Your Questions
Your Questions
Q: Dr. Eppley, I’m trying to find out more about lateral epicanthoplasty, could you help me find more information about this before I take this procedure?
A: Unlike the better known medial epicanthoplasty, a lateral epicanthoplasty procedure also exists.The epicanthoplasty procedures can elongate the length of the eyes, increase the eye size, and improve the aesthetic results of double-eyelid surgery. In addition to focusing on the fold at the inner eye (medial epicanthoplasty), the lateral procedure also addresses the outer portion of the eye. Lateral epicanthoplasty is done to lengthen the eye and correct a slant that makes an eye appear droopy or tired. The most common misconception about lateral epicanthoplasty is that it is like its medial cousin when in fact it is not. The medial epicanthoplasty is about correcting the overhanging skin fold. The lateral epicanthoplasty, more accurately called a lateral canthoplasty, changes the position of the corner of the eye and is not an external skin removal procedure. It does require small skin incision to do but its objective is to elevate the outer corner of the eye by tightening the lateral canthal tendon. In short, a lateral epicanthopasty is not a unique procedure but is the well known lateral cantoplasty procedure which has been around for decades. In many cases it is not even a true lateral canthoplasty but is really a lateral canthopexy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I reached out to you last year regarding a consult for reconstructive facial surgery following an ATV accident several years ago. Since I have had several reconstructions and am now looking to improve my overall appearance and have reached out to you because of your experience in both aesthetic and reconstructive plastic surgery. Your name was also mentioned in a report by Advance Medical as an expert in this area.
At the time, you had requested a CT scan of the face, which I did not have–but now have one. I have attached photos, 3D reconstructed CT scan, and a brief medical history for your review. The goals of surgery are:
– Improve symmetry of the face, especially involving the eye. This includes the buldging of the eye ball itself, and position of the lid. I fully realize that a full restoration of symmetry is not possible and that surgery on the opposite eye may be necessary to get the most aesthetically pleasing result.
– Reduce the appearance of the port wine stain on the left side of face, near the eye
– Reduce the appearance of the scar on left cheek
– Improve overall appearance, ie. what procedures could be done in combination to ENHANCE overall appearance. Would a strong chin/jaw divert attention from eyes? Would other facial implants help? Would removing the nose bump? (This is why I value your experience in aesthetic plastic surgery)
I know you are very busy and I appreciate you taking a preliminary look at this case for consult.
A: Thank you for sending your pictures and 3D CT scans. What they show is that despite an excellent anatomic reduction of the fractured zygomatico-orbital bones (and an infraorbital-malar implant) your face is not normalied. The problem now, and is a quite common one after facial trauma and multiple reconstructive surgeries, is that the original injured tissues have become ‘skeletonized’. There has been loss of subcutaneous fat with scar tissue that has caused lower eyelid scar contraction as well as the lower facial scar prominence. I think that the left eye does not really bulge but that the lower eyelid is vertically short and contracted, exposing more sclera in that eye.
From a reconstructive standpoint focusing on the original injured tissues, I would recommend the following:
- Lower Eyelid Reconstruction with Dermal-fat Graft and Lateral Canthoplasty (your prior canthopexy was insufficient)
- Left Geometric Facial Scar Revision (your prior laser resurfacing probably made little difference)
- Injection Fat Grafting to Left Cheek and Infraorbital areas (the tissues don’t need suspending, they need more volume.
From an aesthetic standpoint, I would need more pictures for better assessment for both rhinoplasty and jawline enhancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in eye reshaping surgery. I am 26 years old and interested to have slanted/exotic/cat eyes. I’m not sure if canthoplasty alone will achieve my goals.
I don’t know if canthoplasty alone or canthoplasty combined with a cheek lift would work better. Will the canthoplasty and/or cheek lift fail in the short run due to gravity? such as lasting no more than a few months?
