The pathogenesis of ageing within the lower eyelid is multifactorial and varies among patients. Periorbital age-related changes include crow’s feet and lower eyelid rhytides, scleral show, infraorbital hollowing, herniated fat pads, excess upper and lower-lid skin, festoons, and eyelid hooding. In addition, attenuation of the lateral canthal tendons results in loss of the youthful architecture of the eye secondary to a decrease of the aesthetically pleasing upward tilt19–25.

The change in the lateral canthal complex position is functionally important, as its changes contribute to lower eyelid laxity, which may result in rounding of the lateral commissure and narrowing of the palpebral fissure1,3,6–8,13–16.

Traditional transcutaneous lower blepharoplasty corrects multidimensional aspects of periorbital ageing by tightening the lower eyelid skin and muscle, and through manipulation of orbital fat13–16. In the study, a canthopexy was used to prevent the most common complication following lower eyelid blepharoplasty: the lower-lid malposition.

Lower-lid laxity was evaluated during the surgery using a lid distraction test (anterior and lateral). Many different methods of canthal support have been documented in the literature1–4,6–8. In general, all methods correct tarsoligamentous laxity, and counteract the downward forces of healing. The required surgical techniques for patients with prominent or morphologically prone eyes include routine lateral canthoplasty or canthopexy, which overcorrects the lateral canthus superior to medial canthus and creates additional vertical support for the lower eyelid, as described by a number of authors1–4,6–8.

The two most important aspects of the study were tightening of the posterior lamella with canthal support based on Flowers6 and Lessa8 techniques, and resuspension of the anterior lamella, as described by Cordner3, 14. After the surgical procedure there was a statistically significant improvement of tarsoligamentous laxity in all patients. During the analysis of pre- and postoperative results of canthopexy it was seen that tarsoligamentous laxity was improved in all cases.

Postoperative care

Methylcellulose eye drops are recommended while the patient is awake, and lubricating ointment for night use for a few days postoperatively. The patient’s head should remain elevated to reduce oedema and ophthalmic pressure. Patients are advised to avoid strenuous lifting, bending, and vigorous activities for 2 weeks following the procedure.


For a proposed procedure to gain wide acceptance, it must be surgically logical, consistently effective, low in complication rate, and reproducible by other surgeons. Lateral canthal support should be considered a routine component of lower transcutaneous blepharoplasty to obtain the desired cosmetic result and maintain the natural appearance of the eyelid shape, tension and position.