Mehryar (Ray) Taban, MD
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Mehryar (Ray) Taban, MD
Oculoplastic surgeon | Views: 53036

Friendname: mytaban
Business Name: TabanMD
Website: www.TabanMD.com
Location: 435 N Roxbury Dr, #104
Beverly Hills, CA 90210
United States
Telephone: 310-278-1839
Languages Spoken: English

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Ask An Expert > Mehryar (Ray) Taban Message Board > Bone Anchored Canthoplasty after Lower Eyelid Retraction (blepharoplasty)
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Vancouver, Canada
Bone Anchored Canthoplasty after Lower Eyelid Retraction (blepharoplasty)

I had lower bleph surgery done 3 years ago. Transcutaneous approach. No skin taken. Fat was removed/some redraped.

I ended up with lower eyelid retraction in my right eye. Directly after surgery my eyelid was horribly bruised and swollen. I have 1 mm of scleral show and a pulling sensation whenever I try to squint, look up, smile or laugh. Because no skin was taken, I know (and was told) I probably had a scar contracture.

The orginal surgeon went in again through a transcutaneous approch and tried to find the scar tissue. I know he failed to find it b/c after the swelling went down my eyelid still pulled down. When I squint or smile, one eyelid stays frozen down, while the normal one moves up
and I get the same pulling sensation.

So, the surgeon did a canthopexy twice where he put a dissolvable suture through the lining of the bone and both times it has relaxed or pulled down where I have 1 mm of show again. The canthal angle is still higher in the canthopexy eye, but it feels like it has just pulled down the lining with it until it sags again

The treated lower eyelid feels loose still and I can easily pull it tighter as if "tightening the canthopexy). when I do this, I don't feel the pulling sensation.

Before the second canthopexy, I went to an oculoplastic and he said that doing a hard palate graft would probably make the situation worse because I have fine skin and it would make it look bulky. He recommended tightening the canthoplasty since the skin does not appear to be super tight.

He did not state what type of canthoplasty to do.

My question is:

Would a bone anchored or drill hole canthoplasty work better to fight the gravitational force of the cicatrix.

It is weird b/c if I gently hold the eyelid up 1 mm higher, I don't get a pulling sensation anymore. SO, I am not sure if the pulling sensation is coming from the eyelid sagging down and bunching up when I smile or whether I still have a scar contracture.

Plastic surgeon
Miami, FL
United States
View My Professional Profile
  June 10, 2012 4:28 AM

Very very detailed issue that can not be correctly addressed over the internet. Seek more in person opinions.

Your original doc was not current or conversant in lid preserving techniques  June 11, 2012 12:37 PM

I think you described your problem very well and gave some salient details and enough so to give you some feedback.

OK, first let me say that the trans-cutaneous approach, even if they don't remove skin involves cutting through the orbital septum. Violation of the orbital septum in that way is associated with scar contracture of the lid pulling down. There are a good handful of 'eye guys' and also PSs who avoid that sort of thing by doing something sometimes referred to a "no touch technique". For example, if one of the objectives is to remove fat from the orbital septum, the fat is accessed via trans conjuctival technique (from the eyelid flipped inside out) so the orbital septum is not cut through. Then they make incision in front of eye lid to tighten muscle and to cut skin IF needed but they never cut through a whole slice. Instead they separate the skin from the muscle and then tighten the muscle.

So, in your case, since you say that you had the "transcutaneous" approach and also say; "fat was removed/ some redraped", with that I would conclude that they cut through the orbital septum ("violated" it) just to get to the fat contained in it. The 'good' eye guys avoid doing just that by instead approaching the orbital septum from behind (transconjunctival where they flip eye lid inside out to get to it.)

You also report that your doctor then, cut into this area AGAIN "looking for scar tissue". Well that just means he violated the orbital septum AGAIN which is not going to make the area better but rather worse.

You also report that after that, your doctor used a TEMPORARY suture for his cantho procedure and he did that 2X. That type of cantho is the type used as "prophylactic" as in helping to prevent droop soon after a bleph procedure is done and it's done at same time the bleph is being done. He should have done that at the SAME time he did your original bleph as doing that type of cantho during an original bleph (especially one with transcutaneous approach where more things are cut through than JUST the skin!)

To address your question about a drill hole cantho procedure:

As you might know, that's done by drilling a hole through the lateral orbital rim and then putting sort of a 'figure 8' wire through it which can be twisted to tighten what ever pull one is aiming for. It's a perm 'suture' (actually a thin wire) and done because a hole in the bone, itself, with a wire going through it is a very strong anchor point.

Depending on the scar tissue, how bad it is, the "inner lamella" is already compromised so not best idea to try to stick hard palate graft in there. Sometimes a subperiosteal Midface Lift needs to be used to 'recruit' cheek skin as lower lid skin (in addition to the drill hole cantho procedure) IF the pulled down lower lid is severe. Thing is you can't assume all 'eye guys' or 'oc docs' are conversant in MFL to do that.

I think you certainly are on the RIGHT TRACK to be looking into drill hole cantho procedure for what you have. But just don't ask the doc who did your eyes in the first place to do it.

Your original doctor sounds worse the more you describe the facts and circumstances. He sounds like a dolt with no CME (continued medical education) credits to keep up with current techniques in bleph procedures that limit this sort of bad thing from happening.

DROP THE GUY NOW and don't have him touch your eyes anymore. Also, if you can, e-mail me (MissJ521@aol.com) his name, I shall enter him on my 'no no' list in the event a private client coming to me for PS consulting entertains going to him for eyes. 100 to 1 he's NOT on my 'yes yes' list (doctor roster).

Oculoplastic surgeon
Beverly Hills, CA
United States
View My Professional Profile
lower lid retraction -- revisional eyelid surgery  June 11, 2012 8:57 PM

You should consult an oculoplastic surgeon. There are probably multiple factors in your eyelid retraction including scar, tight skin, weak orbicularis muscle. The type of suture or bone anchoring won't make a difference unless the tightness of the lower eyelid is taken care of.



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