1 The lower lid retractors are fascial extensions (the capsulopalpebral fascia) off the inferior rectus muscle, which inserts into the lower tarsal plate, an analog of the levator in the lower lid.

2 When a person looks downward (using the inferior rectus), this extension also pulls the lid down a bit so it does not get in the way of looking downward.

3 Therefore, in lower lid reconstructions where the retractors are lost and, e.g., cartilage replaces the lower lid fascia, the lid will not move down with down gaze, so walking down stairs or reading may be problematic and require adjustment.

4 There exists, however, some substance and laxity to these retractors, so sutures will hold well. In addition, after lid retractor transection via the transconjunctival incision, separate reapproximation is unnecessary.

5 Recent efforts at cosmetic lower lid blepharoplasty have aimed at nonremoval of fat or repositioning of fat over the rim to correct tearthrough problems or deficiency there. Others have suggested keeping the fat by pushing it back inside the orbit.

Suturing the orbital septum is problematic because its thinness varies, and the older patient may have an evanescent orbital septum. To keep the orbital volume and replace the fat, suturing the lower lid retractors where they are close to the rim has worked well. Running simple sutures from a lower lid retractor to the arcus marginalis (the junction of the periosteum and periorbita) works very well and will hold up long term.