Detached canthi from eyeball: how can this be resolved? (photos)
Doctor Answers 5
The answer is simple: lateral canthoplasty is not powerful enough to repair this.
The lower blepharoplasty damages the motor nerves to the muscle along the edge of the lower eyelid margin that holds the eyelid against the eye. Surgeons attempt to replace this hammock function that is damaged by tightening the lower eyelid. There are several problems with this approach. First weakness of the muscle along the edge of the lower eyelid is not the only problem here. There is also powerful scar caused by lower eyelid surgery that is also pulling down on the eyelid. The lid is tethered to the cheek by this scar. This couples the lower eyelid margin to the weight of the cheek. The lateral canthoplasty is not powerful enough to repair all these issues. The gap is there because your surgeon is not placing the tendon far enough and deep enough to the orbital rim. Even if they managed to accomplish this, it would not correct all of the anatomic problems you have. I have pioneered a definitive approach to these issues by lifting the cheek soft tissue off the top of the cheek bone and placing a hand carved rim implant made of ePTFE (Gore tex). The implant improved the situation by better supporting vertically lifted cheek soft tissue. This recruits skin into the lower eyelid without a skin graft. This also uncouples the weight of the cheek from the lower eyelid. A hard palate graft is sewn into the back of the lower eyelid to control the shape of the lower eyelid. Then the lower eyelid is then resuspended to the orbital rim. All of this work is performed through a small incision at the lateral canthus and behind the eyelid. I have helped almost 1000 people with this surgery. There are more details on my website and in my free ebook on eyelid surgery cited below.
Full canthoplasty and skin graft
You may need canthoplasty and canthopexy plus anterior lamella (skin) augmentation with a skin graft if things haven't improved after the canthopexy. You darn sure can't take any more skin. Look into full reconstruction with a skin graft. In LA area Guy Massry MD is excellent.
From the photographs, you have notable lateral retraction and inferior displacement of the lateral lower eyelid. It is unclear what the etiology is from the photograph - unlikely to be due to lateral laxity and more likely related to scarring, but you would need a thorough assessment of the lateral canthal angle and lower eyelid to determine the best course of action. I would suggest seeing an oculoplastic specialist if you have not already.
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Retracted lower eyelid/ectropion
After a previous blepharoplasty, retraction and separation of the lid from the eyeball itself can result from any combination of the following factors:
1, too much skin removed
2. Scarring in the middle / inner layer of the eyelid
3. Scarring on the back of the eyelid. Swelling and weakenef muscle tone can also contribute to a lingering retraction and separation of the eyelid from the globe.
If enough time has passed and conservative measures have been exhausted, a surgery to address these problems needs to be performed including any combination of the following. A mid facelift to bring up extra skin into the lower eyelid, repositioning of the lateral angle of the eyelid so that it is sewn closer to the eyeball and inside the outer/lateral bony orbital rim and possible placement of a graft on the inner lining of the lower eyelid to add for the support.