AESTHETIC SURGERY JOURNAL - JANUARY/FEBRUARY 1998

A Simple Method of Noninvasive Canthopexy During Routine Lower Blepharoplasty Hamid Massiha, MD Lower blepharoplasty treats one of the most delicate and sensitive areas in plastic surgery. Often slight weakness, redundancy, or shortness of the lower eyelid will produce unsightly results and an unhappy patient. I tackled this problem about 18 years ago with a split skin-skin muscle flap technique with lateral suspensions.(1) This tech- nique, in most cases, is adequate in firming the lower lid laxity, which is often preexisting and is worsened by blepharoplasty. For lack of better terminology, this laxity could be called "presenile ectropion" (Figure 1). In some cases, however, laxity will still occur. During the last 10 years, I have tried a variety of techniques of canthopexy. I have found the techniques presented in this article to be the least invasive; they provide a very effective means of firming up the lower lid margin, not only in its inferior-superior dimension, but also in the anterior-posterior direction, resulting in close contact of eyelid to eyeball. Basically, the preseptal part of the orbicularis muscle is sutured to an area under the lateral palpebral ligament at the lateral orbital rim (Figure 2). Thus, while tightening the lower lid, it helps to reduce the nasojugal and zygomatic fold of the lower lid with conservative lift of the cheek and nasolabial fold. The higher point of insertion permits lateral orbital rim structures, orbicularis muscle, and lateral tarsal ligament to be detoured to a higher point without detaching and resuturing all these structures (Figure 3). In effect, it shortens and firms up the lid margin and lifts the lateral canthal angle upward. This method (procedure 1) is adequate in most cases. In cases where the above technique does not firm up the lid margin adequately, procedure 2 is used. This involves a suture that attaches the lateral orbit angle and tissue close to it to the inside edge of the lateral orbital rim. This maneuver helps to pull the lower lid toward the globe so that it hugs the eyeball firmly. To test the success of this procedure, gently grasp the lower lid margin and pull it away from the globe. The firmness will be evident compared with preoperative test results by use of the same maneuver with the patient in the prone position. Lower lid distortion and malpositions have been rare when these two techniques have been used.

Figure 1. Typical apprearance of presenile ectropion.	Figure 4. Preseptal muscle attached to lateral orbital rim. Arrows show effects of increased tension.
Figure 2. Direction of vector of pull of preseptal part of orbicularis muscle under lateral canthal ligaments.	Figure 5. Bowing upward of lateral canthal ligament sa a result of suturing of preseptal orbicularis muscle under it.
Figure 3. The goal of surgery - to shift the whole lateral eyelid higher without shortening it.

Technique With the patient under monitored sedation or general anesthesia, both incision lines in the lower eyelid are marked. Then injection of a mixture of 0.5% lidocaine (Xylocaine(R)) and 0.25% bupivacaine (Marcaine(R)), both with epinephrine, is used for vasoconstriction and local anesthesia. An incision is made, and the skin flap is first raised at the pretarsal part of the orbicularis muscle; then at the lower border of the lower tarsus it is converted to a composite skin/muscle flap. Dissection is then carried out under the orbicularis mucle to the inside border of the orbital rim and inside border of the muscle. The exact distance is determined by how much lift of the check nasolabial fold and correction of the lower lid and crescent-shaped deformity of the lower eyelid are needed. The herniated fat pads are removed as required. The free lateral edge of the preseptal portion of the orbicularis muscle is then grasped with a forceps, and the whole lower eyelid structure and cheek attached to it are shifted upward and slightly laterally to get an idea how high the attachment of this lateral muscle should be.

Figure 6. A 46-year-old female patient with early senile changes. Procedure 1 ws used for suturing, and correction was adequate, with a natural look to the eyelids. A and C, Preoperative view. B and D, Six-month postoperative view.

