Featured Operative Technique

Youthful palpebral fissure is long and narrow, witha slight lateral upward inclination (Figure 1).Distortions of or deviations from this shape may

be secondary to heredity, aging, paralysis, trauma, orprevious surgery.1 This distortion of shape inevitablymanifests as rounding of the fissure, with inferomedialdescent of the lateral canthus and concomitant descentof the lower lid margin. Lateral canthopexy, the surgicalrepositioning of the lateral canthus, is fundamental toaltering or restoring the shape of the palpebral fissure.

ANATOMY OF THE LATERAL CANTHUSAnatomically, the lateral canthus is more correctlytermed a lateral retinaculum. The retinaculum receivescontributions from the lateral horn of the levatoraponeurosis, the lateral extension of the preseptal andpretarsal orbicularis oculi muscle (lateral canthal ten-don), the inferior suspensory ligament of the globe(Lockwood’s ligament), and the check ligament of thelateral rectus muscle. It splits into anterior and posteriorleaflets. The anterior leaf is contiguous with the orbitalperiosteum and the posterior leaflet inserts on the lateralorbital (Whitnall) tubercle. A change on the point ofattachment or length of the retinaculum will cause sig-nificant changes in eyelid shape, tension, and coutour.2,3

HISTORY OF LOWER LID CANTHOPEXYLower eyelid tarsus suspension was originally describedby Lexer and Eden4 in 1911, followed by Sheehan.5 Sincethen, many different techniques have been designed torestore lateral canthal position and correct lower eyelid

malposition. Two requisites of lateral canthopexy makeit technically challenging: symmetry and stability.Suturing of lateral canthal structures to similar points onthe inner aspects of both lateral orbital rims can be diffi-cult. Stable suture fixation can also be challenging, par-ticularly when previous eyelid surgery has scarred anddistorted periorbital tissues. Hinderer,6 Whitaker,7 Ortiz-Monasterio and Rodriguez,8 and Flowers9 reported tech-niques using drill holes made in the lateral orbital rim,which provided points of fixation that were bothanatomically defined and secure.

In this article, we describe our technique of lateralcanthopexy, an adaptation of the technique described byWhitaker.7 The lateral canthal structures are purchasedwith a figure-of-eight suture of titanium wire. Drill holesare placed in the lateral orbital rim using the zygomati-cofrontal sutures as reference landmarks. This measured

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Bridge of bone canthopexy has utility when significant movements of canthal position are required. It is a tech-nique whereby the lateral canthal structures are purchased with a figure-of-eight suture of titanium wire. Drillholes are placed in the lateral orbital rim using the zygomaticofrontal sutures as reference landmarks. A can-thal fixation point (the inferior drill hole) creates a measured distance from a fixed anatomic point (the zygo-maticofrontal suture) assuring accurate and symmetric canthus positioning. Wire suture fixation over thebridge of bone created by the two drill holes provides maximum stability to counter soft tissue deformingforces. Fine adjustments can be made to the canthal position by twisting or untwisting the wire ends. (AestheticSurg J 2009;29:323–329.)

Dr. Yaremchuk is Chief of Craniofacial Surgery, MassachusettsGeneral Hospital, Boston, MA. He is also a Clinical Professor ofSurgery, Division of Plastic and Reconstructive Surgery, HarvardMedical School, Boston, MA. Dr. Chen is from Chang GungMemorial Hospital, Taipei, Taiwan.

Bridge of Bone CanthopexyMichael J. Yaremchuk, MD; and Yi-Chieh Chen, MD

Figure 1. Dimensions of the palpebral fissure as seen in a youngwhite woman. The mean height of the palpebral fissure measuredfrom the upper lid (PS) to lower lid (P1) margin at the midpupil was10.8 � 1.2 mm (n � 200). The mean length of the eye fissure meas-ured from medial commissure to lateral commissure was 30.7 �1.2 mm (n � 200). The mean inclination of the eye fissure was4.1° � 2.2° (n � 50).1

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placement aids in achieving symmetric canthal re -positioning. The bridge of bone between the drill holesprovides a stable platform over which the wire ends canbe tied. Fine adjustments can be made to the canthalposition by twisting or untwisting the wire ends.

SURGICAL TECHNIQUE

OverviewBridge of bone canthopexy requires exposure of the lat-eral orbit and mobilization of the lateral canthus soft tis-sue mechanism. Its efficacy is based on the stable suturefixation point provided by drill holes placed in the boneof the lateral orbit. This procedure can be performedunder local or general anesthesia.

