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DOI: 10.1177/1090820X13479970
2013 33: 497 originally published online 1 April 2013 Aesthetic Surgery Journal
Clinton D. McCord and Gabriele C. Miotto
Dynamic Diagnosis of ''Fishmouthing'' Syndrome, an Overlooked Complication of Blepharoplasty

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Oculoplastic Surgery
Aesthetic Surgery Journal
33(4) 497 504
2013 The American Society for
Aesthetic Plastic Surgery, Inc.
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DOI: 10.1177/1090820X13479970
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Inadequate eyelid closure following blepharoplasty can pro-
duce symptoms secondary to exposure and drying of the
eye surface. In many cases, the cause of dysfunctional eye-
lid closure may be diagnosed without difficulty, such as in
the presence of visible lagophthalmos, scleral show, or
ectropion. Poor eyelid closure in these patients is commonly
the result of tissue tethering due to skin deficiency (anterior
lamella) or intrinsic eyelid stiffness secondary to cicatricial
changes within the middle and posterior lamellae.
1-7
Another cause of poor eyelid closure is dynamic dys-
function of the lateral canthus, wherein reduced tone of
the lid attachments contributes to ocular dysfunction.
Eyelid closure problems resulting from dehiscence and
loss of support of the upper lid and lower lateral canthal
attachments appear to be an overlooked complication in
Dynamic Diagnosis of Fishmouthing
Syndrome, an Overlooked Complication of
Blepharoplasty
Clinton D. McCord, MD; and Gabriele C. Miotto, MD
Abstract
Background: Dysfunction and/or dehiscence of the lateral canthus is 1 source of symptomatic eyelid closure disorder after blepharoplasty. Because
the resulting concentric blinking movement resembles mouth closure in a fish, the name fishmouthing syndrome (FS) was given to this condition.
Fishmouthing syndrome appears to be an overlooked complication of blepharoplasty.
Objectives: The authors performed dynamic assessments of patients who had eyelid discomfort after blepharoplasty to establish the clinical signs of
FS.
Methods: Preoperative and postoperative videos of 36 patients who presented for secondary blepharoplasty were analyzed retrospectively. All 36
patients experienced symptoms of dry eyes and eye discomfort after their initial blepharoplasty and desired symptomatic and cosmetic improvement. The
dynamic signs and diagnostic criteria for FS were established clinically and through video analysis of patients blinking movements.
Results: The most common clinical characteristics of FS included lash deformity (cow lash sign), abnormal medial displacement of the lateral canthus
during blinking, deformity (rounding/narrowing) of the lateral scleral triangle, and visible eyelid closure deficiency or gapping. Other characteristics were
lower-lid retraction and compensatory hypercontraction of the orbicularis oculi adjacent to the inner canthus.
Conclusions: Patients with FS present with a combination of clinical symptoms and signs and are best diagnosed through dynamic visualization of
the animated tissue during blinking. Evaluation of preoperative videos is an essential tool for surgical planning and for analyzing the results, both before
and after corrective surgery, in patients with potential FS.
Level of Evidence: 4
Keywords
drill-hole canthopexy, canthoplasty, blepharoplasty, dry eye, canthal dehiscence, fishmouthing syndrome, oculoplastic surgery
Accepted for publication November 7, 2012.
Dr McCord was an oculoplastic surgeon in private practice in
Atlanta, Georgia, at the time this research was conducted. Dr Miotto
was a plastic surgeon in private practice in Florianopolous, Brazil,
and was a Fellow in a private practice in Atlanta, Georgia, when this
research was conducted.
Corresponding Author:
Dr Gabriele C. Miotto, 3200 Downwood Circle NW, Suite 640,
Atlanta, GA, 30327. Email: gabrielemiotto@hotmail.com
Scan this code with your smartphone to
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498 Aesthetic Surgery Journal 33(4)
blepharoplasty patients. Lateral canthal dysfunction may
not be as detectable from static photographs as it is during
active blinking. Therefore, for patients who present with
ocular dysfunction after blepharoplasty, we recommend
dynamic diagnostic evaluation with systematic analysis of
eyelid blinking to detect signs of lateral canthal dehis-
cence, which we have termed fishmouthing syndrome
(FS).
