17.4.2 Modified Canthoplasty

A canthotomy and dissection to the orbital rim is performed as described above. No cantholysis or lid shortening ensues; however, the canthal angle is split (upper from lower lid). As stated previously, complete lid disinsertion and shortening is rarely needed in cosmetic eyelid surgery. The goal in this procedure is to secure the lid laterally with less distortion of canthal anatomy as is inherent to the more powerful tarsal

strip procedure. The terminal eyelid is grasped (Fig. 17.16). A small separation of skin/muscle from underlying tissue (tarsus or LPL) is created. The terminal tarsus or ligament is engaged with a 4–0 Vicryl suture in a similar fashion as with the tarsal strip procedure (Fig. 17.17). The suture is secured to the inner orbital rim periosteum and checked for position (Fig. 17.18). When appropriate, the knot is tied. The canthal angle is then recreated with a grey line–grey line suture (6–0 chromic or 6–0 silk) (Fig. 17.19). The grey line is the terminal

Fig. 17.16 The terminal eyelid is grasped

Fig. 17.17 The tarsus/LPL is engaged with suture for fixation

Fig. 17.18 The lid is secured to orbital rim

fibers of the pretarsal orbicularis muscle (muscle of Riolan). It is just anterior to the openings of the meibomian glands. The suture is passed through the grey line of the terminal upper and lower eyelid. Engaging the periosteum with suture

between the grey line bites may be performed to further enhance the canthal angle before securing this suture. When tying this suture, special attention is given to make sure the upper and lower lid meet equally at the canthal angle. This will prevent one lid from over-riding the other, and a blunted or irregular appearance to the canthal angle after surgery. The canthus is then closed as with the tarsal strip surgery.

17.4.3 Canthopexy (Muscle suspension)

In this procedure, the canthotomy is through skin and muscle only. It is not necessary to split the canthal angle. A subcutaneous dissection of skin from preseptal orbicularis muscle is performed. If there is associated skin excision, an infracilliary incision is made continuous with the canthotomy and an open exposure of the orbicularis is created. The terminal orbicularis is engaged with a 5–0 Prolene or Vicryl suture and secured to orbital rim periosteum for fixation. In isolated lower blepharoplasty surgery, the suture is secured to the orbital rim periosteum through the canthotomy incision (Fig. 17.20). When performed in conjunction with upper eyelid blepharoplasty, the suture may be secured to the periosteum of the orbital rim at a higher position through a temporal upper eyelid crease incision (Fig. 17.21). This is performed by tunneling a connection between the upper lid crease incision and the canthotomy incision. This technique often provides more support to the eyelid. If folds or puckers are created in the lower lid skin when the suture is tied, further subcutaneous dissection is necessary. The canthus is closed with 6–0 chromic or Nylon suture (Fig. 17.22). A grey line suture is not needed as the canthal angle is not disrupted.

17.4.4 The Prominent Globe

Patients with negative vector eyelids (prominent globes) present a special challenge when lid tightening is performed. Whichever procedure is selected can lead to “bowstringing” of the globe by the lid. This occurs because the length of lid needed to overcome the additional globe surface area (from globe prominence/projection) is lacking. When a relatively short lid is secured to the lateral orbital rim, it rides down the globe. In this setting, the globe will appear to protrude further and the lower lid will retract. This is discussed in detail in Chap. 26.

A surgical modification which may avert this problem is to hang back the canthal support suture. When the lower lid is secured to the lateral orbital rim, the suture can be left loose. This anteriorizes the attachment site of the lid and may prevent bowstringing as the lid is psudo-lengthened by the suture. The suture tying can be graded to select the best lid position. In addition, the suture can be secured to a higher

Fig. 17.23 Artist’s illustration of (left) bowstringing of a prominent eye with lid tightening as is shown in Fig. 17.6. Note scleral show and lid retraction (arrow) created by lid tightening. (Right) Modification of

Fig. 17.24 This man underwent canthoplasty, skin trim, and orbicularis suspension in addition to lower lid transconjunctival blepharoplasty with fat repositioning to the nasojugal groove (tear trough) and

canthoplasty by hang-back and supra-placement of eyelid fixation suture. This prevents the “bowstringing” effect. Note elevation of lower lid and reduction of scleral show

fat grafting to the orbito-malar groove (temporal lid/cheek junction depression). (a) Preand (b) postoperative frontal views