BACKGROUND: There are numerous approaches to correcting laxity of the lateral canthal tendon, each with advantages and drawbacks. Critical evaluation of these techniques is not possible, however, as there is no grading system currently in use to describe this condition or to report outcomes, and prospective trials are lacking. OBJECTIVES: To report and assess a new procedure for repair of the lateral canthus (lateral transorbital canthopexy) and to describe the Ectropion Grading Scale (EGS), with a prospective outcome analysis of their use. DESIGN: Prospective outcome study of 15 consecutive patients (16 procedures). SETTING: Tertiary referral center in Zurich, Switzerland. PATIENTS: Consecutive sample of patients referred for treatment of ectropion of various causes. INTERVENTIONS: Preoperative and postoperative EGS grades were recorded, a preoperative and postoperative patient-based questionnaire was administered, and lateral transorbital canthopexy was performed. MAIN OUTCOME MEASURES: Outcome was determined by improvement in EGS grade and results of the patient-based symptom questionnaire. RESULTS: There were no surgical failures or complications in the study. An average of 83% reduction in patient-reported discomfort was achieved. Two patients with facial paralysis needed medial canthal repositioning. The EGS allowed clear recording of lower eyelid position before and after lateral transorbital canthopexy, and the procedure was uncomplicated to perform. CONCLUSIONS: Lateral transorbital canthopexy is an effective technique for the correction of lower eyelid laxity and appears to allow refined, durable adjustment of the lateral canthus. Self-reported patient satisfaction confirmed the high rate of success of the procedure in this study. The EGS permits critical evaluation and reporting of results and may assist in predicting which patients will need concomitant correction of the medial canthus. Arch Facial Plast Surg. 2000;2:9-15