Normal blinking movement produces vertical closure
and consists of contraction of the inner canthal orbicularis
offset by a firm counter pull of the lateral canthal attach-
ments of the upper and lower lids. Dehiscence or stretch-
ing of both upper- and lower-lid components of the lateral
canthal tendon can cause an abnormal, medially oriented
movement of the eyelid during blinking, resembling a con-
centric fishmouth movement, rather than the more verti-
cally oriented movement that is characteristic of normal
blinking (Figure 1).
Fishmouthing syndrome is most commonly recognized
in patients who present with eyelid closure deficiency and
complain of eye discomfort following blepharoplasty. The
primary clinical symptom of FS is dryness of the eyes,
which commonly occurs weeks or even months after sur-
gery due to progressive laxity or dehiscence at the lateral
canthus. Clinical signs of FS can be recognized during
blinking and include inward pulling of the lateral canthus
and eyelids toward the nose, compensatory hypercontrac-
tion of the medial canthal orbicularis oculi muscle accen-
tuating vertically oriented lid rhytids, medial rotation and
straightening of the upper-lid lashes, and incomplete eye-
lid closure with various degrees of gapping of the eyelids.
Static clinical signs of canthal dehiscence can be seen
mostly in the lateral scleral triangle. The lateral canthus is
often displaced medially, causing various degrees of
rounding and/or narrowing of the lateral scleral triangle,
with distortion of the shape of the eye. In addition, in
many patients afflicted with FS, the upper-lid lashes are
straight and medially rotated, which is accentuated by
blinking. The change in lash curvature appears to be pro-
portional to the degree of dehiscence of the upper-lid
Figure 1. (A) Normal eyelids with firm lateral canthal attachments. (B) Normal vertical closure of eyelids, with contraction
of inner canthal orbicularis combined with lateral resistance from the canthal tendon. (C) Laxity and dehiscence of the lateral
canthal tendon. (D) A weakened and fishmouthing blinking movement caused by a reduced lateral counter pull to the inner
canthal orbicularis contracture.
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McCord and Miotto 499
canthal tendon, and it is most noticeable in the lateral
third of the upper-lid lashes. This eyelash deformity
resembles the lashes of a cow (straight and medially ori-
ented), which is why we have nicknamed it cow lash
deformity (Figure 2).
The eyelid finger repositioning maneuver, performed at
the lateral orbital rim, is an important diagnostic tool to
determine whether canthal tightening could improve a
patients FS. This maneuver involves pushing the lateral
canthal tendons (upper and lower) toward the lateral
orbital rim and may demonstrate how canthal tightening
could improve both eyelid closure during blinking and
lash position (Figure 3).
METHODS
The charts of 56 patients who presented to the authors
private clinic for secondary blepharoplasty between 2003
and 2011 were retrospectively reviewed. All 56 patients
who presented for secondary blepharoplasty over a period
of 8 years had FS. All patients had undergone previous
bilateral upper and lower blepharoplasty and sought relief
of eye dryness and discomfort. Many of these patients also
desired cosmetic improvement of their eyelid appearance.
Of the 56 patients diagnosed with FS, videos of blinking
movements were preoperatively and postoperatively
recorded for 36. Only these 36 patients were included in
the present analysis. There were no other inclusion or
exclusion criteria. Each author retrospectively analyzed all
36 videos in an effort to determine the dynamic signs of
FS and to establish its diagnostic criteria.
RESULTS
Most of the patients (n = 32) were women, and the aver-
age age was 53 years (range, 45-65 years). Fishmouthing
syndrome was observed at different degrees of severity,
from subtle clinical signs in some patients to more severe
and visible deformities in others. Subtle cases of FS were
sometimes characterized only by symptoms of dry eye and
eye irritation after previous blepharoplasty. In some subtle
cases, eyelid gapping on closure was difficult to visualize.
Figure 2. (A) This 53-year-old woman presented with canthal dehiscence, a small lateral scleral triangle, eyelash deformity,
and fishmouthing syndrome after previous blepharoplasty. This patient is also featured in Video 3, available at www.
aestheticsurgeryjournal.com. (B) When blinking, the patients lashes rotated downward (cow lash deformity). (C) Image of a
cows eye shows the natural downward rotation of the lashes.
