Can my eyes be improved upon (loosened lids/canthus removed from eyeball)? (Photo)

After previous surgery I ended up with loosened lower eyelids and a space between the canthus + eyeball. My eyes kept getting dry/irritated/debris got trapped. I underwent bilateral canthopexy. The concerns seem unchanged: eyes are still dry/debris gets trapped, and lower lids still loosened plus canthus removed from eyeball. Compared to my original eyes, the canthus appears to be in a much lower position after the surgeries plus the lower eyelids seem longer. What can still be done to improve?

Doctor Answers 1

Your eyes and eyelids can be restored from previous surgery by an eyelid specialist - an oculofacial/oculoplastic surgeon

Thank you for your question. You state in your question, which you did not submit a photo, that you had lower eyelid cosmetic surgery, but after had an issue where the eyelid was away from the eyeball, or the canthus which is the corner of the eye, was away from the eyeball. You underwent a lateral canthopexy, but it did not seem to change or improve the situation. In addition, you feel the lower eyelid is lower and longer. In the absence of a photo, there are some limits of what I can describe in terms of my approach, but I am very familiar with your type of situation.

A little background - I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I’ve been in practice in Manhattan and Long Island for over 20 years, and one of my areas of specialty is the revision of complications of cosmetic eyelid surgery. In fact, we take care of situations like yours for patients who come to us from all over the world.

To understand what your issue is, and why the most recent procedure did not work as expected, I’ll give  you a little understanding of the terminology and principles on how I approach this problem. From your description and from my experience, you likely had a lower blepharoplasty or lower eyelid surgery done from the outside of the eyelid. Subsequently in the healing process, your eyelid pulled away from the eye, which we refer to as ectropion where the margin of the eyelid is away from the eyeball. You also feel like your lower eyelid is lower, which is called lower eyelid retraction. In what you describe as the eyelid being longer, I suspect you are seeing is more of the white  of the eye which we call scleral show, which can make the eyelid appear longer. However, it is more typical that the horizontal width of the eyelid actually becomes shorter.

There are 3 important elements in lower eyelid support:  the connection of the lower eyelid to the bone called the lateral canthal tendon, which is like the suspension part of a suspension bridge; the front of the eyelid which is the skin or the orbicularis or the anterior lamella; another part is the posterior lamella which is the lower eyelid retractor of the conjunctiva and the orbital septum (sometimes called the middle lamella). This is a lot of terminology, but the point is when I do a revision for lower eyelid surgery, these elements have to be assessed – are they intact or do they need repair?

Often, people do some type of a shortcut procedure, or make a best effort to address the issue. In the lateral canthopexy, one element may have been addressed which is the lateral canthal tendon or the suspension of the eyelid. In my experience, the problem may be inadequate support from behind the eyelid. If you think of  the supporting structure of the lower eyelid as pillars, when surgery is done without maintaining support, or the healing of that support is compromised, the pillars collapse. My job as a revision surgeon is to restore anatomical support, so I place grafts in the inside of the eyelid. If there is a skin shortage in the front, we place skin grafts in front of the eyelid.

Often, the doctor who did the original cosmetic eyelid surgery may not be as comfortable with these procedures and will try to do something as a shortcut, whether it is a lateral canthopexy or lateral canthoplasty which can sometimes be enough. Ultimately, you have to be happy with the final result. In my experience, people will go through anywhere from 1 to 7 or more operations before they find an alternative which involves more in the short-term, but will provide long-term benefit.

I think it is very important for you to understand that there are options available for you,  but you’ll have to discuss with your surgeon what would be the next step. I think it is still important to maintain communication with the original surgeon, and see if there are options such as the one I described that they are familiar with. If they are not familiar and comfortable, then you may want to move forward and look for a specialist, someone who is a cosmetic and reconstructive oculofacial/oculoplastic surgeon who specializes in the eyelids. In my practice in Manhattan and Long Island, we focus in these particular areas, so we do a lot of fairly routinely. In addition to experience, we also use a lot of advanced wound healing technologies such as t extracellular matrix and platelet-rich plasma (PRP). Basically, the systems are in place so we get consistent outcomes. I think this is a kind of situation where you don’t have that many more options in first level repair. Discuss this with your doctor, and if your doctor is not comfortable, look for additional information by consulting with a specialist. I hope that was helpful, I wish you the best of luck and thank you for your question!


New York Oculoplastic Surgeon
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