Thank you for your question.
You state in your question, which you did not submit a photo, however you describe the
details of your concerns regarding your lower eyelids.
You state that you had lower eyelid cosmetic surgery and you dealt with an issue where
the eyelid was away or the canthus, the corner of the eye, was away from the eyeball and
that you underwent a procedure called lateral canthopexy.
And further along, you also described that the canthopexy did not seem to change or improve
the situation.
And in addition, you feel like the eyelid is lower and the lower eyelid is longer.
So again, in the absence of a photo, certainly there are some limits of what I can describe
in terms of my approach but I can tell you, I am very familiar with the type of situation
you are in.
A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial
plastic and reconstructive surgeon.
I’ve been in practice in Manhattan and Long Island for over 20 years and one of the areas
of specialty, which I have in my practice, is the revision of complications of cosmetic
eyelid surgery.
In fact, we take care of situations like yours in our practice for patients who come to us
from all over the world.
So to essentially understand what your issue is as well as why perhaps the most recent
procedure did not work as expected, I am just going to give you a little bit of understanding
of the terminology and the principles that guide on how I approach this problem.
To begin with, when you had lower eyelid blepharoplasty, it seems likely, from your description and
from my experience, that you had blepharoplasty or lower eyelid surgery done from the outside
of the eyelid.
And subsequently, in the healing process, your eyelid pulled away from the eye.
Well, we refer to that as ectropion which means the margin of the eyelid is away from
the eyeball.
Now beyond that, you feel like your lower eyelid is lower.
The terminology for that is lower eyelid retraction.
And in terms of the description of the eyelid being longer, I suspect what you are seeing
is more of the white or what we refer as scleral show and can certainly make the eyelid appear
longer but I would say that it is more typical that the horizontal width of the eyelid actually
becomes shorter.
Now as far as the principles, the guiding principles of how to address this problem,
we have to deal with just basic simple anatomy.
Simple but in a way the lower eyelid is much more complex in the way the lower eyelid support
is critical and balanced.
There are 3 elements that are important: one is the connection of the lower eyelid to the
bone called the lateral canthal tendon.
It is a suspension part of a suspension bridge.
The next part is the front of the eyelid which is the skin or the orbicularis or the anterior
lamella.
Then another part is the posterior lamella which represents the lower eyelid retractor
of the conjunctiva and the orbital septum.
The orbital septum is sometimes referred to as the middle lamella.
Now there is a lot of terminology but the point is that when I do a revision for lower
eyelid surgery, these elements have to be assessed – are they intact or do they need
repair.
A lot of times people do some type of a shortcut procedure or make a best effort at doing what
they feel are an issue.
So in the lateral canthopexy, basically one element may have been addressed which is the
lateral canthal tendon or the suspension of the eyelid.
Typically, in my experience, the problem is there is inadequate support from behind the
eyelid.
And if you think about the supporting structure of the lower eyelid is like pillars and when
surgery is done and this area is not addressed to maintain support or the healing of that
support is compromised, so the pillars collapse and my job as a revision surgeon is to restore
that anatomy.
So we will place grafts in the inside of the eyelid and then if there is a skin shortage
in the front, so we place skin grafts in front of the eyelid.
A lot of times the doctor who did the cosmetic eyelid surgery may not be as comfortable with
these procedures and will try to do something as a “shortcut“ whether it is a lateral
canthopexy or lateral canthoplasty and sometimes it can be beneficial enough.
Ultimately, you have to be happy with the final result.
But it has been my experience that people will go through anywhere from 1 to 7 or more
operations before they find an alternative which is more involved in the short-term but
will provide long-term benefit.
So at this point, I think it is very important for you to understand that there are options
but you’ll have to discuss with your surgeon what would be the next step.
I think it is still important to maintain this communication with the original surgeon
and see if there are options such as the one I described that they are familiar with.
If they are not familiar and comfortable then you may want to move forward and look for
a specialist, someone who is a cosmetic and reconstructive oculofacial plastic surgeon.
In my practice in Manhattan and Long Island, we focus in these particular areas and we
do a lot of this so this becomes something that we do fairly routinely.
And I think it is important that experience and in addition we use a lot of advanced wound
healing technologies such as the use of extracellular matrix and platelet-rich plasma (PRP).
Basically, the systems are in place so that we are able to get consistent outcomes.
I think this is a kind of situation where you don’t have that many more options in
terms of the limitations of traditional first level repair.
Now, discuss this with your doctor and if your doctor is not comfortable, look for additional
information by doing consultations with a specialist.
So I hope that was helpful, I wish you the best of luck and thank you for your question!