IncisionsThis procedure requires access to the lateral orbital rimfrom the level of Whitnall’s tubercle to the zygomati-cofrontal suture. This can be accomplished through thelateral extent of an upper blepharoplasty incision. Mostoften, we prefer the lateral extent of both upper and lowerblepharoplasty incisions because the lower blepharoplasty

incision provides superior visualization of the lateral can-thal tissues (Figures 2 and 3). This anatomy can also beapproached from the access provided by a bicoronal inci-sion if a concomitant brow lift is performed.

Figure-of-Eight SutureWhen only 1 or 2 mm of superior or lateral movements ofthe lateral canthus and adjacent lid margin are desired,one or both limbs of the lateral canthus may be purchasedwith a figure-of-eight suture without freeing the lateralretinacular structures from the lateral orbit (Figures 4 to6). The amount of commissure movement will be limitedby the length of the ligament, the point of suture purchaserelative to the lateral commissure, and the position of thelateral orbit drill holes. This approach is most often appro-priate when there is minimal commissure malposition andno local scarring from previous lid surgery.

When more significant movements of the lateral com-missure and lid margin are desired, complete sub -

Aesthetic Surgery Journal

Figure 2. Through the lateral extent of the lower blepharoplasty incision, the lateral canthus is identified and is freed from Whitnall’stubercle by subperiosteal dissection.

Figure 3. Through the lateral extent of an upper blepharoplasty incision, the zygomaticofrontal suture has been exposed.

Figure 4. The lateral canthus is purchased by a figure-of-eight, 30-gauge titanium wire suture.

Figure 5. The lateral canthal mechanism being purchased with30-gauge titanium wire suture.

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periosteal freeing of the lateral retinacular structures isrequired before figure-of-eight suture purchase of bothlimbs of the ligament. Through the lateral extent of thelower blepharoplasty incision, the lateral retinaculum isidentified and dissected, and both limbs of the lateralcanthus are purchased with a figure-of-eight 30- or 32-gauge titanium wire suture. If middle lamellar scarringfrom previous lower lid surgery restricts canthal move-ment, the lateral third of the middle lamellae is sufficient-ly incised with needle tip electrocautery to allow it to befreely mobile.

Drill HolesThrough the upper access approach, the zygomati-cofrontal suture is identified. This suture provides alandmark to allow symmetric placement of drill holesmade in the lateral orbital rim. Using the zygomatico -frontal suture as a landmark, two drill holes are placedin the lateral orbital rim. The position of the lower drillhole is important, because it determines the maximumupward movement of the canthus. The upper drill holeis necessary to create the bridge of bone, a stable fix -ation point (Figure 7).

The lateral canthal position and aperture shape aredetermined by the position of the drill holes, whichshould be 2 to 3 mm above the medial canthal plane inorder to give the intercanthal axis a slight upward tilt.The drill holes should also be placed in the internal orbitabout 3 to 4 mm posterior to the anterior margin of thelateral orbital rim, so that the lateral lid will not bedrawn away from contact with the globe. To determinethe ideal position of the drill holes, one can grasp thelateral canthus and tuck it against the lateral orbital rimuntil the desired canthal and lower lid position isobtained. The positions are marked and drill holes arethen made at that point. Most often, they are positionedjust at and 2 mm below the zygomaticofrontal suture.Each end of the wire is then passed from within theorbit and through the drill holes to the lateral orbital rim(Figures 8 and 9). The wires are then twisted togetherover the bridge of bone between the two holes (Figure10). Wire twisting will determine canthal movement.The location of the lower drill hole dictates the limit ofmovement. The point of fixation of the lateral canthusrelative to the lateral orbital rim determines the relationof the lower lid to the surface of the globe (Figure 11).

The strand of twisted wire ends is left approximately5 mm long. This length of twisted wire ends has twoadvantages. First, it allows intraoperative (or postopera-tive) adjustment of the canthal position by simply twist-ing or untwisting the wires, making it unnecessary torepeat the suturing process. Second, this length allowsthe ends to be placed into one of the drill holes orinto the orbit. This maneuver avoids postoperative visi-bility or palpability of the wire ends (Figure 12). If localincisions are used for access, an ellipse of skin and mus-cle is removed from the lateral aspect of the upper lid inorder to eliminate the lid redundancy caused by theupward movement of the canthus. The wounds areclosed in layers.

Figure 6. The lateral canthal mechanism has been secured with tita-nium wire.

Figure 7. A drill hole is made in the lateral orbital rim at the zygo -matico frontal suture. The second drill hole will be made just below.