Figure 3. (A) This 61-year-old woman with fishmouthing syndrome (FS) presented with incomplete closure of the right eye when
blinking. This patient is also featured in Video 4, available at www.aestheticsurgeryjournal.com. (B) The finger repositioning
test, an important diagnostic tool for FS, involves digital tightening at the level of the lateral canthus. Note that the manual
repositioning of the upper and lower canthal tendons at the lateral orbital rim produced complete closure of the eye.
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500 Aesthetic Surgery Journal 33(4)
Symptomatic patients with subtle FS complained that they
knew something wasnt right with their eyes but had
received no diagnosis for the problem. Some of these
patients whose eyes appeared normal on static examina-
tion had a disproportionate severity of symptoms between
the appearance of eye shape and closure and level of
symptoms, and subsequent observation of their blinking
movements showed subtle clinical signs of FS.
Analysis of the preoperative videos showed changes in
the shape and direction of the upper-lid lashes (cow lash
deformity) in 32 of the 36 (88.8%) patients. Twenty-eight
(77.7%) patients had abnormal medial displacement of the
lateral canthus during blinking. Twenty-four (66.6%)
patients had deformity of the lateral scleral triangle (round-
ing or narrowing), and 24 (66.6%) patients had visible
eyelid closure deficiency or gapping. Compensatory hyper-
contraction of the inner canthus orbicularis was present in
20 (55.5%) patients, and lower-lid retraction (on 1 or both
sides) was present in 21 (58.3%) patients. The latter was
not considered a diagnostic criterion of the syndrome but
rather an associated finding (Table 1). On the basis of our
results, we propose diagnostic criteria FS in Table 2.
Two videos demonstrating a mild and severe case of FS,
respectively, are available at www.aestheticsurgeryjournal.
com. Seven other videos demonstrating dynamic evaluation
of FS and the various degrees of severity, as well as surgical
correction and postoperative appearance, are also available at
www.aestheticsurgeryjournal.com. You may also use any
smartphone to scan the code on the first page of this article
to be taken directly to the videos on www.YouTube.com.
DISCUSSION
Although the term fishmouthing has been described
briefly by one of the authors (C.D.M.) in previous publica-
tions,
3,6
the importance of dynamic evaluation of patients
with the syndrome and its primary diagnostic findings
have not been fully explained elsewhere. Close attention
to the lateral scleral triangle and shape of the eye fissure
during blinking is key to the diagnosis of lateral canthal
dehiscence causing FS. The evaluation of patient videos
(rather than static photographs), both pre- and postopera-
tively to the secondary surgery, is an important tool in the
clinical assessment of patients with eyelid closure problems
after blepharoplasty. The videos helped us determine that
acquired laxity or dehiscence of both upper and lower lateral
canthal tendon components appears to be the main cause of
FS and that establishing firm canthal tendon anchoring is
fundamental to effective correction of the problem.
Denervation of the orbicularis oculi muscle has been
cited as a cause of poor eyelid closure due to disruption of
the zygomatic branches of the facial nerve, which can occur
during transcutaneous skin-muscle flap lower blepharo-
plasty.
8,9
However, because the obicularis receives dual
innervation, it should be thought of as having 2 separate
muscle groups, from a functional standpoint. The inner
canthal orbicularis is the main muscle responsible for the
blinking mechanism and is innervated by the buccal branch
of the facial nerve. This branch enters the orbicularis oculi
muscle medially and is not disrupted by the traditional
blepharoplasty procedure.
10
Contraction of the inner canthal
orbicularis is also primarily responsible for tone in the
lower lid and is exclusively responsible for the pumping
mechanism of the lacrimal apparatus (Figure 4).
The extracanthal orbicularis muscle, which generally
involves the lateral two-thirds of the arcs of the orbicularis
in each eyelid, is independently innervated by zygomatic
branches of the facial nerve. Contraction of the extracan-
thal orbicularis muscle provides expressional animation to
the eyelids and plays a role in eye protection (Figure 5).
Anatomic and electromyographic studies in postblepharo-
plasty patients and in people with blepharospasm have
confirmed the presence of muscle innervation following
transection and resection of the extracanthal orbicularis
muscle.
