What is The Most Effective Method To Improve My Congenital Inferior Scleral Show?

Q: Dr. Eppley,I would appreciate your thoughts on the below given expertise across the below techniques. 

I had a lateral canthoplasty in September 2023 but it did not elevate the 3-3.5mm of congenital inferior scleral show, and hardly improved the canthal tilt (relapsed to original position largely after 3 months) – would periosteal flaps with lower lid retractor recession  as a standalone procedure; be able to correct the scleral show and canthal tilt? I have read studies where this worked in reconstructive cases of facial palsy – but wondering if it can also be used aesthetically.

I have seen three surgeons with differing opinions: 

  • Infraorbital rim implant + and/or Orbital decompression., revision canthoplasty with thin spacer graft
  • lower lid retractor recession, medial and lateral horn lysis, periosteal flaps and release of arcus marginalis (no spacer graft)
  • upper to lower lid Hughes flap with revision lateral canthoplasty and an alloderm spacer graft in the centre of the lid,  with ptosis surgery.   


1.   Would appreciate if possible to review the second opinions below, and share thoughts 

2. Thoughts on an infraorbital rim implant, and/or orbital decompression – to correct scleral show with longer-term results (noting negative vector and anatomy, Hertel measurements). Know we only got to briefly touch on the latter. 

3. Different opinions have been given on using an additional spacer graft – one doctor is against this, and feels it would add ‘bulk’ or compromise aesthetically. Is this something you would recommend or not, in terms of desired outcome aesthetically and functionally? 

4. s i) the Hughes tarsoconjunctival flap reconstruction, or  ii) lower lid retractor recession medial and lateral horn lysis, periosteal flaps and release of arcus marginalis, release of arcus marginalis – more appropriate to address the residual scleral show I still have? I have seen studies stating this can be feasible, albeit unclear if also applicable to patients with a slight negative vector profile. 

A: These various and diverse opinions in regards to treating your congenital scleral show are common and are a reflection of the surgeon’s experience, training and how they see the problem. As you have learned and was completely predictable a lateral canthoplasty is going to fail for scleral show and that procedure is best viewed as an adjunct to the needed surgery rather than a primary procedure for it.

The basic concept to grasp is that your scleral show issue, and I seen no pictures so these are general statements, is very challenging and represents a tissue deficiency at multiple levels. (bone and soft tissue) Thus tissue addition is essential not just tissue rearrangement. (e.g., lateral canthoplasty) Also in such challenging issues it is essential to do multiple maneuvers that are diametric in nature to assure some substantial improvement.

To answers your specific questions:

1) An infraorbital rim implant is essential. As opposed to a standard infraorbital implant which merely provides horizontal augmentation, the implant needs to saddle the rim to raise the level of the rim upward as well as forward. This requires a custom implant design.

2) A spacer graft is needed for the lower eyelid with a double hole lateral canthoplasty. A medium thickness Alloderm graft is fine, a palate graft is not needed and is very bulky.

3) The addition of orbital decompression is the diametric maneuver as dropping the eyeball a bit will help make #1 and #2 more effective.

Dr. Barry Eppley

World-Renowned Plastic Surgeon