Figure 8. One end of the canthopexy wire has been passed frominside the orbit to outside the orbit through the upper drill hole. Theother end of the canthopexy wire is being threaded through a wiredoubled on itself, which was passed from outside the orbit to withinthe orbit. This doubled wire creates an eyelet through which the oth-er end of the canthopexy wire is threaded. Pulling the doubled wirewill bring the canthopexy wire outside of the orbit.

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COMPLICATIONS AND OUTCOMESWhen extensive dissection is performed, postoperativechemosis is common. In addition to ophthalmic lubri-cants, we have found that a temporary tarsorrhaphystitch left for five to seven days significantly attenuatesthis process. The tarsorrhaphy is performed by placing a

single 5–0 nylon suture through the upper and lower lidmargins and adjacent skin. Tying the suture approxi-mates the lids.

The potential “weak link” in the bridge of bone can-thopexy is the point of wire attachment to the canthus.In our experience, revision surgery after bridge of bone

Figure 9. Each end of the wire suture is passed from within the orbitthrough drill holes made in the lateral orbital rim. The ends of the wiresuture are twisted together over the bridge of bone. Passing the wirefrom inside to outside the orbit applies the lid to the globe.

Figure 10. Wires are twisted sufficiently to position the lateral canthus.

C

B

Figure 11. The position of the lateral canthus relative to the lateral orbital rim determines the relation of the lower lid to the surface of the globe.A, The lateral canthopexy stitch is passed through the inner surface of the lateral orbital wall and tied on its outside surface. B, The axial view ofpart A shows that the lid is applied to the globe. C, The lateral canthopexy stitch is attached to the periosteum of the anterior surface of the later-al orbital rim. D, The axial view of part C shows a gap between the surface of the globe and the lateral aspect of the lower lid.

D

A

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canthopexy has been necessary after two clinical scenar-ios that may compromise this point of attachment. Oneof the scenarios that limits the procedure’s efficacy iswhen the integrity of the lateral canthus has been com-promised, thereby undermining the purchase of the can-thopexy suture. This is not uncommon when a previouscanthoplasty has been performed. The other situationleading to relapse is when the canthopexy is performedwithout achieving sufficient mobility of the canthalstructures to passively place the canthus in the desiredposition. When a canthopexy is performed in the face ofsevere vertical lid deficiency, scar contraction forces willinevitably result in the canthopexy suture cuttingthrough the purchased canthal soft tissues, with subse-quent canthal descent.

Clinical outcomes from the use of the bridge of bonecanthopexy are shown in Figures 13 through 16.

CONCLUSIONSThe terminology of lateral canthal surgery is confusing.A lateral canthopexy repositions the lateral canthus. Itmoves the displaced or attenuated lateral canthal mecha-nism to a desired position with or without its disinser-tion. Because it does not violate the lateral commissureor lower lid margin, it maintains (or has the potential torestore) palpebral fissure shape, including the lateralcanthal angle. By design, canthoplasty procedures suchas the lateral tarsal strip alter the shape of the palpebralfissure because they disrupt the lateral commissurewhile shortening the lower lid margin.10 Lateral can-thal/horizontal eyelid shortening procedures were firstdeveloped to treat functional eyelid disorders. Bydecreasing the surface area of exposed cornea, they ame-liorated symptoms of dry eyes. They were later adaptedto aesthetic surgery as prophylaxis against or a correc-tion for postblepharoplasty lid malposition. These lidmargin shortening procedures are appropriate treatmentfor senile ectropion and entropion—situations where thelid margin is redundant. Their aesthetic implicationsshould not be discounted. Canthoplasty procedures maybe effective in elevating the lower lid, but they oftenexaggerate senile or postsurgical distortion of pal pebralfissure shape (Figure 17).

Canthopexy procedures that reef or attach the lateralcanthal tendon to the lateral orbit periosteum providesufficient stability and accuracy as prophylaxis againstand correction of mild postblepharoplasty lid mal -position. Bridge of bone canthopexy has its greatest util-ity when significant movements of canthal position arerequired. A canthal fixation point (the inferior drill hole)created at a measured distance from a fixed anatomic

Figure 12. The free end of the twisted wires will be shortened andpositioned behind the lateral orbital rim to prevent their visibilityand palpability.

A B

Figure 14. A, Preoperative view of a 27-year-old woman who desired upward movement of her lateral canthus. She had not undergone previousorbital surgery. B, Six months after bridge of bone canthopexy.

A B

Figure 13. A, Preoperative view of a 35-year old woman with Treacher–Collins syndrome who underwent augmentation of her coloboma withcustom-carved porous polyethylene implants and bridge of bone canthopexy. B, Two years after bridge of bone canthopexy.

