Lateral Canthal Positions and Why That is So Important
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I did a podcast talking a little bit about eyelid shape preservation and I believe it’s worth exploring this even more in detail. The biggest thing with an eyelid that looks natural to me is the preserving the shape of the eyelid. This is the single most important thing when creating a natural result where the person’s identity is not changed. Now for me a big beef that I have is doing a way overdone eyelid by removing too much fat and skin and skeletonizing the eyelid and that’s another subject where I’m balancing it doing fat grafting as well as some removal of some tissue so that it’s not overdone in one direction or the other and I will do a separate podcast talking about that. But in this podcast, what I’m really focused on is the concept that the eyelid shape does not is not altered in any way. What makes an eyelid shape different? Well, the biggest thing for me is the canthus and so the canthus is a fancy word c a n t h u s that describes the joining of the upper and lower eyelids and that can be a medial canthus which is toward the nose and the lateral canthus which is the outer portion of the eyelid and the lateral canthus is really what I’m going to focus this podcast on. What this lateral canthus is and lateral canthal that’s the adjective form lateral canthal position. It’s that the lateral canthus cannot be shifted inward, downward, upwards, or outwards. Otherwise you get weird looking eyes that just look artificial that don’t look, don’t look done, and don’t look natural. And I’ve done unfortunately a lot of jobs to fix this. A lot of procedures to try to fix this and it’s not easy entirely correct this. In fact is impossible to entirely corrected you can only slightly improve it. So what causes canthal distortion? So let’s talk about lower eyelids and then stockpot talk about the upper eyelid brow complex and I really want you to have a better understanding of this. So the lower eyelid if you make an incision underneath the lower eyelid and what’s called a skin muscle flap, which essentially means or transcutaneous through the skin of your cutting through that skin. It seems very easy and harmless and innocuous to do that because you could just sew up the skin right underneath, you know, right underneath the eyelid and not have a visible scar and that’s true. It’s not that scarred but it’s false in the sense that your eyelid actually becomes much weaker from just the active in sizing the lower lid. And then what you have to do is a surgeon is to rebuild that strength to lower lids. You’ve got to tighten up that weakness and if you don’t tighten it you’re going to have a weaker lower lid where it actually hangs down. Looks like a droopy dogging also can cause functional problems. So the biggest thing is making sure that you retighten that eyelid but the problem with the canthal suspension is that if you tighten it slightly too much and you have to actually slightly over tighten it so that because it’s going to slip a little bit your eyelid will look a little bit pulled upwards if the scar tissue brings it in by a millimeter or two. It’s going to search is going to round out the eye if it’s slightly over tighten outwards going to look Asian.
It can look artificial. So these are all the problems. So how do you avoid that? The biggest way you avoid it is to make an incision on the lower lid. So the way that I do not lower blepharoplasty is a combination of fat grafting to restore the hollowness around the rim of the orbital rim, and then I do a transconjunctival which is a big fancy word to describe an eyelid surgery where I’m in sizing from inside. And so how do you do with all the extra loose skin? What’s interesting is oftentimes that’s can just tighten backup. Now in Caucasians are fair skinned individuals that skin can be good crepey and loose I’ll just do a light laser they’ll tighten up. But I don’t remove skin and I don’t cut through the muscle and if you do that, the eyelid shape just doesn’t change whatsoever. I’ve never in 20 years had an eyelid position be over pulled down or pulled up or change. Now, it’s particularly appealing for African Americans are very very dark skin patients to say look, there’s no scar, there’s no cutting, no incision. That’s a great appeal to them, you know, but to me, the biggest benefit is not the scarless of it, not the avoidance of an incision, but the preservation of the lower eyelid shape where it’s not going to change. It’s going to be the same and that’s something that people don’t have the eye necessarily to look at, that look slightly fake, but I can be at a cocktail party and notice someone’s have their eyelids done and it really irritates me. It’s something that probably you would say, you know, Dr. Lam. I really don’t want to look fake. The problems I have women tell me that I look at them. They already look fake. I can tell that they’ve had their eyelids done because their canthal position is not right and so the lower blepharoplasty in my opinion really should almost never, never say never, but I should say almost never be cut from outside of the skin.
And I used to do trauma cases through the skin when I can’t do it transconjunctivale and I would see a slight alteration to the shape of the eyelid even my best hands. So that’s the way I saw it, you know, when I was doing that for trauma cases where I had to go outside but for cosmetic cases I have shouldn’t say never but I can’t recall almost ever doing that at least in the last 15 years. I certainly have not done it. And then for the upper eyelids the biggest trick with this is when people do brow lifts. The brow lift, there’s a release along the lateral margin of the eyelid near the so hard to describe this anatomywise but the periosteum the lining of the bone when you release that area the canthus can also shift. This is one of the big reasons why I’m not a big fan of brow lifts. I don’t think they look great. But I really believe that a little fat, a little bit of skin removal, a little bit of laser tightening can actually make the brows look incredibly natural and beautiful and they look more like the way you used to look when you were young. So that is the powerful thing of performing an upper blepharoplasty.
Why you say so if you say well, Dr. Lam now, do you make an incision for the upper eyelid blepharoplasty? Yes, I take a little skin away. So, wait a second. You just told me you wouldn’t do that for the lower lid of why is that different? What is very interesting is when you take away skin from the upper eyelids, it does not affect the eyelid shape. It’s only affected when you cut the lower lid and the other benefit of doing so on the upper eyelid is that it’s hidden inside the crease so that you don’t even see it. So even though it looks it may look like in a line that line is something that actually exists when you close your eyes you look at someone with a crease they have that line already there so it doesn’t look like a scar. Even if you’re an African-American or dark skin. Now, there’s a different story of your an Asian without a crease whatsoever. But that’s a whole different method of approaching an upper eyelid. It is a topic of it whole different podcast, but this is really focused on the concept that if we can preserve the eyelid shape and its entirety where it’s not distort, especially that lateral canthus that outer joining of the upper and lower eyelids where it’s not blunted in words not tilted up where it’s not stretched out words. Not only is it more attractive and more natural but it’s also safer. And so when that eyelid functionality is not been compromised, you know, the dry eye issues, the rounded eye, those problems. I really have not seen with this technique, which is really awesome. You know, people often times if they’ve been else wearing they’ve had not only a compromise in the way they look but they also have functional problems with her eyes where they either can’t close their eyes, they have issues with tearing of the eyes, they’ve got all these problems. It’s really due to the fact that, in my opinion, it’s besides an aggressive surgeon, it’s also based on the technique and so we can choose a better technique of not making a decision to lower lid. I think we’re going to be much much safer. And as I said in 20 years, I’ve never had an eyelid position that looks weird or patient with permanent dry eye issues, of course, temporary for a week is normal or having an eyelid shape that just doesn’t look natural.