Concerned About Possibility of Scleral Show After Lower Bleph

Im thinking about to having a lower bleph. I am very concerned about possibility of lower white of eye showing , or eye shape changing. what are the percentages of these undesired results. If they occur, can they be repaired. My goal is to eliminate minimal bags and reduce sagging skin. I also have harsh line in tear trough. My age is 49

Doctor Answers 17

Increased scleral show after lower blepharoplasty- how to avoid and treat

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I believe that the incidence of changes of lower eyelid shape with a conventional lower blepharoplasty is very high indeed.  After all, you are removing skin and fat through a lower eyelid incision.  The lower eyelid is weak and pulls down.  The eyes round subtly or they pull down in the corners.  Even in series of greatly respected surgeons, this phenomenon is noted.

In our practice, we NEVER perform a conventional subciliary blepharoplasty on any patient for this reason.  Rather, we perform an ultrashort incision cheeklift with a simultaneous transconjunctival incision, place grafts as necessary, and simultaneously elevate the cheekpad, reducing the hollowness at the eye cheek junction.

The eyes and brow are considered as a unit, not just individual pieces, to achieve a harmonious rejuvenation.

Rather, we support the lower canthus by elevating the cheekpad, decompressing the strain and downward vector on  the lower eyelid.  This does enable removal of skin from below the eyelid without changing eye shape... and in redo cases allows for an improvement in lower eyelid shape.  We can often restore the beautiful almond eye shape in post-conventional bleph patients.

I would disagree with the view that therefore a transconjunctival approach is recommended for all patients.  While the transconjunctival approach is better for strictly removing fat, it does nothing to reposition the cheekpad, does nothing to help the nasojugal groove and tear trough area, and does not address the hollowness that happens with large fat removal.

It is difficult but possible to perform fat repositioning procedures through a transconjunctival approach.  Fat repositioning, in my opinion, is overrated because of the tendency of the fat to retract back into its pre-surgical position, and patients wonder why their bulges are coming back.  We prefer instead to remove the fat transconjunctivally, and then replace lost volume with precisely placed fat-fascial grafts (LiveFill) at the eye-cheek junction.

That was a very long answer to a simple question.  Yes, you should be concerned about scleral show unless you are having a procedure that supports the lower eyelid, and not just with a canthopexy, but with a minimal incision cheeklift.

Below are referenced several articles and textbook chapters we have written on this subject.

Beverly Hills Plastic Surgeon
4.9 out of 5 stars 188 reviews

Fat grafting will help the tear trough and reduce scleral show

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Scleral show is a very challening risk which requires both having skill, experience, and luck! Never the less, in most people scleral show can be temporary.

In my experience fat grafting to the lower eyelid and the tear trough helps to build up lower eyelid support and reduces the incidence of scleral show.

Eyelid, blepharoplasty,tear trough

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It sounds like you are a good candidate. If you wanted to definitely avoid those problems you could have a "scarless" blepharoplasty but that would only remove the fat and do nothing to tighten the skin. The chances of the things you mention are usually small depending on the surgeon. Watch my videos.

Risk of scleral show after lower blepharoplasty

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Using the transconjunctival approach where the lower lid fat is removed from the inside of the eyelid significantly minimizes any risks of scleral show. If there is any extra skin that needs to be removed, a very conservative pinch at the lash line on the outside can be done. The transconjunctival approach with or without the pinch technique will minimize the risk for any scleral show. Scleral show typically occurs when the muscle is violated during a traditional blepharoplasty procedure. When approached from the transconjunctival approach with a pinch this is avoided.  

Scleral Show is the Sign of an Inferior Result From Eyelid Tuck

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'Scleral show' occurs when lower eyelids have been treated with traditional lower eyelid surgery, often seen with 'lateral bowing'.  What does that all mean?  When the eyelid has been operated on with traditional techniques, the following results are common: The lower eyelid was smoother, but the lid no longer covers the lower part of the iris (the colored  part around the pupil), and the shape of the edge of the lower lid is altered so that the lower lid dips downward towards the outer corner of the eye.  The first part, where more of the 'whites of the eye' could be seen is called 'scleral show', and the second part where the outer part of the lower lid bowed downwards is called lateral bowing.

