Tightening the Outer Corners of the Eyes with Blepharoplasty?

Question

I am planning to have a face lift with both upper and lower blepaharoplasty.  I have dry eyes which I am concerned with that may have been a result of a previous blepharoplasty. My eyes are big and they also somewhat pretrude slightly, but are not unsightly. My surgeon says that he can tighten the outer corners of my eyes during the blepharoplasty to prevent futher dryness.  Is this possible, and if so, will I look different?

Brent Moelleken, MD · Answer

The eye shape can and should be addressed when a lower blepharoplasty is performed.
Often, the problem occurs during a first blepharoplasty, when skin is removed from the lower eyelid.  This causes pulling down of the eyelid and rounding of the eye.  In some patients, theyr eyeball (globe) is prominent, and protrudes out of the bony socket.  Both of these conditions can cause dry eye by too much rounding of the eye and too much exposure of the very sensitive cornea, the lining of the eyeball.
When the corners of the eye are corrected, a canthopexy or canthoplasty can be performed.  In our practice, we almost always combine this with a cheeklift (LUSIC cheeklift), in order to "give" tissue to the lower eyelid so that can then be used to be reconstruct the corner of the eye.
The eye can change in shape, almost always for the better.  Most patients prefer the unoperated appearance of an almond shaped eye to the rounded, operated appearing eye.
The lower eyelid is one of the trickiest areas in all of plastic surgery, and the patient should do their research carefully before undertaking the procedure.  The highest incidence of unfavorable results in all of eyelid surgery occurs in patients with prominent globes.
There are several publications on this topic on our website drbrent.com for patients interested in the fine details.

Raffy Karamanoukian, MD, FACS · Answer

A blepharoplasty procedure can be performed successfully during a facelift procedure.
In the case of a patient with dry eyes, a plastic surgeon should be cautious of exacerbating the dry eyes by revisional surgery on the upper or lower eyelid.  A thorough analysis of the causes of dry eyes is appropriate, with examination of the cornea, tear output, and lacrimal gland function.
A canthoplasty can also be performed during a blepharoplasty procedure to tighten the lower eyelid to prevent further exposure of the lower eyelid. However, this will help based on the identification of the causes of the dry eyes.
In your case, I would perform a complete eye examination and also have a referral to a corneal specialist who would examine the lacrimal gland function.  These tests, in addition to an anatomic examination will allow a thorough plan to minimize further injury to your eyes.

Steven H. Williams, MD · Answer

Thanks for your questions Page -
In my practice, we perform upper and lower blepharoplasty, and a careful history about dry eye must be obtained.  The issue is that blepharoplasty can make eye dryness worse and interfere with your ability to protect your eyes, causing complications that can be as serious as blindness.
The fact that you note you have some prominent globes increases possible complications.
For patients with multiple risk factors, we typically employ several tests to determine the severity of your issues. These tests look at the anatomy and elasticity of your lids, your ability to protect your cornea, and the quality of the lubrication of your eyes.
It sounds like your surgeon has recommended a canthopexy to tighten your lower lid.  This can help with some of these problems.  The cathopexy can have an impact on cosmetic result, but when done properly, this can be part of improving the overall look.
Proceed with caution and make sure to discuss these issues in depth with your surgeon.
Be sure to be dealing with a board certified plastic surgeon in this situation.
I hope this helps!

David Shafer, MD, FACS · Answer

Page,
It sounds like your surgeon is planning to perform a canthopexy or a canthoplasty.  In either case, the lateral canthus (corner of the eye) is tightened.  This is often performed during blepharoplasty to tighten up the lower lid.  It can change the angle of the eye, but this is dependent on the level at which your surgeon secures the corner stitch.  Just talk with your surgeon beforehand to make sure you are both on the same page.  Good luck with your surgery.

William Portuese, MD · Answer

Before undergoing a canthoplasty or canthopexy to reduce dry eyes, one should check with their ophthalmologist about placing silicone plugs in the tear ducts to gain more tears in the eye itself. Other eye drops prescribed by an ophthalmologist can help with dry eyes. Tightening the corners of the eyes will change the shape of the eyes to more of an almond shape, which may help a little bit with the dryness. Your eyes will look different, especially for the first month.

Steven Wallach, MD · Answer

Dry eye syndrome after a previous blepahroplasty is not uncommon, especially if you sleep with your eyes partially open at night. I think your surgeon is talking about a canthopexy or canthoplasty when describing tightening the corner of your eye. This can help symptoms in some patients that have laxity laterally and have too much scleral show. If your eyes don't completely close, then this won't correct the problem completely. Because your eyes are prominent, the canthopexy/canthoplasty may not help.

Jeffrey Zwiren, MD · Answer

I would not be so concerned about appearance of the lower eyelid as I would with the function of the lid itself and protection of your eye. There are many points of caution for your to consider. 1. this is a repeat surgery, there may already be problems with your lower eyelid function since you continue to have dry eyes. 2. You should be evaluated by an ophthalmologist as to your existing tearing function. A 4 lid blepharoplasty will, at least temporarily, effect the dryness of your eyes. This coupled with your existing problem will make it much worse unless prevented and addressed before surgery. 3. If there is some pre-existing bulging of your eyelids some consideration should be made to your thyroid function. Bulging of the globe will effect the lower lid position. This will change the location for the placement of your canthopexy or canthoplasty. I hope that your procedure goes well

Kenneth R. Francis, MD, FACS · Answer

Page,
Your situation is a very complex one, in which your dry eye syndrome may be worsened if the wrong procedure is done and may be improved if the correct procedure is performed.  It sounds as if your surgeon is familiar with the issues that your present eye condition creates. 
However, the terminology of a repeat lower blepharoplasty concerns me.  He may be using that term as a generic for your real requirement of lower lid repositioning.  Be sure he/she is a board certified plastic surgeon. 
Sometimes just a tightening of the lower eyelid across a prominent globe (eyeball) causes a clothesline effect and further exposure of the cornea.  So the condition usually requires a cheek or mid face lift to provide structural support to the lower eyelid. 
If this is the plan, then you are right on course.  Good luck!

Roger P. Friedenthal, MD · Answer

Your problem is actually quite common. With time, the attachment of the lower eyelid to the bony rim of the eye laterally stretches, particularly if your eyes protrude slightly. This stretching changes your eye shape from almond to round. Tightening the attachment can restore the shape. The procedure is called a canthopexy. When a patient's eyes protrude somewhat, the early shape after surgery shows a steeper slope than will finally be present, so some patient is called for while this settles down. You should ultimately look different to some extent from how you do now, but in the direction of how you used to look. I hope this helps.

Robin T.W. Yuan, MD · Answer

Your surgeon must evaluate your orbital anatomy very careful. While in general tightening the lower eyelids (i.e. canthopexy or canthoplasty) is designed to prevent ectropion or scar contracture of the lower lid that may result in corneal exposure, it will usually produce a more upward slanted look (i.e. exotic, Asian, cat-like, etc.) and can also make things worse if you have what is known as a negative vector alignment. Here, the tightening can cause the lid margin to slip lower under the eyeball and may make the exposure (i.e. dry eye) problem worse and your appearance more "bug-eyed".

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