the patient looking toward
the feet. Loupe magnification as well as a focused headlight is recommended to
aid with visualization of key structures.
Approach
■ Numerous surgical techniques have been described to address lateral canthal
position and to correct lower eyelid malposition. These include dermal

orbicular pennant lateral canthoplasty, tarsal strip lateral canthoplasty cheek
suspension with Mitek anchor fixation, and bride of bone canthopexy.1,4 The
specifics of these is beyond the scope of this chapter; we will focus on inferior
retinacular lateral canthopexy and canthoplasty techniques.
T E C H N I Q U E S
■ Inferior Retinacular Lateral
Canthopexy/Canthoplasty
■ The inferior retinacular lateral canthopexy/canthoplasty can be performed
through a horizontal canthal incision or an upper lateral eyelid incision.5
■ The advantage of an upper eyelid incision is that this incision is already
being applied to patients undergoing concomitant upper blepharoplasty.
■ The inferior edge of the lateral upper eyelid incision is grasped, and a
submuscular dissection is performed in a supraperiosteal plane heading in an
inferomedial direction.
■ The skin and muscle flap is then elevated 2 cm around the lateral canthus
and lower eyelid using a combination of blunt scissor dissection and fine-
point electrosurgical dissection.
■ An insulated Desmarres retractor is used to retract the skin and muscle flap
and help expose the lateral retinaculum, which is located just superior to the
lower eyelid lateral fat.
■ One additional advantage of this approach is that lower eyelid fat can also be
removed at this stage, which creates an open space (Jelks cave) and allows
visualization of the lateral retinaculum as it inserts on Whitnall tubercle
(TECH FIG 1A).
■ In a canthopexy, forceps are then used to grasp the inferior retinaculum
(TECH FIG 1B), and U-stitch is placed through with two passes of
permanent or semipermanent suture (Mersilene 4-0, Polydek Silky II-ME2).
TECH FIG 1 • A. The inferior retinacular lateral
canthopexy is performed through the lateral aspect of

an upper eyelid blepharoplasty incision. B. The inferior
retinaculum is grasped with forceps and fixated to the
inner periosteum of lateral orbital rim.
■ In a canthoplasty, the inferior retinaculum is divided from its insertion so
that repositioning is possible.
■ The lower eyelid is then everted to confirm that the suture has not violated
the conjunctiva.
■ In a canthoplasty, the inferior retinaculum is cut, thereby detaching the lower
lid from the lateral orbital wall, before the suspension suture is placed.
■ Fixation of the suture is then performed to the inner periosteum at the lateral
orbital rim at the level of the superior aspect of the pupil in primary gaze.
Placement of this stitch should be performed with great care, as this sets the
new height of the lateral canthal tendon. Of note, corneal shields may limit
one’s ability to assess the level of the pupil. In the orbit, this represents the
portion of the lateral orbital rim that starts to take an inward curve.
■ The wound is closed as a single layer.
■ The same principles and surgical technique apply when using a horizontal
canthal incision. If an upper blepharoplasty incision is not being used, one
may also perform a transcanthal canthopexy. In this case, the lateral
retinaculum is approached directly and grasped from below, but similar
principles apply.
PEARLS AND PITFALLS
Indications
■ Inferior retinacular lateral canthopexy was developed to help prevent
lower eyelid malposition in primary blepharoplasty patients.
■ A canthoplasty can be used for correction of secondary lower eyelid
malposition associated with a negative vector.
■ Lateral canthal tightening can address redundant lower eyelid skin,
thus diminishing or obviating the need for more skin excision.
Advantage
■ Inferior retinacular lateral canthopexy does not separate the lower
eyelid from the lateral palpebral commissure.
Approach
■ The lower eyelid should appear overcorrected and cover

approximately 1–2 mm of the inferior limbus as it settles into position
in 2 to 6 weeks.
POSTOPERATIVE CARE
■ Minimal activity for 24 hours and head of bed elevation to at least 45 degrees
should be maintained.
■ Cool compresses may be applied for the first 24 hours.
■ Ophthalmic antibiotic ointment is used two to three times per day for the
eyelid suture lines. Steroid ophthalmic solutions are prescribed for 3 to 5 days.
■ Tear supplements may be used for the 1st week, but are usually not necessary.
■ Patients should sleep at 30 to 45 degrees elevation for 2 to 3 weeks.
■ Patients may resume preoperative physical activity by 3 to 4 weeks
postoperatively.
■ Patients follow up 5 days postoperatively for suture removal and are followed
4 weeks, 3 months, 6 months, 9 months, and 1 year postoperatively.
■ Photographs are taken at 1-year follow-up.
OUTCOMES
■ See FIG 6.
FIG 6 • A. A preoperative photograph of a patient with
lower eyelid malposition. B. The inferior retinacular
lateral canthopexy allows for proper lower eyelid
positioning as well as improving canthal tilt.
COMPLICATIONS

■ Postoperative complications from proper lateral canthal support are
uncommon but may include the following:
■ Bleeding
■ Infection
■ Lower lid malposition
■ Scar formation
■ Chemosis
ACKNOWLEDGMENTS
We thank Steve Sultan and Elizabeth Jelks for their assistance in the preparation
of this chapter.
REFERENCES
1. Jelks GW, Elizabeth BJ. “Lateral canthal suspension techniques”. Aesthet
Plast Surg. 2009:329.
2. Tepper O, Steinbrech D, Howell MH, et al. A retrospective review of patients
undergoing lateral canthal techniques to manage existing or potential lower
eyelid malposition: identification of seven key preoperative findings. Plast
Reconstr Surg. 2015;136(1):40-49.
3. Jindal K, Sarcia M, Codner MA. Functional considerations in aesthetic eyelid
surgery. Plast Reconstr Surg. 2014;134(6):1154-1170.
4. Yaremchuk MJ, Chen YC. Bridge of bone canthopexy. Aesthet Surg J.
2009;29:323-329.
5. Jelks GW, Glat PM, Jelks EB, Longaker MT. The inferior retinacular lateral
canthoplasty: a new technique. Plast Reconstr Surg. 1997;100(5):1262-1270.

