Lower lid tarsal suspension was originally described in 1911 by Lexer and Eden, and since then, multiple modifications have been made most notably by Tenzel, Anderson, and Gordy. The alteration in the contour and position of the lower eyelid has been described by various names such as the tarsal strip procedure, the lateral canthal sling, lateral canthoplasty, canthopexy, the tarsal tongue, the periosteal strip, horizontal shortening, and tarsal suspension. The tarsal strip canthoplasty is used in the functional treatment of lower lid laxity and malpositions (i.e., ectropions and entropions) and also in aesthetic surgery of the lower eyelid.

The upper and lower eyelids serve to distribute moisturizing tears over the surface of the eye and to protect the delicate tissues of the ocular surface. Compromise of eyelid function can have significant repercussions with regard to ocular irritation and pain as well as the potential for visual loss. Abnormalities in the position of the lower eyelid can either be congenital or acquired and often relate to changes along the lateral canthus. Anatomic contributions from the lateral horn of the levator aponeurosis, Lockwood’s ligament, lateral orbicularis oculi, and the check ligament from the lateral rectus muscle comprise what is collectively described as the lateral retinaculum and commonly known as the lateral canthus. Direct and effective treatment of malposition of the lower eyelid commonly entails the undertaking of a tarsal strip canthoplasty, which is the focus of this chapter.

It is important to evaluate the patient preoperatively and to identify the cause of malposition of the lower eyelid. Does the patient have laxity of the lower lid with or without shortening of the anterior lamellar and lower lid retraction? In cases of isolated laxity of the lower lid, a lateral tarsal strip canthoplasty alone can be sufficient to provide an appropriate cosmetic result. When there is shortening of the anterior lamella, recruitment of anterior lamella through midface resuspension may be required. Very severe cases of shortening of the anterior lamella may require skin grafting. Patients with retraction of the lower lid may also require posterior lamellar grafting in addition to a lateral tarsal strip canthoplasty. Various substrates can be used, but the authors generally prefer autologous hard palate grafting in moderate to severe cases. Allografts such as Alloderm graft can suffice for cases of mild to moderate retraction of the lower lid.

Furthermore, it is important to assess the patient for the:

Surgical technique: tarsal suspension technique for repairing lower lid malposition

The general steps for the lateral tarsal suspension technique including the following:

A number 15 blade is used to create a lateral canthal incision of approximately 1 cm in an aesthetically pleasing skin fold (Fig. 5.1). With upward traction on the lateral aspect of the lower eyelid, the inferior crus of
the canthal tendon is severed with a Stevens scissors (Fig. 5.2). The scissors are directed posteromedially, and the orbital septum is released with sharp dissection (Fig. 5.3).