The shape of the eyelid fissure is a key feature of the aesthetic of the entire face, to the point that it has been showed that attractive Caucasian faces have a relatively narrower eyelid fissure width compared to the average Caucasian face (Seung Chul Rhee, et al. Biometric Study of Eyelid Shape and Dimensions of Different Races with References to Beauty. Aesth Plast Surg 2012; 36:1236–1245). Ageing has a significant impact on the lower eyelid, secondary not only to the gravity; its role in fact is that of support the weight of a relatively heavy structure such as the eye globe. The stretch of the suspensory tendons of the lower eyelid seems to affect more predominantly the lateral canthal angle. As beautifully depicted by Rembrandt in the XV century it causes medial displacement and rounding of the lateral corner, inverted canthal tilting, lateral rounding of the eyelid margin with consequent inferior scleral show. These laxity changes, combined to the ageing changes that affect the upper eyelid, such as upper sulcus deepening, cause a modification of the overall shape of the eyelid fissure from elongated, almond-shaped to saggy, round-shaped fissure. Quite commonly canthal and lower eyelid ‘malpositions’ can be of constitutional origin, minor forms of congenital euriblepharon with inferior scleral show, that give the impression of bigger, bulging eyes.
At the time of aesthetic rejuvenation or beautification of the periocular region it is crucial to recognise the position of the lower eyelid and lateral canthus to achieve improved our results. While I don’t perform nor advocate canthal surgery in primary blepharoplasty, I have a very low threshold to restore eyelid and canthal position when indicated.
In this respect there are many variant of canthal surgery that have been proposed during the last 20 years, and after having personally performed almost all of these variants I have now come to a rationalisation depending on the surgical indications: 1) if I want to correct an inverted canthal tilting with lateral scleral show, and restore an acute lateral angle I invariably perform a closed trans-canthal canthopexy as described by Hamra (Plast Reconstr Surg J 102:5, 1998) as this procedure is much more respectful of the anatomy of the lateral canthal structures while at the same time offering the right amount of correction with natural results.
2) if I need to correct lower eyelid and canthal malpositions secondary to a previous lower eyelid blepharoplasty, i.e. cicatricial ectropion i have come to rely primarily on the benefits of the endoscopic approach associated with Hamra’s canthopexy and lower eyelid retractors release. The endoscopic approach, offers to perform temporo-malar dissection associated with lateral canthal and orbital retaining ligament release under beautiful visualisation of the anatomy. The full release of the temple, cheek and lower eyelid offers an en-bloc mobilisation of these structures; proper suture fixation at the superior part of the malar eminence, near the lateral canthal area gives a strong elevation up- and outwardly. The lower eyelid retractor release allows to free the middle lamellar scarring from the eyelid margin and the associated trans-canthal canthopexy secures the canthal position firmly against the orbital rim, where it belongs. Compared to what has been previously reported, i.e. aggressive canthoplasties with bone screw fixation associated with trans-palpebral sub-periosteal mid-face lifting the endoscopic approach to the difficult lower eyelid offers a higher vector of tissue elevation with consequent improved effectiveness of the lifting factor on the lateral canthal/eyelid position allowing to minimise the amount of canthal surgery with consequent more natural results.
Summary: Autologous fat grafting for blepharoplasty-induced lower eyelid retraction offers potential for a long-term solution while avoiding the morbidity associated with posterior lamellar spacer grafts. By combining traditional methods of lifting the retracted lower eyelid with autologous fat grafting, both functional and aesthetic concerns can be successfully addressed in these patients.
(Plast Reconstr Surg Glob Open 2016;4:e1190; doi: 10.1097/GOX.0000000000001190; Published online 23 December 2016.)
Before electing to have cosmetic surgery, there are some things you should be aware of to make sure you are taking an intelligent, realistic approach to the procedure. Here are some Do’s and Don’ts to consider when considering cosmetic surgery.
