What Can Be Done To Lift Up My Sagging Lower Eyelid And Improve My Scleral Show?

Q: Dr. Eppley, I got combined medpor orbital/cheek rim implant(with midface lift) and canthoplasty last year. The orbital rim and canthoplasty was supposed to fix my scleral show and negative vector. I still have the scleral show. I am not sure why. I am not sure if I still have negative vector. I like to get scleral show fixed. Can you tell me if you can fix the scleral show and what do you propose?

A: While there was aesthetic benefit to the concept of infra-orbital rim/cheek implants, they alone are not sufficient to ‘ drive up’ the horizontal level of the eyelid. To do so they would have to be extremely large and highly disproportionate to your face. It is a flawed concept that you can push from below and think that the lower eyelid will be pushed up. Such implants are protective but not curative of a lower eyelid problem. Given your natural state of a low horizontal eyelid with scleral show, I would not have expected a canthoplasty to produce significant elevation either. In theory one would think that the combination of the two would be effective but they usually aren’t for several reasons. First the problem in the lax natural lower eyelid with scleral show is that there is a vertical tissue deficiency in the eyelid. When this exists there is no amount of pushing and pulling that is going to overcome it and have a sustained result. Secondly, the need to make a subciliary (lower eyelid) incision and lower eyelid dissection for implant placement and the midface lift creates a lot of scar. This will have a natural tendency to pull the eyelid downs as it heals. Lastly, the space occupied by the implants actually fights against the midface lift often creating a zero sum gain…as your result indicates.

The problem that you have now is that the lower eyelid is scarred and is not easily going to be mobilized without the issue if postoperative scar contracture. What I would recommend is to first have some fat injections done to make the lower eyelid more supple and help replace scar tissue with more vascularized tissue. Then after three months you could have an eyelid procedure that would introduce an interpositional palatal or alloderm graft to the inner lamellar of the lower eyelid and an osseous-based canthoplasty that is more effective than just a simple tendon tightening.

Dr. Barry Eppley