Blepharoplasty, Lower Lid, Canthal Support Treatment & Management
- Author: David C Cho, MD; Chief Editor: James Neal Long, MD, FACS more...
Some symptoms caused by lower lid laxity can be treated with artificial tears, lower lid taping, or digital massage.
Pentagonal wedge resection
This procedure corrects excess horizontal length. A pentagon of full-thickness eyelid is excised where the ectropion is most marked. Incisions should be at right angles to the eyelid margin. Appropriate tension upon closure should reappose the eyelid to the eye.
Lateral tarsal strip
A canthotomy is performed. The inferior lateral retinaculum is divided (cantholysis), and the tarsal strip is formed by excision of the surrounding conjunctiva, cilia, and skin. The tarsal strip is suspended to the lateral orbital wall periosteum. This procedure decreases the length of the horizontal palpebral aperture. See the images below.
A study by Baek et al indicated that in patients with involutional lower eyelid entropion, treatment with Quickert suture with modified lateral tarsal strip is associated with a lower recurrence rate (9.1%) than is treatment with Quickert suture alone (25.5%).
Dermal orbiculare pennant
A de-epithelized pennant-shaped flap of skin and pretarsal orbicularis muscle is created from the lower lid. The lateral palpebral commissure is not violated. The lower eyelid becomes mobile with lysis of the inferior retinaculum. The pennant flap is sutured to the lateral orbital wall. This repair is useful in the patient with a large distance from lateral canthus to orbital rim. The dermal orbicular pennant flap provides ample length to reach the lateral orbital wall.[7, 12]
Inferior retinacular lateral canthoplasty or canthopexy
Performed through an upper blepharoplasty incision, the lower lid lateral fat pad is exposed. The fat pad can be removed to better reveal the lateral retinaculum. The lower lid component of the lateral retinaculum can then be plicated (canthopexy) or can be lysed from its bone insertion with reattachment to the lateral orbital rim periosteum (canthoplasty). Suture location to the lateral orbital rim should be at the same level as the superior aspect of the pupil when in primary gaze. The lower lid margin should cover 1-2 mm of the inferior cornea and appear as an overcorrection. This procedure does not disrupt the horizontal palpebral aperture.[12, 13]
Dermal-orbicular pennant with tarsal strip horizontal lid shortening and midface suspension
The dermal orbicular pennant flap is created, followed by a lateral canthotomy. A tarsal strip is created with resection of skin, cilia, and conjunctiva. Access to the mid face is achieved via the lateral incision. Subperiosteal or supraperiosteal dissection is performed. The mid face is suspended to the zygoma bone with suture and screw fixation. This is a powerful technique for the patient with complicated lower eyelid malposition in the setting of multiple prior cosmetic operations.
Vertical spacer graft
Midlamellar cicatricial retraction may be present. An interpositional graft may be required to correct a vertical lid defect. Palatal mucosa or auricular cartilage may be used as graft material. The scarred capsulopalpebral fascia is released, and the graft is sutured in between the tarsus and the released edge of the capsulopalpebral fascia.
The application of a silk suture (Frost suture) to suspend the lower eyelid in a superior direction prevents malposition of the lower eyelid during the acute healing process. This suture can be left in place for 2-5 days, depending on the degree of swelling.
Skin incisions should be aggressively treated with antibiotic ointment to prevent infection and maintain a moist environment for skin healing.
The application of cold packs after surgery may assist with inflammation and edema control.
Oral narcotics are usually sufficient to control the postoperative pain associated with eyelid surgery.
Blepharoplasty carries the risk for several complications, including the following:
Lower lid malposition: Any procedure in blepharoplasty risks malposition of the lower lid.
Chemosis: Swelling or edema of the conjunctiva after surgery is a possible complication.
Ectropion: The lower eyelid may turn outward.
Corneal abrasion: As with any periorbital surgery, injury to the corneal surface may occur.
Pain: Postoperative pain may last from a few days to 1-2 weeks.
Wound dehiscence: Meticulous closure is required to prevent dehiscence.
Infection: Postoperative infection is uncommon and can frequently be managed with oral antibiotics.
Granuloma: Postoperative healing may result in granuloma formation.
Hematoma: This is a surgical emergency and requires return to the operating room for decompression. 
Outcome and Prognosis
Outcome from lower lid blepharoplasty and canthal support techniques is quite favorable. Complications are rare with careful patient selection, thoughtful analysis of the deformity, and execution of the correct surgical procedure.
Jelks GW, Jelks EB. Preoperative evaluation and treatment of lower lid ectropion following blepharoplasty. Plast Reconstr Surg. 1990. 85:971.
Garza RM, Lee GK, Press BH. Tarsal ectropion repair and lower blepharoplasty: A case report and review of literature. J Plast Reconstr Aesthet Surg. 2012 Feb. 65(2):249-51. [Medline].
Massry GG. Comprehensive lower eyelid rejuvenation. Facial Plast Surg. 2010 Aug. 26(3):209-21. [Medline].
American Society of Plastic Surgeons (ASPS). 2000/2006/2007 National Plastic Surgery Statistics. ASPS Web site. Available at http://www.plasticsurgery.org/Media/stats/2008-cosmetic-reconstructive-plastic-surgery-minimally-invasive-statistics.pdf. Accessed: June 18, 2009.
McCord CD Jr. The correction of lower lid malposition following lower lid blepharoplasty. Plast Reconstr Surg. 1999 Mar. 103(3):1036-9; discussion 1040. [Medline].
Griffin G, Azizzadeh B, Massry GG. New insights into physical findings associated with postblepharoplasty lower eyelid retraction. Aesthet Surg J. 2014 Sep. 34(7):995-1004. [Medline].
Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg. 1993. 20:417.
Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York: Raven Press; 1985.
Spinelli HM, Jelks GW. Periocular reconstruction: a systematic approach. Plast Reconstr Surg. 1993 May. 91(6):1017-24; discussion 1025-6. [Medline].
Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol. 1979 Nov. 97(11):2192-6. [Medline].
Baek JS, Choi SC, Jang SY, Lee JH, Choi HS. Comparison of Surgical Outcome Between Quickert Suture and Quickert Suture With Modified Lateral Tarsal Strip in Involutional Lower Eyelid Entropion. J Craniofac Surg. 2016 Jan. 27 (1):198-200. [Medline].
Jelks GW, Glat PM, Jelk EB, et al. The evolution of the lateral canthoplasty: techniques and indications. Present at the American Association of Plastic Surgeons, 74th annual meeting, San Diego. April 30 to May 3, 1995.
Fagien S. Algorithm for canthoplasty: the lateral retinacular suspension: a simplified suture canthopexy. Plast Reconstr Surg. 1999 Jun. 103(7):2042-53; discussion 2054-8. [Medline].
Hester TR, Codner MA, McCord CD. Subperiosteal malar cheek lift with lower blepharoplasty. McCord DC, Codner MA, Hester TR, eds. Eyelid Surgery: Principles and Techniques. Philadelphia: Lippincott-Raven; 1995.
Kim DY, Lelli GJ Jr. Delayed orbital hematoma after lateral canthoplasty. Ophthal Plast Reconstr Surg. 2010 Nov-Dec. 26(6):481-3. [Medline].