Surgical technique. (A) Lower blepharoplasty skin removal. The skin is detached up to the lower portion of the pretarsal orbicularis muscle. (B) Resection of the myocutaneous flap. Excessive skin and preseptal orbicularis muscle are completely resected using the radiofrequency device in the blend mode. (C) Incision in the orbital septum at the upper-lateral orbital rim to expose the white region, which corresponds to the lateral canthal tendon. (D) A prolene 5-0 suture needle transfixes the tendon, passing under it. (E) The needle is inserted outward through the lower border of the pretarsal orbicularis muscle at the same height of the eyelid lateral canthus. (F) The pre septal muscle is identified and fixed by moving the needle in the opposite direction (towards the upper eyelid). (G) Before entering the tunnel (below the lateral canthal tendon), the needle is introduced between the pretarsal orbicularis muscle and inferior tarsus and rotated 180° prior to being reinserted into the tunnel (under lateral canthal tendon) and being removed via the entrance site. (H) The suture is fixed in the periosteum of the upper-lateral orbital rim. (I) Three knots are tied. Notice that the knot is buried just to the periosteum, underneath the orbicularis muscle that is isolated at the time of suture, to avoid trapping its fibers with the suture. (J) The needle is again introduced in the tunnel, but this time in a more lateral position compared to the first knot. (K) The needle penetrates the submuscular space to the topography of the upper border of the superficial musculo-aponeurotic system, shown by the tweezer in the figure. (L) Plicature of pre septal orbicularis muscle in a lateral position. (M) Pre septal orbicularis muscle elevation shown by the skin traction. (N) The needle is again introduced in the tunnel, in a more lateral position compared to the first knot, without fixing the periosteum. (O) Another knot is tied, lying internal do the septum. (P) The final aspect without a skin suture showing, and featuring the correct positioning of skin and muscles without any traction.