Canthoplasty and canthopexy

What it is

• The outer corner of the eye is tied to the bony rim by a tendon, and normally sits 1 to 2 mm higher than the inner corner. With age it moves down (PMID 19289688).
• In most loose lower lids the tendon has stretched while the lid itself has not, so tightening at the corner corrects the looseness (PMID 508189).
• Canthopexy tightens the corner with stitches without cutting the tendon. Canthoplasty cuts the tendon, shortens the lid if needed and reattaches it to the rim (PMID 12832900).
• The reason to do either: after lower eyelid surgery the lid can be pulled down, showing white below the iris (scleral show), or turn outward (ectropion). Oculoplastic surgeons name earlier eyelid surgery as the most common cause of a pulled-down lower lid (PMID 30931685).

Where it came from

• In 1979 Anderson described the lateral tarsal strip: the corner is opened, a strip is made from the outer end of the lid and stitched to the inside of the rim (PMID 508189). It is still the standard repair for a very loose or turned-out lid (PMID 25050757).
• In 1993 Flowers proposed canthopexy as a routine part of lower blepharoplasty, to restore lid tone and avoid removing skin that only looks excess because the lid has dropped (PMID 8485945).
• In 1997 Jelks described the inferior retinacular canthoplasty (PMID 9326791), and in 1999 Fagien published a simpler stitch canthopexy with a guide for choosing between the options (PMID 10359271).
• Most oculoplastic surgeons who answered a society survey add canthal support to lower blepharoplasty (PMID 28151825). A 2026 review graded the evidence for doing it to prevent problems as low (PMID 40907566).

Who it suits

• People having lower eyelid surgery, a midface lift through the lower lid, or laser treatment of the lower lid, when the lid is loose (PMID 11884849, PMID 31444052).
• Eyes at higher risk of a pulled-down lid: prominent eyes, a cheek that sits behind the front of the eye (negative vector), and an outer corner that already tilts down (PMID 32549720, PMID 41677016).
• How loose the lid is decides the method: a lid that pulls 10 mm or more from the eye on a gentle tug receives a tarsal strip; most others need only a canthopexy (PMID 12756124, PMID 25050757).
• People with a lid already pulled down after blepharoplasty, often combined with a midface lift (PMID 20489542).
• Cosmetic canthoplasty to change eye shape carries its own risk: one clinic repaired webbing, rounding and pulled-down lids in young women after it (PMID 37622520).

How it is done

• Canthopexy: through the upper or lower eyelid incision, a stitch fixes the outer corner's support tissue to the lining of the bone inside the rim, without cutting the corner (PMID 19617786, PMID 25050757, PMID 10359271).
• Canthoplasty: the corner is opened, the tendon released, the lid shortened if loose, and the lid edge reattached to the rim with a strip or stitches (PMID 508189, PMID 20489545).
• Drill-hole canthopexy: the corner is raised to a new anchor through a small hole in the bone, used for down-slanting eyes (PMID 30874720).
• Options range from a simple stitch to full sling reconstruction for severe cases (PMID 39505478).

Results and how long they last

• With routine canthal support in skin-incision lower blepharoplasty, about 1 in 30 patients needed surgery for lid malposition (PMID 18176227).
• Without a tarsal sling, scleral show after lower blepharoplasty increased and had not fully recovered at two years; with it, the lid sat slightly high at two years (PMID 25568230).
• Retinacular canthopexy kept the corner's angle and position unchanged (PMID 31985628). In a randomized trial with routine canthal support, all patients improved with few complications (PMID 20082201).
• For an established loose or turned-out lid, modified tarsal strip techniques had high success and low recurrence (PMID 39631150).
• Some surgeons support the lid without cutting the corner, or skip support when the lid is firm, and report no new scleral show or ectropion (PMID 12172161, PMID 40952103).

Risks and how surgeons lower them

• Swelling of the white of the eye (chemosis) followed about 1 in 8 operations with canthal support, and persistent chemosis is more common after outer corner surgery (PMID 18176227, PMID 38610858).
• Minor revisions, for small cysts, stitch reactions or webbing at the corner, were needed in about 1 in 9 in the same series (PMID 18176227).
• Reoperation within two years for a recurrent droop or a misshapen corner was needed in about 1 in 33 (PMID 20489545).
• A failed corner shows as webbing, a rounded corner, a pulled-down or turned-out lid, or incomplete closure; it can be rebuilt with a tarsal strip or a Z-plasty (PMID 37622520, PMID 33746208, PMID 40848070).
• Anchoring the corner cannot rescue a lid after too much skin was removed or after a poorly done midface operation (PMID 12832900). Loose lids, a weak eyelid muscle and a negative vector are common in patients referred with a pulled-down lid, so surgeons check for them before surgery (PMID 25168805, PMID 32549720).

Recovery

• For the first two weeks after canthopexy the lid feels tight, slants slightly upward and moves less; shape and position were normal by the third week (PMID 19617786).
• After drill-hole canthopexy the corner is set high on purpose and settles over about six months (PMID 30874720).
• Lid position after a tarsal sling kept changing for two years (PMID 25568230).
• For a lid pulled down early after blepharoplasty, most surveyed surgeons start with massage or steroid injection, and about half wait at least six months before more surgery (PMID 30931685).
• A temporary droop after combined facelift and blepharoplasty settled within four weeks with massage and taping (PMID 20442069).

With a facelift

• The lower lid should be supported when the midface is lifted through a lower lid incision and when the lid is treated with a laser (PMID 11884849).
• With orbitomalar suspension during a high SMAS facelift and lower blepharoplasty, ectropion was rare and came from a broken stitch (PMID 20442069).
• A midface lift with canthoplasty corrected lower lids pulled down by earlier blepharoplasty, and tearing and eye irritation resolved (PMID 20489542).

Questions to ask a surgeon

• Is my lower lid loose, and do I have a negative vector? (PMID 32549720)
• Will you support the outer corner, and with which method? (PMID 12832900)
• Will you cut the tendon, or only stitch it? (PMID 25050757)
• How often do your patients need a revision? (PMID 18176227)
• What will my eyes look like in the first two weeks? (PMID 19617786)

Open 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).
• Evidence: the evidence for preventive lid suspension is low quality (PMID 40907566).
• High-risk eyes: spacer grafts at the first operation did not prevent retraction in every patient (PMID 37326309).
• Established retraction: a lateral tarsoconjunctival flap improved lid position in nearly all lids (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 outer rim (PMID 508189).
• Canthopexy: tightening the corner with stitches 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 the lid edge stitched to the rim (PMID 508189).
• Lateral retinaculum: the outer corner 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 corner angle after surgery (PMID 37622520).
• MRD2: distance from the light reflex on the eye to the lower lid edge (PMID 25050757).

Papers