A: Changing one’s eyes to a look that is more ‘exotic’ almost always means the lateral canthus (corner of the eye) needs to be elevated and be substantially higher than the inner corner. (hence the out to inner ward downward slant. Certainly the basis of doing requires a canthoplasty procedure of which the most secure would be what is known as a drill hole lateral canthoplasty which can really pull up and maintain a new lateral canthal position. This would be far more effective and secure than a canthopexy or even a standard lateral canthoplasty procedure where the tendons is sewn onto itself or to the periosteum of the inner orbital wall. Whether that would be enough depends on the tightness of your lower eyelid and the cheek skin which can really only be determined by a physical examination. The concept of a cheek lift is a supportive one to the corner of eye and/or providing more of an upward and outer sweep to the cheek and outer eye area. At your young age it would seem a cheek lift would most likely be excessive.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 22 years old. My question is in regards to my face which is crooked. It does not have the best shape. The right side of my face is not equal with the left side. (see attached picture) Because my face does not look good, I have no confidence. Please suggest to me what I am supposed to do.Your advise is highly appreciated.
A: Your picture shows that you have significant facial asymmetry. The left side of your face shows hemifacial hypoplasia (hemifacial microsomia) as demonstrated by significant left chin deviation, a flattened left cheek and an inferiorly positioned (low) left eye and eyebrow. There are a variety of facial plastic surgery procedures that can help improve your facial asymmetry. Beginning from the bottom of your face and working up, the chin can be brought back to the facial midline by a sliding genioplasty, the left cheek built up by an implant, the eye raised up by an orbital floor implant with repositioning of the left canthus (corner of the eye) and the lower brow lifted by an endoscopic browlift. While all of them done together will produce the best degree of facial symmetry improvement, treatment of the chin and cheek asymmetries are the most important as well as the most improveable of the facial deficiences.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get a new shape to my eye that is more narrow and uplifted. I have attached a picture of the kind of eye look that I would like. I was able to create that look by using elastic bands attached to tapes as was seen in a video on Youtube to create an instant ‘facelift’.
A: Thank you for sending your pictures. What you are illustrating I would consider an extreme lateral eye reshaping result which I am not sure can come completely from a lateral canthoplasty alone. I know you were using tapes that pulled the corner of the eye AND the skin around it so it made a very artificial and not surgically achieveable look without pulling the temporal skin back with it. That issue aside it does illustrate that a subtle change in the corner of the eye will not be enough for you. The entire lateral canthal tendon will have to be shortened and pulled way back onto (through) the lateral orbital bone to create that much change. While that is possible it is likely to create a skin fold at the corner of the eye that can only be eliminated by combining that with a temporal lift.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, is there a procedure to reposition the lateral canthal area into an uptited eye or narrow eye? If so what is the price range? Thank you.
A: Such an eye reshaping as you have described is one in which the outer corner of the eye is more narrow and slightly longer to the side. This can be achieved by an eyelid procedure known as a lateral canthoplasty. This is a change in the position of the lateral canthal tendon in its attachment to the inside of the lateral wall/rim of the orbital bone. The lateral canthal is usually detached and moved up slightly higher and tighter on the inside of the bone. This will then pull the corner of the eye more laterally, making it more narrow and with a slight upward tilt. This is done an outpatient procedure under anesthesia which takes about an hour to do. My assistant Camille will pass along the cost of the surgery to you tomorrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 19 years old and have developed a problem with my face. It looks crooked and I don’t know why. I saw pictures of me before about 6 years ago and my face wasn’t crooked. So I’m kind of worried about what made it crooked. So can it be fixed?
A: Thank you for sending your pictures. My assessment shows that your facial asymmetry is caused by a left-sided orbito-zygomatic deficiency. This is evident by a slightly lower eyebrow, a small amount of redundant upper eyelid skin, a lower globe (eyeball) position, a lower positioned lower eyelid and a small cheek bone on that side. This is caused by the underlying cheek and eye socket bones (orbito-zygomatic skeleton) being more underdeveloped than the right side. This makes the overlying soft tissues, including the eyeball, are positioned lower than the other side.