 These problems are best prevented in the first operation by not damaging the essential supporting layers of the lower eyelid.  The best techniques, in my opinion, avoid cutting through all the supporting layers of the lower eyelid.  It is best to redistribute the fat from the lower eyelid rather than cutting it out, and it is best to remove minimal or no skin separately while increasing the support of the lower eyelid at the same time.  These problems can be fixed, depending on how badly damaged the supporting structures are, but it is much easier just avoiding the whole problem in the first place.  Go to an experienced boarded plastic or oculoplastic surgeon and ask about transconjunctival surgery and canthopexy (altering the fat from the inside of the eyelid, and supporting the lower eyelid).

Claudio DeLorenzi MD FRCS

Claudio DeLorenzi, MD
Toronto Plastic Surgeon

Scleral show following blepharoplasty

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This is certainly a valid concern, and the possibility of this depends on two factors:  You and your surgeon.  if your eyelid has good elasticity, the possibility of scleral show is less common.  If you have a define tear trough, fat repositioning or fillers may correct this.  Check surgeon credentials and before and after pictures.  Good luck!  Performing a lower blepharoplasty is like walking a tight rope.  If too little skin is excised, a less favorable outcome will result.  If too much skin is excised or internal scarring occurs, scleral show will result.  It is a difficult problem to fix, so base your surgeon choice on reviews, personal referral, prior results, credentials, etc.

Good luck!!

Jason Hess, MD
San Diego Plastic Surgeon

Lower eyelid cosmetic surgery

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The statistics for scleral show and other complications are technique and surgeon dependent.  Look at your surgeon's "before and after" results upon other patients.  Do not proceed unless you like the results, and trust the surgeon.  Frankly present your concerns to your surgeon.  He or she should want the best result for you, and should be willing to revise the eyelid result if problems develop.  Find out how often he or she needs to perform these revisions.  Minor post-blepharoplasty revisions are common even in the best and most experienced surgeon's hands.  The problems are usually straightforward, and not difficult to correct.  The final result, in my practice, is well worth any required revision, and if eyelid shape is changed, it is generally improved.

PROMO Concerned About Possibility of Scleral Show After Lower Bleph

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I would really need to see photos to give you the best advice regarding any surgical procedures. Please feel free to send any photos to my office and I would be happy to evaluate them for you. I have a great deal of experience performing blepharoplasty, and other surgery to the area around the eyes, and would be happy to answer any questions you may have. My contact information is listed in my profile. Thank you, and best of luck to you.

Dr. Nassif

Paul S. Nassif, MD
Beverly Hills Facial Plastic Surgeon
4.7 out of 5 stars 49 reviews

Pitfalls of Lower Bleph

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Shape change and scleral show can occur with any form of lower eyelid surgery. Prevention is much easier than correction. The tear trough groove can be hidden by using the fat that is bulging at the time of the eyelid surgery. It is possible that a chemical peel or laser procedure is all that is needed if the laxity is only minimal. A formal evaluation would be necessary to answer all of your questions properly. I hope this helps. 

Avoiding scleral show is easier than treating it

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I am not aware of any specific statstics regarding scleral show after lower blepharoplasty as there are several differant techniques used and several variables.  This much is true; scleral show can happen to even the most experianced plastic surgeon after the most perfectly done operation.  To decrease the risk your surgeon should carefully examine lower lid "snap back", your individual anatomy to see if you are prone to drooping lids after surgery and obviously be meticulous in surgical technique.  After surgery I use several methods to keep the lower eyelid elevated during the period when it is heavy due to swelling and the area of surgery is healing and tightening and tending to pull the lid down.  These methods include tapeing the lower lid upward and differant suturing techniques to keep the lower lid up till the swelling is out of the lids and patient involvement with upward lower lid stretching excersizes to keep the lower lid supple.  This is very successful in preventing this problem.  The sagging skin can be improved with a conservative skin resection, realizing the more skin you resect from the lower lid the more downward pull there is.  Tear troughs can be repair with either fillers or fat grafting.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.