Almond eye surgery

When a request about the outer corner of the eye is discussed, the first step is to define which change is expected. No particular eye shape is taken as a target for everyone, and not having the procedure is also an option.

What is almond eye surgery?

"Almond eye" is not the name of a single operation. The published literature describes various techniques of lateral canthopexy and canthoplasty aimed at changing the position and the shape of the outer corner of the eye.¹² In this article the term is treated as a description of an appearance, used in order to discuss those procedures.

The lateral canthus is the corner where the upper and lower eyelids meet on the outer side. The lateral canthal tendon plays a part in anchoring that region to the outer rim of the eye socket and has two components; because the deep component provides the support of the outer lid, detaching it is not advised in procedures carried out for appearance.¹ The aim of surgery is not only to change the line seen from outside; the relationship of the lid margin with the surface of the eye must also be preserved.³

The natural position of the outer corner is not the same in everyone. Three-dimensional measurements in healthy volunteers report that brow and eyelid shape differ both between individuals and between the groups examined.⁴ Such differences are not treated as a defect that needs correcting on their own. An appearance one person prefers does not create a medical need for another.

Who is it suitable for?

Someone who wants to change the position of the outer corner and someone who needs support because of lid laxity or a problem with closing are not assessed with the same aim; canthopexy and canthoplasty can be used in both situations.¹² Where a change of shape is requested, in which direction and to what extent a change is expected is discussed separately at the examination.¹

In a study examining 294 eyes of 147 healthy volunteers, brow and eyelid measurements were reported to differ between the Chinese and Caucasian groups examined and between the sexes.⁴ That study did not examine surgical results. The mean measurements are not used as a surgical target, nor as a normal limit for all populations.

Dry eye, previous lid surgery or laxity of the lid margin matter in planning; investigating these beforehand is advised in the assessment for eyelid surgery.⁵⁶ An existing complaint does not by itself mean that surgery cannot be performed, but the factors that could affect the ocular surface need identifying.⁶

Whether the request about appearance can be met and whether the function of the lid is preserved are assessed together.³ Where the expected change is not found suitable at the examination, discussing a more limited aim, or not operating, is also part of the decision.

What does the examination assess?

The outer corner and the lid margin: The height of the outer corner, its relationship with the inner corner, its distance from the bony rim of the eye socket, and the contact of the lid with the globe are assessed.¹³ The differences present at the outset between the two sides are recorded separately; recognising pre-existing asymmetry matters in the assessment for eyelid surgery.⁵

The lower lid and support: Laxity of the lower lid, the position of the globe relative to the surrounding bone and cheek tissue, the amount of skin and any old scars are examined.⁷ The opening and closing of the lid and the state of the ocular surface are assessed.⁶

The ocular surface: Dryness, stinging, watering, sensitivity to light and complaints relating to contact lenses are asked about.⁶ Where it is thought necessary, further assessment of the ocular surface and lid function is carried out.⁶

Neighbouring structures: Excess skin on the upper lid, the position of the brow, and drooping related to the structures that open the lid are told apart from one another.⁵ Previous eye surgery, medicines in use and eye disease should be reported at the consultation.⁸

How is the operation planned?

The plan is not built on the name of the procedure alone. Whether the tendon is preserved or released, where it will be reattached, and the direction of movement intended all differ between techniques.¹² Adding a procedure on the lower lid, the upper lid or the brow is a separate decision; a request concerning the corner of the eye alone does not require all of them.⁵

Canthopexy or canthoplasty?

The difference between the two lies in how the tendon is handled. In the context of repairing lid malposition, canthoplasty descriptions include detaching the lateral canthal tendon from the bone, shortening it, and reattaching the framework of the lid to the outer orbital rim at an adjusted height.² These steps are not generalised to every cosmetic canthoplasty technique; in the cosmetic approach, preserving the deep component of the tendon is advised.¹ In canthopexy the tendon is not detached from the bone; the tightening is achieved through the placement of the suture.²

Which is used is decided by weighing the effect that is wanted together with the person's examination findings. The change achieved by canthopexy is expected to be more limited than that of canthoplasty, and the choice of method takes that expectation into account. A technique described for repairing a marked malposition is not adapted directly to everyone who wants only a change of shape.²

How far can the corner of the eye be moved?