36
CHAPTER
Indications and Techniques
for Fat Grafting for
Periorbital Rejuvenation
Oren M. Tepper, Jillian Schreiber, Elizabeth B. Jelks, and
Glenn W. Jelks
DEFINITION
■ The periorbital region is an essential component of a youthful appearing face.
Aesthetic rejuvenation of the eyelids is a frequently requested and challenging
procedure offered by most plastic surgery practices. Although soft tissue
descent and cutaneous changes have long been recognized as a sign of
periorbital aging, volume loss or deflation has more recently been appreciated
as an important contributing factor as well.1,2
■ Traditional blepharoplasty is subtractive in nature. Conventional approaches to
upper and lower blepharoplasty include excision of excess skin and fat, with
potential risk of creating a hollowed or “operated” appearance.2–4 In light of
the importance of periorbital fat to provide support and contour in the youthful
eyelid, there has been a shift in blepharoplasty techniques away from excision
alone toward preservation and restoration of periorbital volume.2,5–7 The goals
of this chapter are to provide an updated approach to fat grafting in the
periorbital region as a primary means of achieving upper and lower eyelid
rejuvenation and/or correction of secondary deformities.
■ Autologous fat grafting has gained widespread popularity as an effective
means of volume augmentation for various facial procedures due to its ease of
harvest, longevity, rapid execution, and relative safety.8–10 Autologous fat
grafting is used to address changes due to aging in the upper and lower eyelid,
the brow, and the eyelid-cheek junction.1
Upper Eyelid

■ Atrophy of fat and skin in the upper eyelid and surrounding regions can result
in skeletonization of the bony orbit, protuberance of remaining periorbital fat,
poor soft tissue support, and eyebrow descent.
■ In general, fat grafting of the upper eyelid is most commonly performed for
correction of a hollowed appearance to the upper eyelid sulcus. This may be
the result from aging or secondary to over-resection of retroseptal fat during an
upper blepharoplasty procedure.
Lower Eyelid
■ A prominent nasojugal groove, often described as the “tear trough,” is a
common finding in patients seeking periorbital rejuvenation. The anatomical
junction of the lower eyelid and cheek (palpebral malar interface) extends from
the medial canthus inferolaterally above cheek tissue to form a depression
(nasojugal groove). This is distinct from colloquial terms such as “dark circles”
and “puffiness” of the lower eyelid that are commonly used interchangeably.
■ Fat grafting to the eyelid-cheek junction, with or without skin and fat excision,
is an effective means to treat a tear trough deformity and camouflage the
prominence of fat in the lower eyelid compartments.
ANATOMY
■ The periorbital region is composed of the bony orbital rim, orbicularis oculi
muscle, orbital fat compartments, and the upper and lower eyelids. The upper
and lower eyelids are layered structures composed of an anterior and posterior
lamella divided by the orbital septum (FIG 1).
■ The thin eyelid skin and orbicularis oculi muscle constitute the anterior
lamella of the upper and lower eyelids. The orbicularis oculi muscle is divided
into pretarsal, preseptal, and orbital components. The pretarsal and preseptal
portions make up the palpebral segment and provide involuntary blink,
whereas the orbital portion provides voluntary eyelid closing.
■ The posterior lamella is composed of different but analogous structures
between the upper and lower eyelids. The upper eyelid posterior lamella
includes the palpebral conjunctiva and tarsal plate. Above the tarsal plate, it is
composed of the palpebral conjunctiva and Müller muscle. The posterior
lamella of the lower eyelid is similarly made up of the palpebral conjunctiva
and tarsal plate and inferior to the tarsal plate the conjunctiva and
capsulopalpebral fascia and inferior tarsal muscle.

FIG 1 • Upper eyelid anatomy. Sagittal section through
the upper eyelid demonstrating the anterior and
posterior lamella and the relationship with the orbital
septum.
FIG 2 • Upper eyelid anatomy highlighting the
relationship between the levator muscle, the tarsus, and
lateral canthal tendon.
■ The upper eyelid retractors are the levator palpebrae superioris innervated by

the oculomotor nerve and the sympathetically innervated Müller muscle (FIG
2). The lower eyelid retractors include the capsulopalpebral fascia and inferior
tarsal muscle.
■ The prominent tear trough is often addressed in periorbital rejuvenation.
Factors that contribute to a prominent palpebral malar interface include
alterations in the quality and elasticity of the overlying skin, subcutaneous
tissue, orbicularis oculi muscle, orbital septum, capsulopalpebral fascia, and
retroseptal orbital fat.2 The anatomical position of the arcus marginalis on the
zygomatic and maxillary bones determines the location of the palpebral malar
interface2,3 (FIG 4).
■ The arcus marginalis is defined by the bony origin of the orbital septum,
orbital periosteum, and the maxillary periosteum. The origins of the preseptal
and orbital orbicularis oculi muscle, the orbital retaining ligaments, malar
septum, prezygomatic space, and arcuate bands are related to the arcus
marginalis.
■ The upper eyelid fat is composed of the medial and lateral fat compartments.
In the lower eyelid, three distinct fat compartments of retroseptal fat exist:
lateral, central, and nasal. The nasal and central compartments are divided by
the inferior oblique muscle tendon. The medial (nasal) compartment is derived
from the white orbital fat and the lateral (central) fat compartment from the less
dense, yellow preaponeurotic fat.1