Lateral canthoplasty: Expand horizontally or lower vertically? Differences in techniques and limitations

Lateral canthoplasty (lateral canthal plasty) involves either expanding the lateral canthus horizontally or expanding it both horizontally and vertically downward[1]Traditionally, horizontal lateral canthoplasty and vertical expansion surgery were performed separately, but techniques aiming for both in a single procedure have also been reported[1]Which approach is suitable depends on whether you want to increase horizontal width, reduce the upward slant, or preserve the shape of the lateral canthus and Lower-lid love band[2][3].

What changes with lateral canthoplasty: width and inclination

Lateral canthoplasty is a surgery that extends the horizontal width of the eye and relaxes the upward slant of the eye[2]By detaching a portion of the lateral canthal ligament and fixing it in a new position, and removing an appropriate amount of skin and muscle at the lateral canthus, reports indicate that the horizontal width increases by 3–6 mm[4].

It is often performed simultaneously with Double eyelids surgery or medial canthoplasty, though it can also be performed alone[2]Textbooks organize contemporary eye surgery for Asian patients with the concept of expanding in four directions—up, down, left, and right—with vertical expansion being correction for mild ptosis, and horizontal expansion being achieved through medial and lateral canthoplasty[5].

Expand horizontally only, or lower vertically as well

Traditional lateral canthoplasty was a surgery to expand horizontally, and when vertical expansion of the lateral canthus area was desired, a separate procedure was necessary[1]A review of Before-after cases from 2018 to 2023 introduced a technique to expand both horizontally and vertically in one procedure, measuring the distance from the pupil center to the lateral canthus, the inclination from medial to lateral canthus, and the distance from the pupil center to the lower eyelid margin at 6 months for evaluation[1].

The technique that also lowers vertically requires additional manipulations involving the support structures of the lower eyelid, as it lowers the lower eyelid margin[1][6]Textbooks define the technique of completely detaching and reattaching the lateral canthal ligament as originally addressing lower eyelid laxity[6].

Recurrence and scarring: How much occurs?

A 2017 report states that in a 6-month follow-up, the extended horizontal width remained stable, with no recurrence of lateral canthal angle reduction or hypertrophic scarring observed[2]In another report, the risk of infection, bleeding, and scarring is said to be less than 5%, with satisfaction rates of 85–95%.[4]However, no studies comparing long-term relapse rates between surgical techniques were found in the literature reviewed this time.

What happens if you widen it too much?

If the outer corner is widened excessively and the lateral canthus position shifts, the eyelid may not close easily, and the cornea may become exposed and damaged—this is what ophthalmology textbooks state.[7]It is important not only how much the eye widens, but also that the position of the lateral canthus and the support of the lower eyelid are maintained.[7].

There are also precautions regarding the operation to lift the lateral canthus. A 2026 paper on lower eyelid surgery states that Asians do not dislike round eyes; conversely, they tend to dislike eyes that are tilted too much upward or appear small. Many patients dislike the Lower-lid love band disappearing when the lateral canthus is lifted.[3]The same paper concludes that unless there is sagging (skin laxity) in the lower eyelid, it is not necessary to perform surgery on the lateral canthus ligament every time.[3].

Which one to choose? Three key questions

The decision can be organized by three questions: Do you want increased horizontal width, a change in tilt, or downward expansion?[2][1]Is there sagging (skin laxity) in the lower eyelid?[6]Do you want to preserve the shape of the Lower-lid love band and the lateral canthus corner?[3].

The Japan Society of Plastic Surgeons guideline mentions techniques on the lower eyelid side, such as the lateral tarsal strip procedure and canthopexia, which repositions without cutting the ligament.[8]It will be easier to understand the explanation if you remember that there is a distinction between the method of cutting and reattaching the ligament and the method of repositioning without cutting.[6][8].

What to confirm during consultation

What you want to confirm is the horizontal width of your own eyes, the tilt, the sagging (skin laxity) of the lower eyelid, and the condition of the Lower-lid love band.[2][3][6]Please confirm together with photos how many millimeters horizontally and how many millimeters downward you are aiming for, and how to preserve the shape of the lateral canthus corner.[1].

Whether the lateral canthus ligament is cut and reattached, or repositioned without cutting, affects the support of the lower eyelid.[6][8]Whether the eyelid becomes difficult to close or the white of the eye becomes more exposed is a judgment to be made with the physician after the lower eyelid is examined during consultation.[7].