The limit of the movement is not set by the desired angle alone. What is decisive is the distance of the corner from the bony rim and whether the lid margin can maintain its contact with the eye once it is reattached.¹³ Fixing it in an unsuitable position can lead to the lid turning outwards or inwards.¹

Extending laterally, positioning downwards and raising are not the same movement; the results of techniques aimed at different directions are not used in place of one another.¹ At the examination the request is made concrete in terms of these directions. It is not said that a particular shape will be achieved in everyone.

How does it differ from the support used in lower eyelid surgery?

During lower eyelid surgery, canthopexy or canthoplasty can be used to support the lid margin. Lateral canthopexy and canthoplasty are reported to have become an integral part of lower lid surgery in order to prevent malposition of the lower lid.⁷ Where that support is added to lower lid surgery, the aim is to reduce the risk of the lid margin being pulled down or turning outwards.

There is nonetheless no agreement that support is needed in everyone. Some authors are reported to advise prophylactic canthal tightening in all operations carried out below the lashes, while a series of 265 people did not find routine prophylactic tightening necessary for everyone, deciding the need for support according to the examination findings.⁹ Nor does applying support mean the risk is reduced to zero.

The subject here, by contrast, is a request to change the shape of the outer corner. Operating on the same surgical structure does not mean the aims are the same.¹

How does it differ from a temporal lift and from brow procedures?

The outer part of the brow, the skin of the upper lid and the outer corner where the lids meet are separate structures; in assessing the area around the lid, the position of the brow and the excess skin need telling apart.⁵ The change in the outer brow targeted by a temporal lift is not the same as repositioning the canthal attachment covered here.¹

Upper eyelid surgery addresses excess skin on the upper lid; moving the outer corner and repairing a drooping lid call for separate assessment.⁵ A forehead lift is likewise a separate procedure concerning the brow and forehead. Non-surgical applications such as thread suspension are outside the scope of this article.

Where is the incision made?

In the lateral canthoplasty approach described by Chae and Yun the incision is planned along the natural crease at the outer corner of the eye, and care is taken that its outer end does not pass the bony wall of the eye socket.³ Because a different approach can be used in the methods described for canthopexy, not every procedure is carried out through the same outer incision.²

Preserving the sharp junction of the outer corner, the lash-bearing margin and the surface in contact with the eye is part of the plan.³ Wound closure strips are applied to the incision line, and the stitches are removed after 1 week.

How is the anaesthetic planned?

The operation is performed under general anaesthetic and takes 45-90 minutes. The hospital stay is planned as 1 night. The form of anaesthetic is not chosen by looking at the site of the incision alone; the procedures added and the health history also enter the assessment.⁸

Where a procedure on the lower lid, the upper lid or the brow region is added, the operation time, the hospital stay and the recovery timetable are reassessed together.

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.¹⁰ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.¹¹ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹² Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹³ The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Tests and anaesthetic assessment: The tests required are determined by general health and by the anaesthetic assessment.¹⁴ Any previous problem with anaesthesia or drug allergy should be declared. The instructions given about fasting and about how to take medication on the day of surgery are followed.

Home and transport: Someone is arranged to accompany you home on discharge.¹⁴ The timing of check-ups, the help you may need in the first days and the plan for time off work are organised beforehand. Follow the surgical team's guidance on preparing the operation area; do not shave or prepare the incision area at home on your own initiative.

Preparation relating to the eyes: Eye drops in use, problems experienced with contact lenses and previous eye surgery are reported.⁸ Where there is dryness, stinging or sensitivity to light, these need assessing before surgery.⁶

What is recovery like?

The timetable below is the framework of clinical practice for an operation directed at the outer corner of the eye. The physical demands of your work and the course of healing can change these times. If another procedure is added, this timetable is assessed again.

