Canthoplasty and canthopexy

What it treats

• Eye shape depends on the bony orbit, orbital volume, eyelid integrity and the tendon and ligament support of the lids (PMID 2015744).
• The lateral canthus normally sits 1-2 mm higher than the medial canthus; aging and gravity move it down (PMID 19289688).
• In most lax lids the lateral canthal tendon is stretched while the central tarsus is not, which is why tightening at the canthus corrects the laxity (PMID 508189).
• The lateral canthus also attaches to the rim at a superficial level through the orbital septum, the "superficial lateral canthal tendon," 4 cadavers (PMID 11884849).
• Negative vector: in 123 normal adults, those with lower lid retraction had a mean orbital vector of -13.65 degrees and Hertel 16.27 mm, against 9.76 degrees and 14.08 mm without retraction (PMID 32549720).
• Post-blepharoplasty retraction, 46 referred patients after transcutaneous surgery: orbicularis weakness, skin shortage, volume deficit, negative vector and lid laxity were common; a significant internal scar was present in 17% of lids (PMID 25168805).
• Survey of 196 oculoplastic surgeons: blepharoplasty was the most common cause of lower lid retraction (31.6%) (PMID 30931685).

How it is done

Canthopexy (tendon not cut)

• Canthopexy restores lid tone and reduces the need to remove skin that only looks excess because the lid has dropped; Flowers proposed it as a routine part of lower blepharoplasty in 1993 (PMID 8485945).
• Lateral retinacular suspension: a transpalpebral suture canthopexy within an algorithm for choosing canthal support (PMID 10359271).
• Canthopexy through the upper blepharoplasty incision without canthotomy, 316 patients with moderate laxity: laxity corrected in all (PMID 19617786).
• Canthopexy can be placed through an upper or lower lid incision without a suture at the canthal angle (PMID 25050757).

Canthoplasty (tendon cut and reset)

• Lateral tarsal strip: canthotomy, release of the tendon limb, a strip made from the posterior lid layer and sutured to the lateral orbital wall periosteum, 51 cases (PMID 508189).
• Inferior retinacular lateral canthoplasty, developed from over 15 years of practice (PMID 9326791).
• One surgeon's 1,565 canthoplasties in 684 patients (1981-1994), 196 of them cosmetic, follow-up 1-14 years (PMID 9385950).
• Canthoplasty through an upper lid crease incision, 600 patients (1,050 eyelids, 244 cosmetic) (PMID 20489545).
• Drill-hole "dynamic canthopexy" raises the canthus to a new bony anchor, 30 patients (18 with downslanting eyes, 12 cosmetic) (PMID 30874720).

Choosing the method

• Canthopexy suits most patients; significant horizontal laxity needs cantholysis with lid shortening (PMID 12832900).
• A lid that pulls 10 mm or more from the eye on distraction received a tarsal strip; the rest (98% of 247 patients) received a canthopexy (PMID 12756124).
• The lateral tarsal strip remains the choice for severe laxity or ectropion; resuspension without canthotomy lowered MRD2 slightly more than the tarsal strip (PMID 25050757).
• Current options range from simple canthopexy through canthoplasty and drill-hole fixation to full tarsoligamentous sling reconstruction (PMID 39505478).
• Surgeon survey: 96% of responding ophthalmic plastic surgeons reported lateral canthal suspension as an adjunct to lower blepharoplasty (PMID 28151825).

Results and evidence

• Routine canthal support in transcutaneous lower blepharoplasty, 264 patients, median follow-up 264 days: lid malposition needing surgery 3.5% (PMID 18176227).
• Superficial lateral retinacular canthopexy, 104 patients: intercanthal angle and lateral canthal position unchanged after surgery (PMID 31985628).
• Tarsal sling canthopexy, 40 patients: without it, scleral show increased and had not fully recovered at 2 years; with it, a slight overcorrection persisted at 2 years (PMID 25568230).
• Randomized trial, 50 lower blepharoplasties, all with routine lateral canthal support, median follow-up 395 days: all patients improved, with low complication rates (PMID 20082201).
• Subtle retraction after skin pinch or laser was prevented by prophylactic lateral canthal resuspension (PMID 31444052).
• Selective canthopexy (18% of 248 patients) with orbicularis-sparing surgery: 3 complications and 6 revisions (PMID 21200234).
• No canthal division, 100 patients including 50 with lax lids, prominent eyes or negative vector: no new scleral show or retraction; 3 patients kept some preexisting retraction (PMID 12172161).
• Transcutaneous blepharoplasty with selective omission of canthoplasty, 340 patients: no ectropion (PMID 40952103).
• Negative preoperative canthal tilt was associated with scleral show after transcutaneous blepharoplasty, 78 patients (PMID 41677016).
• Systematic review of treatment for lower lid malposition, 15 studies, 709 patients, 12 randomized: modified lateral tarsal strip techniques had high success and low recurrence (PMID 39631150).

