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I had a midface lift at the time of my eyelid surgery, and now my eyes look different. Will canthal surgery correct my problem?

Published on December 9, 2011


The most critical issue here is to understand how your face has changed.

You are absolutely correct to say that your eyes have changed. However, your analysis of the problem is not correct. I suspect that very few surgeons you consult will understand the issues. At the same time I am equally certain that many surgeons would be more than happy to perform a lateral canthoplasty for you. They will mean well but they are simply going to make your situation worse, not better.

I completely agree that surgery has altered the shape of the eyes. This is the most obvious change. The outer corners of the eyes are higher after surgery compared to your preoperative status. There is also a subtle lower eyelid contour abnormality of the lower eyelids. It is true that a properly executed lateral canthoplasty has the potential to reposition the lateral canthal angle. In my many years of repairing prior eyelid surgery, I have found that very few surgeons are capable of actually achieving that type of result in a natural way. Not impossible, just very difficult as the surgery must be done with the patient at least awake enough to open and close the eyes to judge the effect of repositioning of the angle. If surgery is performed under general anesthesia, then in my opinion, the likelihood of success is very low.

Canthoplasty, and to a lessor degree, cathopexy, risk over shortening the lower eyelid. It is true that many surgeons will shorten the lower eyelid as part of the canthoplasty procedure. The procedure is taught this way and this maneuver is important for pathologically lax eyelids. However, over shortening an eyelid that does not need to be shortened will simply force the lower eyelid below the curvature of the eye. This will actually make the lower eyelid look more pulled down. The outcome will be disappointing.

So lets talk about the real issue. It is interesting how important the eyes are in interpersonal interaction. Subconsciously, we scan the face of the person we are speaking to. During conversation, we actually scan a triangle on the face that includes the eyes, the nose and to a lesser degree, the mouth. This is so profoundly ingrained, that one expects someone listening to you to look at you in this manner. We are not even be aware of this gaze pattern. However, we can be acutely aware when the pattern is altered in someway. What you would experience when you are speaking to someone is the sense that they are not really paying attention to you. When does this happen? Studies have shown that changes in the face will alter this scan pattern. There are some very nice studies of this in the head and neck literature in looking at scan patterns when viewing someone who has a facial lesion or just had surgery to remove a facial lesion.

How does this apply to this situation? If you look carefully at your after photograph, you face demonstrates a classic facial defect caused by your mask lift. The forehead dissection has resulted in atrophy of the fat pads that extend from the temple to the orbital rim. This hourglass hollowing of the temple areas I call the plateau midface deformity. Essentially the loss of the fat volume skeletonizes the zygomatic arch. This little bit of facial fat plays a critical role. This cushion of fat at the side of the face serves to separate the eye aesthetic area from the temple aesthetic area. This slight cushion of volume helps maintain gaze on the eyes. Without this fat volume, the scanning gaze is falls off the eyes and is drawn into the temple area. You are left with the feeling that people are not paying attention to you. Since the primary reason many women (and men) have cosmetic surgery is to stay relevant, this feeling of being ignored can precipitate a narcissistic crisis. The fact that your surgeon cannot understand your concerns (and I promise you they really don’t get it) is even more infuriating. Because like you, they don’t see what the issue is, you get treated like a problematic, ungrateful, impossible to satisfy (insert your own description here) person. Naturally this can precipitate a break down in the doctor patient relationship.

In the example shown here, surgery was used to correct the problem. Previously placed cheek implants were removed and replaced with a hand carved ePTFE orbital rim implant. The lower eyelid was also lengthened using hard palate graft. Because it is necessary to sew the eyelid closed for a week to allow healing means that only one eye can be done at a time. For some individuals who only have the plateau midface, fillers can be used as an alternative to facial surgery.

First, there is no substitute for an actual personal consultation. Generally for this type of problem the best solution for many is adding hyaluronic acid filler to the area where you have lost volume. These products last quite a while and this can be a workable alternative to corrective surgery. For some, surgery is necessary. The most important thing is to avoid having a fix by doctors who do not understand what the issues are. Unfortuately, if you don’t see it, you can’t fix it.


About Dr. Steinsapir

Dr. Steinsapir is a much sought after oculofacial surgeon. He is an innovator in minimally invasive cosmetic and reconstructive procedures and has invented new methods for treating with BOTOX, fillers and cutting edge reconstructive eyelid and midface surgery. He specializes in high precision eyelid surgery and is a leader in correcting prior facial and eyelid surgery, including multiple revised cosmetic eyelid reconstructions. He attended medical school at the UCLA and completed ophthalmology residency at The University of Chicago. He is multiple fellowship trained including three years of fellowship training in oculofacial plastic surgery at UCLA, and a two-year cosmetic surgery fellowship in Rancho Mirage. He is widely published and lectures to other surgeons nationally and internationally. He is an associate clinical professor of Ophthalmic Plastic and Reconstructive Surgery at the Jules Stein Eye Institute at UCLA. His private practice is located in West Los Angeles, immediately serving the Los Angeles and Bevery Hills communities. Additionally, individuals from all over the country and the world regularly come to Los Angeles for this expert care.

To learn more about Dr. Steinsapir’s specialized Restylane treatments, please contact us today.

Services described may be “off-label” and lack FDA approval. This article is informational and does not constitute an advertisement for off-label treatment. No services should be provided without a good faith examination by a licensed physician and an informed consent with a discussion of risks, benefits, alternatives, and the likelihood of treatment success. Only you and your treating physician or surgeon can determine if a treatment is right for you.

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