The hospital stay is planned as 1 night. The first check-up is within the first week. The stitches are removed after 1 week. 1 week is allowed for returning to desk work. A return to driving can be assessed within 1-3 days. 2 weeks is expected for returning to sport, and 2-4 weeks for a full return to daily life.

Bruising is expected to settle over 7-10 days and marked swelling over 1 week. These intervals do not mean everyone reaches the same appearance on the same day. Vision can be blurred in the first few days.¹⁵

The shape becomes possible to assess over 1-2 months, while residual mild swelling can last up to 2-3 months. Assessing the shape therefore does not mean that all swelling has finished by that day. The direction of healing is monitored at check-ups; swelling that increases, is painful or is markedly one-sided is not explained by recovery time alone.

As the swelling reduces, the position of the lid margin, the closing of the eye and the state of the ocular surface are also monitored.¹⁶ Where the lid moves away from the globe, or the eye does not close fully, the next check-up is not waited for.¹⁶

What to pay attention to after surgery

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply.

The incision and strips: Wound closure strips are applied to the incision line. When the strips are removed is decided at the check-up. The stitches are removed after 1 week.

Sleeping: Rest with the head elevated. Your surgeon decides how long that position and the avoidance of physical strain are continued. A sleeping position that puts no pressure on the incision is preferred. Returning to sleeping on the side or front is assessed according to the state of the incision and the swelling.

Cold application: Cold is applied to the operated area without pressing on it. The form and duration of the application are determined by your surgeon's instructions.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Washing your face: A return to washing the face is decided according to healing and is assessed within 3-7 days on average. The incision line is not rubbed, and directing water into the eye is avoided.

Eye care: Eye drops or ointment are given routinely after surgery. Hands are washed before applying them.¹⁵ The eyes are not rubbed and the outer corner is not pulled at.¹⁷

Movement: Strain such as bending the head down, straining and heavy lifting is limited in the early period. Movements that stretch or rub the incision area are avoided. Even if you feel well, do not return to strenuous activity suddenly. Activity and rest through the day are organised according to the plan given on discharge.

Pain: There may be mild pain and tenderness around the eye.¹⁸ The painkillers provided are used as instructed. Pain that keeps increasing, becomes severe eye pain, or comes with a reduction in vision should not be watched and waited out.¹⁶ The surgical team is told if a new painkiller or additional medicine is to be used.

Returning to work and sport: 1 week is allowed for returning to desk work; for physically demanding work, healing is assessed separately. 2 weeks is expected for returning to sport and 2-4 weeks for a full return to daily life. Where dryness or irritation of the ocular surface persists, the plan for returning is assessed accordingly.⁶

Driving: A return to driving can be assessed within 1-3 days. Do not drive while your vision is blurred.¹⁵ Do not take the wheel before the effect of the anaesthetic on attention and reflexes has passed and you have seen that the painkiller does not make you drowsy.

Make-up and contact lenses: Make-up around the eyes and contact lens wear are not planned before 2 weeks; after that time, a return is decided according to assessment at a check-up with your surgeon.

Sexual activity: A return can be assessed once everyday movements no longer cause marked pain and you feel comfortable. Pressure on the head and around the eyes, movements that stretch the incision line, and marked straining are avoided. Rather than a fixed day, the course of healing and the surgeon's advice are taken as the guide.

Smoking: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete.

Findings that are normal: Swelling, bruising and tenderness around the eye, and numbness or altered feeling around the incision, can occur.¹⁹ Irritation, watering and a feeling of dryness in the eye can also occur.¹⁸ What matters is less the presence of a mild finding than how it changes. Swelling that increases rather than settling, pain that progresses, or vision becoming impaired should not be judged as ordinary healing.¹⁵

How do the scars change?

The incision at the outer corner of the eye leaves a scar. Planning it along the natural crease does not mean there is no scar; a conspicuous scar is among the reported risks of eyelid surgery.¹⁹ Among the reasons that held back the wider use of cosmetic lateral canthoplasty is that results leaving extensive scarring had been reported.³

Maturing of the scar is expected to take between 4 and 6 months. An incision line that looks red, firm or more prominent early on is assessed over that period. The final appearance of the scar is not settled on how it looks at the first check-up.

