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DESCRIPTION : Hawaii Facial Plastic Surgery in Honolulu is a leader in facelift services. We'll make you look younger and refreshed with natural-looking results. Our founder Susan Tan, MD, is double board certified and provides neck lifts, nose surgery, and eyelid surgery. Her aesthetic sensibilities and medical knowledge are unmatched by other plastic surgeons in Oahu. We also offer non-surgical facelift options using the latest dermal fillers. Patients love them for the brief downtimes and beautiful results. If you've been looking in the mirror and concerned about what you see, make an appointment for a consultation. A commitment to patient education sets Dr. Tan apart from other plastic surgeons in Honolulu. She takes the time to get to know each patient and understands their needs. Her process involves offering you a range of options before you decide. She is especially well known for rhinoplasty (nose surgery), and rhytidectomy (facelift), platysmaplasty (neck lift), and blepharoplasty (eyelid surgery) and employs the latest techniques.

The human eye conveys a vast spectrum of emotion, but sometimes the anatomy of the eyelid can project a feeling that the person does not actually feel. One of the most common complaints we encounter is the "sad dog" look or a perpetually melancholic expression. Clinically, this is often caused by a condition known as "scleral show." This occurs when the lower eyelid sits too low, revealing the white sclera underneath the iris (the coloured part of the eye). While a tiny amount of scleral show can be normal in certain individuals, excessive visibility of this white band creates an unbalanced, distressed aesthetic that can make a person appear exhausted or older than they are.

This condition can be genetic, but it is frequently a result of aging or previous, overly aggressive surgery. As we age, the tendons that hold the lower eyelid taut against the eyeball can stretch, causing the lid to sag and bow outwards. Correcting this requires a specialised approach that goes beyond simple skin removal. It requires tightening and re-suspending the structural support of the eyelid to restore a neutral, alert, and happy almond shape.

The Mechanics of Lower Lid Laxity

To understand the fix, one must understand the failure. The lower eyelid is held in place by the medial and lateral canthal tendons—essentially like a hammock strung between two trees. Over time, these "ropes" stretch due to gravity, sun damage, or repetitive rubbing. When they loosen, the hammock droops, exposing the sclera below the iris.

If a surgeon simply removes skin from a loose lid without tightening the hammock, the lid will be pulled down further by gravity and the healing process, worsening the scleral show (a complication called ectropion). For patients seeking eyelid surgery Oahu specialists carefully assess the "snap-back" tone of the lid to determine if canthal tightening is necessary alongside aesthetic improvements. A lid that does not snap back instantly against the globe is a lid that needs structural reinforcement, not just cosmetic trimming.

Canthopexy vs. Canthoplasty

There are two primary surgical methods to address this laxity. A canthopexy is a supportive procedure where the existing tendon is reinforced with sutures to the orbital rim, providing a mild lift and support without detaching the tendon. This is ideal for preventative maintenance or mild laxity where the shape needs a subtle refresh.

For more severe scleral show, a canthoplasty is performed. This involves surgically cutting, shortening, and re-attaching the tendon to physically tighten and elevate the lower lid margin. Both procedures are designed to tilt the outer corner of the eye slightly upward, eliminating the sad, downturned appearance and restoring the sharp, youthful angle of the eye.

The Danger of "Cookie Cutter" Surgery

Scleral show is often the unfortunate result of a previous "cookie cutter" blepharoplasty where too much skin was removed from the lower lid. The shortage of skin pulls the lid margin down, creating a rounded, startled look. Correcting this iatrogenic (surgeon-caused) retraction is complex and may require skin grafts or mid-face lifts to recruit tissue upward. This highlights the vital importance of choosing a surgeon who respects the delicate balance of the eyelid and prioritises the preservation of tissue over aggressive removal.

Restoring Confidence and Comfort

Beyond aesthetics, correcting scleral show has significant functional benefits. When the lower lid hangs loose, it creates a gap where tears can pool or evaporate too quickly, leading to chronic dry eye and irritation. By tightening the lid against the globe, we restore the natural "windshield wiper" function of the blink, ensuring the cornea stays hydrated. Patients often report that their eyes not only look happier and more rested but feel significantly more comfortable throughout the day, free from the grit and burning of exposure.

Conclusion

Your eyes should reflect your joy, not a sadness you do not feel. By addressing the structural laxity of the lower eyelid and correcting scleral show, we can restore the natural, almond-shaped contour of the eye. It is a subtle adjustment that dramatically changes the emotional signal your face sends to the world.

Call to Action

Restore the natural shape and happiness of your eyes; schedule a specialised eyelid evaluation today.