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A B

Figure 15. A, Preoperative view of a 50-year-old woman with previous lower lid blepharoplasty who underwent subperiosteal midface lift, infra -orbital rim augmentation, and lateral canthopexy. B, One year after bridge of bone canthopexy.

A B

Figure 16. A, Preoperative view of a 52-year-old woman who had undergone a previous brow lift, rhytidectomy, and upper and lower lid blepharoplasty. Lower lid retraction was treated with multiple canthopexies, spacer grafts, and full-thickness skin grafts. Dry eye symptoms persist-ed. Infraorbital rim augmentation, midface lift, and lateral canthopexy resolved her symptoms. Her brows and hairline were repositioned. B, Oneyear after bridge of bone canthopexy.

A B

C D

Figure 17. A, In young adults with normal skeletal morphology, the palpebral fissure is long and narrow. With aging (B), descent of the lower lidand medial migration of the lateral canthus rounds the shape of the palpebral fissure. Standard blepharoplasty techniques that remove lowerlid skin (and often muscle) tend to lower the lower lid margin, further rounding the palpebral fissure (C). Canthoplasty procedures, by design,alter the shape of the palpebral fissure because they disassemble and reassemble the lateral canthus while shortening the lower lid margin (D).Because it does not violate the lid margin, lateral canthopexy maintains or has the potential to restore palpebral fissure shape, including the later-al canthal angle.

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point (the zygomaticofrontal suture) assures accurateand symmetric placement. Wire suture fixation over thebridge of bone created by the two drill holes providesmaximum stability to counter soft tissue–deformingforces. The senior author (MJY) uses this techniquealone to reposition the lateral canthus and lower lidwhen the periorbital tissues are adequate. When postble-pharoplasty tissues are inadequate, a subperiosteal mid-facelift is added to recruit cheek and lid tissues.11 Toprovide support for lid and midface soft tissues, sagittalaugmentation of the infraorbital rim is added to the lidand canthus repositioning algorithm in postblepharo-plasty patients with midface skeletal deficiency (thosewho are “morphologically prone”).12 ◗

DISCLOSURES

The authors have no disclosures with respect to the contents of thisarticle.

REFERENCES1. Farkas LG, Hreczko TA, Katic MJ. Craniofacial norms in North

American Caucasians from birth (one year) to young adulthood. In:Farkas LG, editor. Anthropometry of the head and face. New York:Raven Press; 1994:241–235.

2. Gioia VM, Linberg JV, McCormick SA. The anatomy of the lateral canthal tendon. Arch Ophthalmol 1987;105:529–532.

3. Most SP, Mobley SR, Larrabee Jr WF. Anatomy of the eyelids. FacialPlast Surg Clin North Am 2005;13:487–492.

4. Lexer E, Eden R. Uber die chirurgische Behandlung der peripherenFacialislahmung. Beitr Klin Chir 1911;73:116.

5. Sheehan JE. Plastic surgery of the orbit. New York: Macmillan; 1927.6. Hinderer UT. Correction of weakness of the lower eyelid and lateral

canthus. Personal techniques. Clin Plast Surg 1993;20:331–349.7. Whitaker LA. Selective alteration of palpebral fissure form by lateral

canthopexy. Plast Reconstr Surg 1984;74:611–619.8. Ortiz-Monasterio F, Rodriguez A. Lateral canthoplasty to change the

eye slant. Plast Reconstr Surg 1985;75:1–10.9. Flowers RS. Advanced blepharoplasty: Principles of precision.

Gonzalez-Ulloa M, Meyer R, Smith JW, editors. Aesthetic plastic surgery, vol 2. Padua, Italy: Piccin Nuova Libraria; 1987:115.

10. McCord CD, Boswell CB, Hester TR. Lateral canthal anchoring. PlastReconstr Surg 2003;112:222–236.

11. Yaremchuk MJ. Restoring palpebral fissure shape after previous lowerblepharoplasty. Plast Reconstr Surg 2003;111:441–450.

12. Yaremchuk MJ. Improving periorbital appearance in the “morphologically prone.” Plast Reconstr Surg 2004;114:980–987.

Accepted for publication July 8, 2009.

Reprint requests: Michael J. Yaremchuk, MD, MassachusettsGeneral Hospital, 15 Parkman St., Boston, MA, 02114. E-mail:dr.y@dryaremchuk.com.

Copyright © 2009 by The American Society for Aesthetic Plastic Surgery, Inc.

1090-820X/$36.00

doi:10.1016/j.asj.2009.07.001