While this is a common facial skeletal deformity seen in cheek bone fractures, yours is clearly development and just grew that way. It has probably only become more evident as you are now nearing full facial skeletal development.
The facial asymmetry could be treated by a combination of procedures including a transpalpebral browlift through an upper eyelid incision (to lift the brow), orbital floor augmentation (to push the eyeball up), lateral canthoplasty (to reposition the outer corner of the lower eyelid) and a cheek implant. (to build up the smaller cheek area) I have attached some imaging which shows the predicted effect of those changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to improve the appearance of my eyes. My upper eyelids (just below my brow) have excess skin that hangs down, often pushing against my eyelashes. Also, I would like the canthopexy in order to make my eyes look more feminine. My eyes are very round, showing a significant amount of my sclera, and are angled down slightly at the outer corners.
A: The description of upper lid skin pushing on the eyelashes certainly indicates that an upper blepharoplasty would be needed to recreate an upper lid sulcus again. That is very straightforward and a standard periorbital rejuvenation procedure. Changing the position of the lateral canthus at the corners of the eyes can be done at the same time as the upper blepharoplasty. This is better known as a lateral canthoplasty as opposed to a canthopexy. In a canthopexy procedure the existing tendon is tightened by maintains its current position on the inner aspect of the lateral orbital wall. As a result, it tightens the lid margins but will not change their vertical orientation. Thus a lateral canthopexy will not correct a downward eye slant. A lateral canthoplasty, which relocates the insertion of the lateral canthal tendon up into a higher position on the bone is what you actually need to achieve your eyelid reshaping goals. That is done through the tail end of the upper blepharoplasty incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is there a such thing as tarsal strip revision? I am also concerned with how this surgery has left me with small and round eyes. Is tarsal surgery permanent? Is there a surgery that can reverse this? Have you performed revision tarsal strip surgeries in the past, or is this an unusual circumstance?
A:Yes there is. Tarsal strip procedures are generally done in an effort to tighten/raise the corner of the eyes, for a variety of medical and cosmetic reasons. Revisions of this procedure may be needed when it is not entirely successful, such as inadequate tightening/lid positioning or widened scars in the corners of the eyes.When the corners of the eyes are tightened, the lateral aperture of the eye (where the upper and lower eyelids meet) can become less sharp and more blunted. This can very well create the appearance of a smaller and more rounded eye. Once a tarsal strip lateral canthoplasty has healed, it will be permanent. A revision can be performed to open up or change the amount of aperture closure although they are not always successful. But a milllimeter or two of aperture change may be aesthetically beneficial.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Can my eyes be made more narrow with an outer tilt to them? How is that done and what is the downtime to do it?
A: One’s eye shape can usually be changed. Depending on your anatomy, that change can be very subtle or more obvious. The first thing I like to know is exactly what a patient’s means when they say ‘more narrow with an outer tilt’. I know what it means to me as a plastic surgeon but I have to be sure what it means to each patient so the changes are what the patient really wanted.
The concept of uptilted eyes, from a plastic surgery perspective, usually means that the outer corner is turned up. In other words, the outer corner of the eye is above the level of the inner corner of the eye. This gives the eyes an inward slant which is often described as being more exotic looking. Giving the eyes such a shape is done commonly with a procedure called a lateral canthoplasty or tendon repositioning. The corners of the eye are held in their position by a tendon that attaches to the bone inside the rim of the eye socket. There is both an inner (medial) tendon and an outer (lateral) tendon. This procedure repositions the lateral canthal tendon at the outer aspect of the eye. By turning up the outer corners this gives the eyes a more upward tilted appearance. Besides some temporary swelling, and some occasional bruising, there are no bandages or restrictions after surgery. The swelling and bruising will go away in a week or two. The result is immediately apparent.
Dr. Barry Eppley
Indianapolis Indiana