Then, with blunt dissection, the lateral canthal area is dissected upward, and a pocket is created under it. Some soft tissue is left in place on top of the periosteum to make suturing to the anterior aspect of the lateral orbital rim possible. Next, the free edge of the preseptal portion of the lower eyelid is sutured to a higher position under the pocket of the lateral canthal ligament (Figure 4). This suturing causes bowing outward and upward of the lateral canthal structures and ligament and brings the lid margin laterally up and makes it tighter over the globe (Figure 5). In some cases, there are a lot of adhesions that attach the whole lateral eyelid to the orbital rim. These may need to be released so that the lateral lid angle will be mobile enough to be shifted to a higher position. During the release of the lower eyelid structures from the lateral interior border of the orbital rim, some more herniated fat pad may become evident that could be removed. Usually, suturing of the pretarsal portion of the orbicularis muscle to the higher position under the lateral canthal structures is adequate to lift the lateral lower lid upward and tighten it. In cases where this maneuver is not adequate, or if it creates a triangular space between the eyeball and the lateral portion of the lower lid, procedure 2 is used- suturing the lateral canthal ligament to the interior medial border of the lateral orbital rim very close to the lateral angle of the eyelids. Usually, one suture of 5-0 Vicryl(R) in this area is adequate. This posterior shift of the lateral canthal angle to a posterior position closes the triangular space between the lateral part of the lower eyelid and the eyeball. These maneuvers are all performed without making any incision in the lateral canthal area (the only incision used would be regular lower eyelid incision). Once the position and firmness of the lower eyelid are satisfactory, excess skin and muscle are trimmed, mostly laterally. Some suturing with 5-0 Vicryl(R) suture is done to approximate the subcutaneous tissues laterally, and the lower eyelid incision at the ciliary area is repaired with running subcuticular 6-0 nylon sutures. Usually, the amount of skin removed from the lower eyelid at the subciliary area is minimal; in my recent experience there has been approximately 1 to 2 mm of excision. This probably is due to the fact that the lower eyelid margin is lifted upward, which tightens some of the excess skin, and that the lower eyelid and its muscle are lifted upward laterally and posteriorly, thereby correcting the deformity of the lower eyelid from convexity to concavity, permitting minimal excision of the lower eyelid skin. Postoperative care consists of elevation and cold compresses during the first 24 hours. Sutures are removed in 5 to 6 days. Normal activity is permitted as soon as it is tolerated by the patient.

Figure 7. A 60-year-old male patient with presenile ectropion and festoons. Procedures 1 and 2 were used in treating this patient. A and C, Preoperative view. B and D, Four-month postoperative view.

Results Overall, satisfactory results have been the norm. Very rarely have these three techniques failed, and I have performed no major lower lid reoperations (revisions) for many years. The rate of ectropions has been almost zero. Preoperative and postoperative photos of two cases are shown in Figures 6 and 7. Although the tightness of the lids may be difficult to distinguish in a photograph, the position of the lower lid in each case could indirectly verify the effectiveness of this technique. Discussion Canthopexy has been used and advocated by many surgeons to prevent or treat postblepharoplasty ectropion.(2-4) The conventional canthopexy operation usually requires an incision at the lateral canthal area and the lateral eye-lid angle. This has created complications such as chemosis, subconjunctival hemorrhage, and an uneven healing of the interface between the deepithelialized and shortened tarsal plate and the upper part of this repair. To eliminate these complications, I have used the techniques described in this article, which basically use only blepharoplasty incision and suturing of the components that tighten the lower lid laxity. The first suture is actually a part of the blepharoplasty, in my technique, and the second suture is used to place the lateral angle of the eyelid in a more posterior and, if desired, higher position. This will bring the free edge of the eyelid around the orbit like a belt around a person's waist. In the first technique described here, the reason for shortening the lower eyelid is to make the route of the lateral eyelid structures a curved one instead of straight both superiorly and anteriorly. This adds to the tension, making the eyelid tighter and bringing the eyelid angle higher, if needed. As briefly mentioned in the description of the technique, some dissection to release the lateral border of the lower eyelid will be required if the angle of the lower lid needs to be lifted upward. This is desirable in many patients. Actually, the lateral eyelid angle is approximately 2 mm higher than the medial angle. In younger people this difference is greater and the lateral eyelid is tilted upward. As a person gets older, this tilt decreases and gradually becomes horizontal. In some people the tilt is actually reversed so that the lateral angle is below the level of the upper medial angle. With my technique, the lateral angle is lifted, giving a more youthful look to the eyelid, as well as tightening the lid margin. In the second suture technique, the lateral eyelid angle is positioned more posteriorly and superiorly. The benefit is obvious, because in some ectropions (or as I call this phenomenon, "presenile ectropion"), the lid is not short, and actually no scleral show is visible; however, its laxity prevents it from hugging or grasping the globe properly so there is always looseness in the lower eyelid. This may actually become bothersome on windy or cold days, because cold air and wind can get between the orbit and the lower eyelid, resulting in burning and epiphora. The second suture would eliminate this problem by bringing the lower eyelid closer to the orbit. I have used these techniques successfully for many years; residents who have learned these techniques readily and used them effectively have also achieved success. In summary, the advantage of this approach is that there are no incisions involved in the lateral canthal area other than the routine blepharoplasty incisions, thus decreasing the chances of chemosis, contracture, scarring, and deformity at the site of the incision. This approach is effective as a therapeutic or a preventive measure. It is basically a part of the lower blepharoplasty operation, and the increase in the duration of surgery is minor. It should be noted, however, that this technique may not be effective in severe or unusual deformities of the lower lid and that muscle attachment may be visible for a few weeks after surgery. References 1. Massiha H. Combined skin and skir)-muscle flap technique in lower blepharoplasty: a 10-year experience. Ann Plast Surg 1990;25:467. 2. Edgerton MT. Causes and prevention of lower lid ectropion following blepharoplasty. Plast Reconstr Surg 1972;49:367. 3. Carraway JH, Mellow CG. The prevention and treatment of lower lid ectropion following blepharoplasty. Plast Reconstr Surg 1990;85:971-81. 4. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg 1993;20:417-25.