Scleral Show with NEGATIVE Vector, Longevity of Canthopexy/Plasty? (photo)

Afternoon, I agree with some of the other surgeons that they canthopexy or canthoplasty alone will not address your issue and could make it worse. You do need to augment your midface and your Orbital rim while lengthening the overall height of the lower eyelid with the canthoplasty and a release of the lower eyelid retractors Followed by a mucosal graft on the posterior side of your eyelid.

I hope that was helpful

It is admirable that your surgeon has made note of the negative vector alignment. This is an important anatomical observation that is often missed with detrimental consequences. Since the negative vector general indicates a lack of inferior skeletal support to the lid and globe, not a laxity of the lid itself, the solution would begin with increasing that support, probably most effectively with some sort of malar implant. Whether or not there is additional vertical lid deficiency should be determine by further examination.

Robin T.W. Yuan, M.D.

     You do not appear to have any significant euryblepharon, as your eyelids appear to rest against your globes.  I would hold on the midface lift at this time.  Canthopexy or canthoplasty would likely give significant improvement in scleral show and vector.  I am not sure that you need a palatal mucosal graft either.  However, I do not have the benefit of an exam.  Bone anchoring canthoplasty has good longevity.

I understand that you’re not happy with your eyes and you want to do something about it. I can say to you that there a more than a few ways to address this anatomic feature. In my practice, I don’t operate on people your age unless there’s a clear medical indication. The majority of my patients with this type of problem have age-related issues or have this appearance as a consequence of eyelid surgery done elsewhere. They come to us because their eyelids are retracted.

Lower eyelid position is a function of the anatomy of the bone structure, which also includes the prominence of the eyes and the soft tissue structure of the eyelid itself. If a patient with negative vector is in their forties or fifties, it's likely about lifting the lower eyelid. This is done by providing additional support in the corner called the lateral canthus, involving a procedure called canthoplasty or canthopexy. This procedure consists of a stitch placed to reinforce the corner, and if we use drill holes it's called a drill hole canthopexy.

As far as vertical support is concerned, I used to do hard palate grafts many years ago. The Madam Butterfly procedure was popular in the oculoplastic community in the late 90’s and early 2000’s. Currently, my preferred materials include hard palate and also a material called Enduragen. These materials will provide vertical support so that the eyelid is supported like pillars in a column.

In your case, it is a fairly extensive amount of surgery. I didn’t address the cheek lifting issue because even in patients who have a consequence of cosmetic eyelid surgery, lifting the cheek vertically may be successful at the time of surgery. In the long term, my observation is it tends to descend a little bit and may cause more retraction. Because of this, I will sometimes combine the lower eyelid retraction repair with a face lifting procedure even a cheek augmentation with malar implants or sub-malar implants or combined implants.

I would caution that whatever you decide, your face will still mature. This procedure will be something that’s hard to undo. In my perspective, I would think more about this and learn some other options. I would probably advice you to defer this type of procedure until you’re a little bit older. I hope this was helpful and thank you for your question.

The photograph demonstrates scleral show between the iris in the lower lid. It appears that this is an aesthetic issue only. It might become functional if any operation is poorly executed or affected by unfortunate wound healing. I would advise you against any surgery.

Common misconception among inexperienced eyelid surgeons.  Canthoplasty and pexy is used to address lax lower eyelids. That is not why your eyelids ride low on your globes.  Shortening and tightening the lower eyelids will actually cause the lower eyelids to ride even lower on the eyes-the lower eyelids follow a geodesic on the globe surface.  The madame butterfly procedure uses a spacer graft to lengthen the lower eyelid from the back of the eyelid.  This procedure is done in conjunction with a lateral canthoplasty which is necessary to reconstruct the eyelid after using a canthotomy and inferior cantholysis (so called swinging eyelid approach) to gain access to the lower eyelid retractors.  The problem with this approach is that it only addressed lower eyelid position.  It does not also correct the mid face deficiencies unless performed with some type of midface procedures.  I have developed a surgery the addresses this issue by placing a hand carved ePTFE orbital rim implant and then using a hard palate graft in the lid.  The canthal angle is then repositioned using the lateral canthoplasty.  This comprehensive addressed the lower eyelid and the cheek.