5,10-12
Lateral tendon laxity or dehiscence appears
to be the cause of FSnot eyelid denervation. Once the
integrity of the lateral canthus is achieved by canthal
anchoring, correction of the eye closure problem is
attained. Patients with eye closure problems after blepha-
roplasty and undiagnosed lateral canthal dehiscence
should not receive skin grafts or gold weights to the upper
lid because they will be of little value in improving eyelid
Table 1. Signs and symptoms in 36 patients who presented with
fishmouthing syndrome after blepharoplasty.
Sign/Symptom Patients, No. (%)
Dry eyes or eye discomfort 36 (100.0)
Cow lash deformity 32 (88.8)
Abnormal medial displacement of the lateral canthus 28 (77.7)
Rounding and/or narrowing of the lateral scleral triangle 24 (66.6)
Visible eyelid closure deficiency or gapping 24 (66.6)
Compensatory hypercontraction of the inner canthal obicularis 20 (55.5)
Coexisting lower-lid retraction
a
21 (58.3)
a
An associated finding.
Table 2. Proposed diagnostic criteria for fishmouthing syndrome.
1. Symptoms of dry eyes or eye discomfort after blepharoplasty
2. At least 3 of the following clinical findings:
a. Cow lash deformity
b. Abnormal medial displacement of the lateral canthus
c. Rounding and/or narrowing of the lateral scleral triangle
d. Compensatory hypercontraction of the medial (nasal) orbicularis
e. Incomplete closure of the eyelids, or eyelid gapping
3. Improvement in clinical findings after digital repositioning of the lateral canthus
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McCord and Miotto 501
Figure 4. Illustration of the inner canthal segment of the orbicularis oculi muscle, which is innervated by the buccal branch
of the facial nerve. This functional unit of the eyelid contributes to lower-lid tone in position and is responsible for blinking as
well as the function of the tear duct pump. Inset: Greater detail of the muscle portions of the orbicularis and inner canthus,
which are innervated by the buccal branch. The size and complexity of the inner canthal orbicularis are apparent.
Figure 5. Illustration shows the extracanthal segment of the orbicularis oculi muscle, which is innervated by the zygomatic
branch of the facial nerve. With normal blinking, there is usually no activation of this muscle group. Contraction occurs only
with facial animation or special protective reactions of the eyelids.
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502 Aesthetic Surgery Journal 33(4)
closure if there has been no concomitant reanchoring of
the upper-lid lateral tendon.
It is important to emphasize that distressed patients
who seek a cure for symptoms of dry or irritated eyes
should be examined for FS. A surprising number may
show telltale signs of this syndrome, such as abnormal
medial displacement during blinking, rounding and/or
narrowing of the lateral scleral triangle, or cow lash
deformity of upper-lid lashes. In the present series, all
patients with FS presented with some degree of upper-lid
laxity and had their upper-lid tone restored through can-
thal anchoring of the upper component of the canthal
tendon. Correction required drill-hole fixation of the can-
thal tendon to the lateral orbital rim for effective restora-
tion of lateral canthal integrity in nearly all patients in our
series.
6
Selection of the drill-hole technique was based on
local tissue condition/scarring from previous surgery and
the certainty that the suture was secure enough to hold the
tissues in place. Both the upper- and lower-lid components
of the lateral canthal tendon were reattached in all 36
patients (Figure 6). The level of canthal reattachment of
the lower lid to the lateral orbital rim was determined in
relation to eye prominence.
13
When canthal attachments
are reinforced, it is important to avoid abnormal supra-
placement of the upper-lid tendon, which could weaken
upper-lid tone and impair upper-lid closure mechanics. In
patients with very prominent eyes, infraplacement of the
upper-lid tendon (crisscross canthal anchoring) is some-
times required, in addition to tightening or shortening of
the upper lid, to achieve the desired upper-lid closure
7

(Figure 7).
In the present study, 58.3% of the patients with FS
presented with associated lower-lid retraction and were
treated via a transcutaneous skin-muscle flap approach for
cheek elevation and lower-lid skin recruitment, plus drill-
hole canthal anchoring. Spacer implantation may also be
necessary for patients who have lower-lid retraction or
prominent eyes.
