Mid Face Lift and Scleral Show? (photo)

Lower eyelid position abnormalities are very difficult to correct. Regrettably they are occasionally seen with a mid facelift that is performed predominantly through the lower lid. More likely you have another operation in your future.

Thanks for the question. Well you have significant scleral show. Depending on the cause it my be correctable with just tightening the lower lid. However I expect you may require this to be combined with a midface lift to correct the scleral show. It not possible to be more accurate without further photos. I suggest you seek several opinions from BC PS or FPS.

Thanks for the picture.  The addition of a profile picture can add powerful information to your question and subsequent answer. A thorough exam of the face is needed. A tightening of the lower eyelid with modest volume replacement of your cheeks with fat would work very well.  Seek several consultations with a BC PS or FPS.

Dr. ES

Whatever you do, do not get malar implants. They have a very high incidence of complications and dissatisfaction and usually make scleral show worse, not better.

Very good question. I agree with you in that you have scleral show and weak support of your lower eyelids. There are several different midface techniques out there and unless your surgeon chooses a technique that increases volume in the midface, you will run the risk of it not working. Cheek implants are an excellent idea for giving you long term stable improvement. Fat grafting and Sculptra could also help (though not as powerful as implants) as a non-surgical option. Take you time and get several opinions before you dive in. Good luck.

Every person has different eyelid and facial anatomy, depending in gene and ethnicity.  In some ethnicity, it is ok to have bigger eyes and mild scleral show. But change (or worsening of the scleral show) is not normal. It can be related to relative bulgy eyes or lower eyelid laxity (besides secondary to previous surgeries). There is are various nonsurgical and surgical options available, depending on the reason behind the scleral show and the goals of the patient. See an oculoplastic surgeon.

Hi there,

You represent a complex problem, and it is just not appropriate to recommend surgical solutions in this forum.

You need expert assessment, a diagnosis then a rational treatment plan.

Your lower lid problem is evident, but is it due to mid face hypoplasia, thyroid eye disease, floppy lid syndrome, a congenital muscle dystrophy or is an appearance you have simply inherited?

I see that you're from San Francisco.  May I recommend that you consider consulting Dr Bryant Toth, who is an expert craniofacial and facial aesthetic surgeon in San Francisco? He will be able to advise you.  There are other superb plastic surgeons in San Francisco as well, some on this site.  Start by seeing one of them. Be careful.  Your situation is not necessarily an easy one to treat.

All the very best.

Dear embarassed,

    Thanks for submitting your picture. Your picture reveals round lower eyelids, significant scleral show, tear trough hollowness amd naso labial folds. The most powerful procedure for you is partial MACS lift. This procedure will lift the folds, fill up the hollowness and support the lower eyelids. Due to the significant scleral show and roundedness  of the lower eyelids , you will benefit from lateral canthopexy. Consult with a board certified plastic surgeon who performs alot of MACS lift surgery.

                   Best of luck,

                                                 Dr Widder

Thanks for the question and photo. We can address your areas of interest one by one:

Midface Descent: There are several options for improvement of the midface, both surgical and nonsurgical. Starting with the nonsurgical options, you could use fillers such as Radiesse, Juvederm Ultra Plus, Perlane and Sculptra to restore volume to the cheeks. Each has unique features including duration of results, ability to be dissolved, cost etc. In my practice, I perform all filler treatments personally. The first surgical option would be fat transfer, which involves liposuction of fat from the abdomen, flanks, thighs or buttocks and injection of this fat in the face. Another option would be a midface lift, as you had mentioned. This is done through two small incisions per side, one behind the hairline in the temple and the other inside the upper lip. The cheek is then suspended upwards with a endotine, a device which dissolves on its own. The third option would be the placement of cheek implants, as you had mentioned as well. An in-person consultation option would be useful to decide which would be most appropriate for you.

Tear troughs: Tear troughs form as the result of fat pooching forward from around the eye, what's called pseudoherniation, as the fibrous septum that holds this fat back grows weaker over time. As the cheek descends, a hollow is formed between the bag and the cheek, what's called the tear trough. There are two excellent options for correction. The nonsurgical option would be the placement of Restylane, a hyaluronic acid gel which is injected in the tear troughs with a couple of injections per side. This filler serves to hide the under eye bags and smooth the transition between the lower eyelids and the cheeks. Restylane can last up to 2 years when used in this area, according to a recent study. The other option is lower blepharoplasty with fat repositioning. I perform this surgery through a tiny incision inside the lower eye lid, through which the fat is repositioned downward, to fill the tear trough.

Scleral Show: Scleral show (excessive show of the white part of the eye) can occur naturally, after trauma, or after prior lower eyelid surgery. Tightening the lower eyelid with a lateral canthopexy could be an option, if you do happen to have a lax lower eyelid. Again, an in-person consultation would be helpful to determine the best course of action. 

Best regards,

Dr. Mehta

       An exam will be necessary to assess laxity of the tissues along with laxity and mobility of the lower eyelids.  The things you mentioned may be appropriate as well as fat grafting and variations thereof.  Kenneth Hughes, MD Los Angeles, CA