Custom Infraorbital-Malar Implants for Reducing Scleral Show and Correcting A Negative Canthal Tilt

Q: Dr. Eppley, I am interested in custom infraorbital rim-malar implants and canthopexy to correct negative canthal tilt to a slightly positive one whilst reducing my slight amount of sclera show)

I just was wondering if I could see this simulated and how it would realistically. If it looks good to me then i’ll be ready to book the surgery within the next couple of months. 

My only concern is in regard to the eye region. I know you’re a well regarded surgeon but I just simply don’t know if i’d be making a bold decision by going the direction of a non oculoplastic surgeon to work on my eye region in regard to canthoplexy. 

Essentially I just want infraorbital rim implants to get rid of my tear troughs in sync with the mid face implant to enhance the zygomatic region for aesthetic purposes. I don’t mind it being fairly conservative and nothing too crazy. 

Also in regard to the eye region I have negative canthil tilt and droopy eyes but i’m not sure if they’re as a result of the lateral canthus. In an ideal world I slightly reduce the amount of sclera show I have to make them slightly deeper set whilst making the tilt go from negative to slightly positive. 

Do you think this sounds feasible and is very possible? Do you think the result will look similar to the morph and do my goals sound realistic?

A:Thank you for your inquiry. In answer to your questions:

1) I have done one front view imaged picture for modest custom infraorbital-zygomatic implants. Whether the lower eyelid would become that smooth is open to speculation but your natural lower eye appearance looks the way it does now because it is volume deficient. The only way to get close to that prediction is to add volume. The custom implant approach is the best method as it increases both vertical height and some horizontal projection of the infraorbital rim as well as blends the augmentation out onto the cheeks.

2) The solution to raising your lower eyelid margin for less scleral show (droopy eyes) is not a canthopexy or a canthoplasty. In my experience a canthopexy is a protective corner of the eye procedure to prevent postoperative sag. A canthoplasty is a procedure to actually raise the level of the corner of the eye. But neither procedure can effectively raise the level of the lower lid margin across the entire lid and, most importantly, at the pupillary level of mid lower eyelid. In short you can’t just pull up the outer corner of the eye and raise the lid margin…that never works in any sustained fashion. It may look like it does on the operative table but not in a healed vertical position later.

3) To raise the level of the lower eyelid margin you have to add support. (build up the lower eyelid and not just try and stretching it)  This can be either a soft approach with an interpositional graft at the middle lamella or a hard tissue approach by raising the level of the entire infraorbital rim. (custom implant) Either method helps drive up the lower eyelid margin and can keep it there in a sustained fashion. 

Dr. Barry Eppley

Indianapolis, Indiana