blepharoplasty guide


Insider's Guide to
Blepharoplasty



Chapter 19

Reinforcement at the
Lateral Canthus

 

Other names: Canthoplasty, tarsal strip resuspension, lateral canthal plication, canthopexy, lateral retinacular suspension, inferior retinacular suspension

Terminology: While the terms canthoplasty and canthopexy are sometimes used interchangeably, the two procedures are very different.

"Canthoplasty" refers to a procedure designed to reinforce lower eyelid support by detaching the lateral canthal tendon from the orbital bone and constructing a replacement.

"Canthopexy," on the other hand, refers to a less invasive procedure designed to stabilize the existing tendon (as well as surrounding structures) without removing it from its normal attachment.

Primary goal: Strengthening the tissues at the outer corner of the eyelids (lateral canthus) to better support the lower eyelid.

Secondary goals: Lessening the chance of surgical complications most commonly associated with transcutaneous (skin incision) lower blepharoplasty.

Anesthesia: Local injection

Operative technique: (Note: If the anatomical terms that follow seem confusing, refer to these detailed illustrations).

Tarsal strip resuspension (a version of canthoplasty) is described:

Scissors are placed at the junction of the outer upper and lower eyelids (the lateral commissure) and a full-thickness cut is made into the lateral canthus towards the orbital bony rim. The lower half of the lateral canthal tendon extending from the bony rim into the lower eyelid is isolated and cut free from its attachment to the bone. An incision is made on the eyelid margin a small distance (approximately 1/5 inch) from the cut tendon, and the tarsal plate closest the tendon is cleaned of all adherent skin and conjunctiva. This creates a small strip of tarsal plate tissue, a cartilage-like structure that will be used to create "a new and tighter tendon." A non-absorbable suture is used to sew this strip of tarsal plate to the periosteum (the lining of the bone) located just inside the socket's bony rim. The attachment is reinforced with dissolving sutures, and the overlying muscle and skin are closed.

Operative photos of tarsal strip canthoplasty
Operative photos of lateral retinacular suspension canthopexy

Variations: There are MANY variations in surgical technique, which allows for the level of reinforcement to range from minimal to marked. For instance, rather than tightening the lateral canthal tendon, it is possible to remove a full-thickness "chunk" of lower eyelid and sew the raw edges together ("full thickness horizontal resection"). While this simplified approach may help the lower eyelid to grip the eye, it is inferior to a tarsal strip resuspension because (1) it does not "reconstruct" a new tendon, and (2) it is quite risky in individuals with prominent eyes or poor orbital rim/cheek bone support in that it may cause the eyelid to retract downward.

Less invasive variations on canthal tendon tightening (canthopexy) involve "tucking" the soft tissues just below the end of the tarsal plate by sewing them to the lining of the orbital bone. While different approaches to canthopexy vary from simple to complex, we prefer our own modification developed over years of experience. While some surgeons use canthopexy on almost every case, we apply it selectively in less than a third of our patients.

The "key" step in all of these closely related operations is the attachment of either supporting tendon, muscle, and/or tarsal plate to the tough periosteum (external lining) of nearby bone.

Advantages: If the lateral canthal tendon, surrounding supporting structures (retinaculum), and/or orbicularis muscle are stretched, canthal tendon reinforcement helps to restore more normal support to the lower eyelid. Canthopexy is not, however, indicated as a "routine" measure in all lower blepharoplasties.

Care and recovery: As noted in Section Four. In addition, swelling in the upper and lower eyelids as well as the eye (chemosis) may persist for several weeks to months due to temporary interruption of the lid's lymphatic drainage.

Risks and complications:

Canthoplasty: The anatomy of the canthus is delicate and complicated. If canthoplasty is not well performed (or sometimes even when it is expertly performed), the junction between the upper and lower eyelids may become rounded, retracted, or deformed either immediately or after several years. In the presence of a prominent eye, shallow eye socket, or inadequate bony cheek projection, canthoplasty may result in unintended downward retraction. If overdone in patients with normal or deep-set eyes, it may, on the other hand, result in an unnatural upward slant to the eyes.

Canthopexy: By reinforcing and stabilizing the stretched supporting structures around the eye, more than just sagging skin and bulging fat are addressed. The procedure is much less invasive than canthoplasty and not associated with many of the risks noted above.

Comments: Some practitioners claim that lateral canthal reinforcement may stabilize the lower eyelid in patients undergoing full transcutaneous lower blepharoplasty in a firm enough manner to preempt this operation's tendency to cause lower eyelid distortion and retraction.

We believe that any such protection is minimal and quite temporary at best against the strong forces created by this dated operation.

Canthopexy: Pros and Cons

Next: Fat Repositioning


Introduction

Chapter 01: Don't jump in blindly
Chapter 02: Do I really need this?
Chapter 03: When should I do it?
Chapter 04: Eyelid anatomy
Chapter 05: Why it all sags
Chapter 06: Cosmetic eyelid surgeons
Chapter 07: Eyelid surgery consultation
Chapter 08: Eyelid surgery prices & cost
Chapter 09: Add-on costs
Chapter 10: Eyelid surgery facility
Chapter 11: Blepharoplasty anesthesia
Chapter 12: Insurance coverage

Chapter 13: Upper eyelid blepharoplasty
Chapter 14: Asian eyelid blepharoplasty
Chapter 15: Repair of eyelid ptosis
Chapter 16: Eyebrow surgery
Chapter 17: Lower eyelid blepharoplasty
Chapter 18: Tissue-sparing lower lid surgery
Chapter 19: Lateral canthus reinforcement
Chapter 20: Fat repositioning
Chapter 21: Cheek and midface lift
Chapter 22: Skin resurfacing
Chapter 23: Botulinum toxin injection
Chapter 24: Tissue fillers and fat grafting
Chapter 25: Eyelid and brow tattooing
Chapter 26: Secondary blepharoplasty
Chapter 27: Laser eyelid surgery

Chapter 28: Risks and complications
Chapter 29: Upper eyelid complications
Chapter 30: Lower eyelid complications

Chapter 31: Do's and don'ts before surgery
Chapter 32: The morning of the big day
Chapter 33: Experiencing the surgery
Chapter 34: Do's and don'ts after surgery
Chapter 35: Is this ever going to heal?
Chapter 36: Eye cosmetics after surgery
Chapter 37: Skin care and prevention
Chapter 38: Patient satisfaction
Chapter 39: Psychological considerations
Chapter 40: Recent advances and the future

  

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