Blepharoplasty, Lower Lid, Canthal Support 

Updated: Feb 23, 2016
Author: David C Cho, MD; Chief Editor: James Neal Long, MD, FACS 



Lower eyelid malposition is one the most common and devastating complications of lower eyelid blepharoplasty; it can be temporary or permanent. Surgeons who perform blepharoplasty should feel comfortable identifying those patients at risk for postoperative scleral show and ectropion.

Surgeons performing a blepharoplasty can choose from many available surgical options. Incisions can be placed on the skin or on the conjunctival surface; fat can be removed, repositioned, or added; and canthal support can be established by tightening, anchoring, or reconstructing. To choose the appropriate procedure to provide lower eyelid canthal support, the surgeon must understand the etiology of lower eyelid malposition and have a thorough knowledge of periorbital anatomy (see Relevant Anatomy).

For detailed descriptions of various blepharoplasty procedures, see the Eyelids section of the Medscape Reference Plastic Surgery journal. For information on many kinds of aesthetic procedures, visit Medscape’s Aesthetic Medicine Resource Center.


In the presence of excess scleral show, ectropion, or both, the lower eyelid appears unnatural and distorted. Some clinicians use these terms interchangeably, but distinguishing between scleral show and ectropion is important. Ectropion requires retraction of the lid with lid margin distraction and lowering from the globe, whereas scleral show alludes to only retraction of the lid.[1, 2, 3]



According to the American Society of Plastic Surgeons, approximately 221,000 blepharoplasties were performed in the United States in 2008.[4] Lower eyelid malposition is the most common complication of blepharoplasty.[5]


The pathophysiology of lower eyelid malposition is multifactorial. One can think of this process as an imbalance between gravity and the lower lid elasticity and canthal support. Involutional or senile ectropion is due to laxity of the lateral and medial canthal tendons. Gravitational forces acting upon excessive eyelid skin and prolapsed orbital fat may distort the lower eyelid. Cicatricial forces can produce an ectropion after prior surgical dissection. Excessive skin resection from the eyelid can retract the lower lid.

A study by Griffin et al indicates that although eyelid laxity, middle lamellar scarring, and anterior lamellar shortage have been associated with postblepharoplasty lower eyelid retraction (PBLER), certain other factors play a more significant role in PBLER than has been thought. The study involved 46 patients, all of whom experienced eyelid retraction following primary transcutaneous surgery. The investigators determined that although eyelid laxity and anterior lamellar shortage were common in these patients, so were orbicularis weakness, negative-vector eyelid, and lower eyelid/inferior orbit volume deficit. Only 17% of eyelids in the study had a significant middle lamellar scar.[6]


First, assess the visual acuity of the patient and document any associated aggravating symptoms. Next, proceed with the assessment of skin and muscle. Excess skin and muscle resection with blepharoplasty may result in scleral show and lid malposition. The following items should be considered and noted during the physical examination:

  • Margin reflex distance-2 (MRD2): The distance from the corneal light reflex to the lower lid margin should be no greater than 5.5 mm.

  • Positive vector relationship: The most anterior portion of the globe lies posterior to the lower eyelid margin, which lies posterior to the anterior malar eminence projection.

  • Neutral vector relationship: The anterior globe, lower eyelid margin, and anterior malar eminence all lie in the same vertical plane.

  • Negative vector relationship: The anterior globe lies anterior to the lower eyelid margin, which lies anterior to the malar eminence. This situation puts the patient at increased risk for lower lid malposition.

  • Lateral canthus to orbital rim distance: A patient with deep-set eyes usually presents with a distance less than 1 cm. A patient with prominent eyes usually presents with a distance greater than 1 cm.

  • Canthal tilt: Assess which canthus (medial vs lateral) lies in a higher horizontal plane. This is important for correction of horizontal lid laxity.

  • Lower lid eversion: This can be divided into 4 subtypes.

    • Type I – Minimal lid margin eversion

    • Type II – Moderate lid margin eversion with scleral show

    • Type III – Lash rotation

    • Type IV – Frank ectropion

  • Assessment of the malar fat pad: Lower lid retraction may present with descent of the malar fat pad. Midface lift procedures maybe combined with lower lid surgery.