DON’T (Cosmetic Surgery)
Do It For Anyone But Yourself
Cosmetic surgery should be done for you and you alone. Having cosmetic surgery to please someone else, like a boyfriend or husband, is not a good reason. Nobody else but you can give you the self-esteem you need to have a healthy image of yourself.
Rush Into It
You must be in good health prior to any operation. Your surgeon will likely require you to be cleared by your primary care physician prior to surgery. It’s also best to be as physically fit as you can, which can make the recovery process go much smoother.
Have Unrealistic Expectations
If you’re looking to cosmetic surgery to transform your entire life, you’re going to be very disappointed. Talk to your doctor before undergoing cosmetic surgery to make sure you clearly understand what is attainable and what results you can reasonably expect.
DO (Cosmetic Surgery)
Ask your surgeon a number of questions before committing to cosmetic surgery, including:
• Am I a good candidate?
• How long can I expect my recovery to be and how can I best prepare?
• What are risks and complications with my procedure?
• How extensive is your experience in performing this type of procedure?
• What results can I realistically expect?
Follow Doctor’s Orders
Your surgeon knows what’s best for you during your cosmetic surgery journey, so make sure to heed his or her advice. This may include quitting tobacco and alcohol prior to your procedure, making certain lifestyle changes such as diet and exercise, and enlisting ways to help yourself heal as quickly and safely as possible for optimal
Remember Your Inner Self-Worth
Improving your appearance can be a tremendous boost to your self-esteem, but at the end of the day, it’s what’s on the inside that counts. Celebrate your new physical traits, but also remember the characteristics that make you who you are as a whole – intelligence, compassion and humor, for example, are just as important.
An obstruction in the lower part of the naso-lacrimal duct (acquired naso-lacrimal duct obstruction) is a fairly common problem in the adult, especially in the female population 50 years of age or older because of their particular anatomy of this region. In the vast majority of the patients we cannot find a possible cause that determined the obstruction, hence the term of ‘primary’ acquired naso-lacrimal duct obstruction (PANDO). Occasionally, the duct may be occluded as a consequence of a facial trauma with the nasal bones involved or a surgical procedure in the nose (rhino-septoplasty, turbinectomy etc).
The most common symptom of a PANDO is the so-called ‘epiphora’, which refers to the constant tearing with tears building up in the eyelid fissure and eventually running down the cheeks, requiring frequent dabbing of the tears. One or both eyes can be affected, even at the same time. Frequently, affected patients refer that they always travel with a paper tissue in their hands do dab their tears. Moreover the sight may result impaired from the excessive fluid accumulation on the surface of the eye. The patients can have frequent recurrent episodes of ‘red eye’ (conjunctivitis), mucus secretion.
Occasionally, more severe episode of inflammation with swelling and pain between the nose and the eye (in the anatomical location of the lacrimal sac), called ‘acute dacryocystitis’ may occur repeatedly and require systemic treatment with antibiotic and even hospitalization.
A medical consult with a specialist in lacrimal surgery (usually an ophthalmologist with a sub-specialty training in oculoplastic surgery) is required to establish the appropriate diagnosis and rule out other conditions.
Normally, after a routine evaluation of the eye and ocular surface, a simple lacrimal siringing is the most reliable test to establish the diagnosis. A standard nasal exam is routinely performed by the oculoplastic specialist. Radiological exams are not required in the vast majority of cases.
Once the diagnosis os PANDO is established, the final treatment is a surgical procedure called ‘dacryocystorhinostomy’ and can be performed through an external approach (a small skin incision over the lateral part of the nose that leaves invisible scar) or though and endonasal endoscopic approach.
The surgical technique is well standardized, is performed under local anesthesia with the help of intravenous monitored sedation, the surgical time takes less than 20 minutes and the patient can be discharge from the surgical facility within two hours from the end of surgery. The success rate is well over 90% in the external approach in the hands of an expert lacrimal surgeon.