1
Although we are unable to provide an
exact number, a high percentage of our patients, particu-
larly those with prominent eyes and preexisting scleral
show, required concomitant spacer implants (porcine acel-
lular dermal matrix [Enduragen; Stryker, Kalamazoo,
Michigan]) as part of the corrective procedure
14
(Figure 8).
Patching of the lateral canthal tendons with autogenous
fascia or acellular dermal matrix may be required to
achieve adequate lid support in patients who have under-
gone multiple previous surgeries
4
(Figure 9).
To achieve optimal correction of FS, factors such as eye
prominence, presence of lower-lid retraction, and degree
of upper-lid laxity must be taken into account intraopera-
tively. Each of these factors, which have been described
extensively in previous publications,
1-7,13
influences the
method of correction for canthal dehiscence. Eye promi-
nence (Figure 7) must always be evaluated preoperatively
because it will define the level of positioning of canthal
anchoring in relation to the pupil at the orbital rim and
will determine the need for spacer implantation.
Repair of the lateral canthal attachments
15
of the upper
and lower lid, together with proper canthal positioning,
will alleviate FS symptoms in most patients by improving
eyelid closure dynamics while restoring eye fissure shape.
Standard canthopexy/canthoplasty or retinacular suspen-
sion
16-18
with periosteal fixation alone may be insufficient
to provide effective repair of lateral canthal integrity.
Patients who have undergone previous eyelid surgery
often have deficient tissue integrity at the lateral rim. All
patients in the present series had some degree of scarring
at the lateral canthus from previous surgery. Thus,
Figure 6. Techniques of lateral canthal anchoring of the upper- and lower-lid tendons with drill-hole fixation at the lateral
orbital rim. (A) Drill-hole fixation with lateral canthoplasty, which is usually performed with shortening of the upper and
lower lids. (B) Drill-hole fixation with lateral canthopexy, without lid resection. (C) Configuration of the anchoring suture
(usually double-armed 4.0 Mersilene [Ethicon, San Angelo, Texas]). A drill hole that extends from the lateral orbital rim to the
temporalis fascia facilitates the attachment of the edges of the upper and lower lids.
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McCord and Miotto 503
Figure 7. Illustration shows the correct location of canthal
anchoring at the lateral orbital rim with respect to preserving
eye fissure shape in relation to eye prominence. Canthal
supraplacement can affect and weaken the upper-lid
tendon, impeding upper-lid closure by reducing tone and
functionality. Inset: Separate infraplacement of the upper-lid
lateral canthal tendon may be necessary to preserve upper-
lid closure strength and velocity in some patients. This has
been termed crisscross canthal anchoring and is more
commonly used for patients with prominent eyes.
Figure 8. Spacers can be implanted either
transconjunctivally or transcutaneously. This technique
is commonly used in patients with prominent eyes when
canthal anchoring cannot be supraplaced and elevation of
the lower lid is needed.
Figure 9. Patch grafts from the lateral canthal area to the
lateral orbital rim. In many patients, the soft tissue at the
canthus may be deficient and require reinforcement in
addition to canthal anchoring for long-term fixation. Either
autogenous fascia or alloplastic material (porcine acellular
dermal matrix) may be utilized. Patching can be used to
reinforce the lower-lid lateral canthus only or may include
the upper lid if appropriate.
drill-hole fixation prevailed as the method of choice for
achieving the most stable and reliable repair in these cases.
Surgeons whose patients have eyelid malpositioning and
closure problems after previous surgery are generally inter-
ested in a single-operation cure, and the predictability of
drill-hole canthal fixation (at least in our hands) made it an
ideal single-procedure corrective technique.
CONCLUSIONS
Patients who present with eye discomfort and dry eyes
after blepharoplasty should be evaluated for fishmouthing
syndrome. Fishmouthing syndrome has a broad spectrum
of clinical signs, which are best diagnosed through
dynamic visualization of the animated tissue during blink-
ing. Video analysis is an essential diagnostic and evalua-
tion tool for such patients, both pre- and postoperatively.
The recognition of FS and application of an individualized
surgical approach can be effective in relieving the symp-
toms and in correcting the eyelid deformities.
Disclosures
The authors declared no potential conflicts of interest with respect
to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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