Risks and complications

• Chemosis 12.1%, orbital hematoma 0.4% and minor revisions 11.7% (incision cysts, granulomas, canthal suture inflammation, canthal webbing) in the 264-patient series (PMID 18176227).
• Persistent type 3 chemosis, 1,047 patients: more frequent with lateral canthus surgery (PMID 38610858).
• Reoperation within 2 years for recurrent malposition or canthal deformity: 18 of 600 patients; transient chemosis was the common minor complication (PMID 20489545).
• Tight lid, slight upward slant and limited lid movement during the first 2 weeks after canthopexy (PMID 19617786).
• Failed cosmetic canthoplasty, 15 women (25 lids): canthal webbing, rounding, lid margin defect, retraction, scleral show, ectropion and lagophthalmos, repaired with a modified tarsal strip (PMID 37622520).
• Canthal rounding repair, 12 patients: one recurrence (PMID 33746208).
• Canthal webbing, 11 patients (17 lids): Z-plasty with canthopexy or canthoplasty and 5-FU injections; no recurrence at a mean 14 months (PMID 40848070).
• Canthal anchoring does not prevent severe lid complications after over-resection of skin or a poorly performed midface procedure (PMID 12832900).

Recovery

• Lid shape and canthal position were normal by the third week after upper-incision canthopexy (PMID 19617786).
• After drill-hole canthopexy an initial overcorrection is needed; the result is stable at about 6 months (PMID 30874720).
• Lid position after tarsal sling canthopexy kept changing for 2 years (PMID 25568230).
• For early retraction after blepharoplasty, 51.3% of surveyed surgeons recommend massage and 25.5% steroid injection; 54.1% wait at least 6 months before surgery (PMID 30931685).
• Transient lid malposition after combined facelift and blepharoplasty resolved within 4 weeks with massage and taping in 2 patients (PMID 20442069).

Combined procedures

• Orbitomalar suspension during high SMAS facelift with lower blepharoplasty, 60 patients: 1 ectropion (2 mm) from a broken suture, repaired; 2 transient malpositions; 2 patients with negative vector not fully corrected but no worse (PMID 20442069).
• The lower lid should be supported during midface elevation through a lower lid incision and during laser treatment of the lid (PMID 11884849).
• Canthal support choice is part of an algorithm for lower eyelid and midface rejuvenation (PMID 10359271).
• Brow, eyelid and midface surgery with ligament release and no canthal division, 100 patients: no new scleral show (PMID 12172161).
• Preperiosteal midface lift with canthoplasty for retraction after blepharoplasty, 28 patients: scleral show 1.96 mm before, lid at or above the limbus after in all eyes; epiphora and corneal staining resolved (PMID 20489542).

Current questions

• Routine or selective support: routine canthopexy (PMID 8485945) and routine canthal support (PMID 18176227) against selective use (PMID 21200234) or none (PMID 12172161), (PMID 40952103).
• Chemosis: canthal surgery is linked to persistent chemosis (PMID 38610858).
• High-risk eyes: primary spacer grafts in 15 patients with Hertel over 17 mm gave a mean MRD2 change of 0.19 mm; 2 developed retraction about 2 years later (PMID 37326309).
• Evidence: a 2026 review graded the evidence for prophylactic lid suspension low (PMID 40907566).
• Treatment of established retraction: a lateral tarsoconjunctival flap improved lid position in 98% of 48 lids; pyogenic granuloma in 8% (PMID 32427733).

Terms

• Lateral canthus: the outer corner where upper and lower lids meet (PMID 19289688).
• Lateral canthal tendon: the band that ties the lids to the lateral orbital rim (PMID 508189).
• Canthopexy: tightening the canthus with sutures without cutting the tendon (PMID 12832900).
• Canthoplasty: cutting the tendon, shortening the lid if needed and reattaching it (PMID 12832900).
• Lateral tarsal strip: canthoplasty using a strip of tarsus sutured to the rim (PMID 508189).
• Lateral retinaculum: the lateral canthal support tissues used in retinacular canthopexy (PMID 10359271).
• Distraction test: how far the lid pulls from the eye; 10 mm or more signaled a tarsal strip (PMID 12756124).
• Negative vector: the cheek and rim sit behind the front of the eye (PMID 32549720).
• Scleral show: white of the eye visible below the iris (PMID 25568230).
• Canthal webbing and rounding: loss of the sharp canthal angle after surgery (PMID 37622520).
• MRD2: distance from the corneal light reflex to the lower lid margin (PMID 25050757).

Papers