  • Midlamellar cicatricial retraction: Manual displacement of the lower lid in the superior direction should normally bring the lid margin to or above the level of mid pupil. Limited movement in this direction may indicate midlamellar scarring.

  • Medial canthal laxity: Distract the lower lid laterally. Normal displacement should be 0-1 mm.

  • Lateral canthal laxity: Distract the lower lid medially. Normal displacement should be 0-2 mm.

  • Horizontal lid laxity: Perform the distraction test or snap test to assess horizontal lid laxity. See the image below.

    A: The lower eyelid is evaluated for the presence A: The lower eyelid is evaluated for the presence or absence of adequate tone. The snap test is shown. This involves pulling the lower eyelid skin away from the globe with the thumb and index fingers. B: This photograph demonstrates the lid retraction test, which involves displacing the lower eyelid inferiorly in order to evaluate lower eyelid tone. C: This is a preoperative oblique view. Note the brow position in relation to the orbital rim. Note also the excessive eyelid skin and crow's feet in this particular patient. D: Preoperative frontal view of the same patient. Note the lower position of the left brow, the redundancy and asymmetry of the upper eyelid skin, and the crow's feet in the lateral orbital areas.

    See the list below:

    • Snap test: The examiner pulls the lower lid inferiorly and releases. The speed at which the lid returns to normal position is assessed. Slow movement indicates canthal laxity.

    • Distraction test: The examiner uses his or her thumb and index finger to displace the lower lid anteriorly. Abnormal laxity is present if the lower lid can be displaced more than 8 mm.


Patients may present with lower eyelid malposition after blepharoplasty. Surgical correction can improve cosmesis and prevent dry eye symptoms. Additionally, patients requesting blepharoplasty who are at high risk for developing postoperative eyelid malposition should undergo an adjuvant procedure for lower lid support in addition to primary blepharoplasty.[7]

Relevant Anatomy

The lower eyelid is divided into 3 separate layers. The anterior lamella consists of skin and orbicularis oculi muscle. The middle lamella consists of the tarsus, superior part of capsulopalpebral fascia, and orbital septum. The posterior lamella is made of conjunctiva and capsulopalpebral fascia.

The orbicularis oculi muscle has 3 components, consisting of the pretarsal, preseptal, and orbital portion. This muscle can be divided into an extracanthal region and a canthal region. The muscle in the canthal region is critical for eye closure with blinking, lower lid tone, and lacrimal pump mechanics.

The tarsus is attached to the medial and lateral orbital rims by the medial and lateral canthal tendons. The lateral canthal tendon is also termed the lateral retinaculum. The lateral retinaculum is made of the lateral horn of the levator palpebrae superioris muscle, pretarsal and preseptal orbicularis oculi muscles, the inferior suspensory ligament of the globe (Lockwood ligament), and the check ligaments of the lateral rectus muscle. The lateral retinaculum attaches to Whitnall tubercle on the lateral orbital rim.[8, 9]

For a more detailed discussion, see Medscape Reference article Eyelid Anatomy.

See the image below.

Eyelid anatomy. Eyelid anatomy.


See the list below:

  • Hypotonicity

  • Involutional changes

  • Malar hypoplasia

  • Shallow orbit

  • Thyroid ophthalmopathy

  • Previous blepharoplasty

  • Graves disease

  • Dry eyes

  • Poor Bell phenomenon reflex

  • Preoperative lower lid laxity

  • Exophthalmos



Laboratory Studies

Perform the Schirmer test. Anesthetize the inferior fornix conjunctiva with tetracaine eye drops. A Schirmer strip is placed in the lateral fornix and the patient remains in primary gaze. More than 10 mm of wetting should occur along the strip over a 5-min period.



Medical Therapy

Some symptoms caused by lower lid laxity can be treated with artificial tears, lower lid taping, or digital massage.

Intraoperative Details

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.[10] See the images below.

Preparing the tarsal strip. Preparing the tarsal strip.
The 4-0 Vicryl suture is paced through the tarsal The 4-0 Vicryl suture is paced through the tarsal strip in a horizontal mattress fashion.
The suture is tied to the periosteum of the latera The suture is tied to the periosteum of the lateral orbital rim and tightened.

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%).[11]

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.[14]

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.

Postoperative Details

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.[15]

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.