Unnaturalness is the first and most important cardinal sin that must be avoided. I am very blunt, at times to a fault. If you look fake but you do not see it, I will point it out to you in a judicious and caring manner; but I think I owe it to you to mention it. One of the worst telltale signs of bad work is when the eyes look different after eyelid surgery. I am not in the business of the witness protection program, so I don’t want to make you look different and certainly not fake. Why do eyes look fake after an eyelid procedure and how can you avoid it? Let’s discuss.

The canthus describes the juncture or union between the upper and the lower eyelid. The inner (or medial canthus) is defined as the joining of the upper and lower eyelid near the nose. The outer (or lateral) canthus describes the joining of the upper and lower eyelid near the ear. The outer canthus is what we will be describing herein. When the lower eyelid is approached with a “skin-muscle flap”, i.e., an incision from the skin side rather than a “transconjunctival” procedure (from inside the eyelid pink conjunctiva), in my estimation there is a risk that there will be distortion to the canthus. This distortion is what causes people to look weird and unnatural. Accordingly, the problem with the skin incision in the lower eyelid is not the fear of having a scar, which is of very limited concern, the risk is having some degree of eyelid distortion. That is why I try never to make an incision in the lower eyelid. Instead I perform the aforementioned transconjunctival approach almost exclusively.

The natural question is why does a skin incision cause this problem? The answer is that when the skin is cut, the muscle must also be cut to access the underlying fat tissue. When this is performed the muscle is weakened and must be restrengthened afterward. To accomplish this end, the surgeon must take the outer muscle and tack it to the lining of the bone called the periosteum. This is known as a lateral canthopexy. The problem is that as the stitch loosens it can cause the eye to round a bit and look like a dog. This can also lead to functional problems of dry eye. Conversely, the canthopexy can be overtightened accidentally or in order to compensate for perceived relaxation over time. However, if the canthopexy does not become lax, then the eye will look overtightened, making the eye look like a cat eye. Even a very slight change to the canthal position, whether up, down, in, out, or any diagonal between these positions can change the way the eye looks and functions, and almost never favorably. Yes, in certain cases after a lateral canthopexy the eyelid canthus does not change at all. However, is it worth the risk? In my opinion, not at all.

How do I do it then? When I work on the lower eyelid, I look at three problems that the lower eyelid suffers: too much volume, too little volume, and loose and crepey skin. I address the problem of too much volume, which can be attributed to too much eyebag fat, by performing a transconjunctival blepharoplasty by removing fat through the conjunctival side. Since I do not touch the muscle or the canthus, the eyelid position should remain exactly the same. In fact, the incision is so small and there is no actual skin incision that I don’t even need stitches to close the incision. With too little volume, I add harvested fat from the belly or thighs to place along the deficient bony orbital rim. I wrote the book on how to do this safely in 2006, Complementary Fat Grafting, and it is still selling well today 11 years later. I do not get lumps and bumps that are typical of inexperienced fat injectors. I believe too many eyelid surgeries make eyelids look hollow, so adding a little bit of volume back is so critical to achieve a balanced outcome. Finally, for those individuals who are lighter skinned than an African-American, they are candidates for a conservative fractionated laser that tightens the skin safely and cleans up the crepey and wrinkled-appearing skin there. This three-part method allows me to obtain very safe and predictable outcomes without major risk of changing the eyelid shape into an unfavorable appearance of a cat or a dog.