Silicone gel and massage are advised for the skin scar at the outer corner. When they are begun and how they are applied are determined by the surgeon according to how the incision is healing. The plan given by the surgeon is followed for care of the incision.

Care is taken to protect the area from the sun, and darkly tinted sunglasses are advised.¹⁸ Where there is wound separation, discharge or increasing tenderness, it is not treated as merely part of the scar maturing; assessment is requested.

Risks and complications

The risks are assessed according to the method used and the aim of the operation; a series repairing lid malposition and a series carrying out a change of shape alone do not represent the same group.²¹ A reported rate is not converted into a person's surgical risk without knowing the method and the follow-up conditions.

Complications and unfavourable results after cosmetic lateral canthoplasty are reported not to be uncommon.¹ For that reason, preserving the junction of the corner is given particular emphasis in the choice of method.¹

Problems of shape, symmetry and the scar

A difference between the two sides, webbing or rounding of the outer corner, notching of the lid margin and failure to maintain the expected position can develop.¹³ Methods that disrupt the junction of the corner are reported to be able to cause these deformities, and methods preserving the corner have been described in order to prevent them.¹ The existence of a described technique does not mean the problem will never occur.

Where a problem develops that calls for correction, a further procedure may be considered; repair of eyelid surgery complications varies according to the underlying scar tissue and the problem with support.¹⁶

The position of the lid margin and closing of the eye

The site and the tension of the fixation can affect the relationship of the lid with the globe. The lid margin turning outwards, turning inwards or moving away from the eye can occur.¹ In eyelid surgery, the lid being pulled back and the eye not closing fully can contribute to the ocular surface being left exposed.¹⁶

A problem with closing and dissatisfaction with shape alone are not assessed with the same priority; where the ocular surface needs protecting, early treatment matters.¹⁶

Dry eye and the ocular surface

The contact of the lids with the surface of the eye and the blinking function contribute to preserving the tear film; impairment of that function can increase complaints of the ocular surface.⁶ Stinging, burning, watering, a feeling of dryness and sensitivity to light can occur.⁶

Exposure of the mucosa at the outer corner and the lid turning outwards are among the outcomes reported to be able to cause dryness of the eye.¹ Complaints of the ocular surface are therefore not treated as a problem of appearance alone.

Bleeding, the wound and infection

Bleeding at the incision line, separation of the wound and infection can develop; these are among the reported risks of eyelid surgery.¹⁹ Redness, discharge and pain that keep increasing call for assessment.¹⁵

Whether a small lump on the incision line is thickening of the scar, a reaction related to a suture or another wound problem is told apart at the examination.¹⁶ Prevention of infection and treatment where needed are decided according to the person's situation; there is no single medication plan for everyone.

Rare situations that threaten sight

In reviews of eyelid surgery, bleeding within the eye socket is described as a rare but serious complication that can affect the blood supply to the optic nerve.¹⁶ That is not a frequency calculated for an operation directed at the outer corner alone; a personal risk percentage is not derived from general eyelid surgery data.

Injury to the eye from instruments and damage to the cornea caused by a problem with closing are also risks described in lid surgery.¹⁶ Sudden reduction in vision, rapidly increasing tight swelling or severe eye pain calls for urgent assessment.¹⁶

Anaesthetic and general surgical risks

Unwanted effects related to the anaesthetic, allergic reactions and general surgical risks such as bleeding are also covered in the assessment for eyelid surgery.¹⁹¹⁷ These are discussed together with the procedure planned and the health history.⁸

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

The approach to preventing clots is decided according to the person's risk and the operation planned. The measures to be used are explained in the discharge and care plan. No blood thinner is started without being prescribed, and existing treatment is not altered on the person's own decision.

Does the result change over time?

In the literature on cosmetic lateral canthoplasty, the outer corner returning towards its previous position is counted among the reported complications.¹ Such a relapse can leave the person with the impression that the surgery had no effect at all, or that the eye has become smaller.¹

For that reason it is not said that the result will remain the same for years. The change achieved by canthopexy is expected to be more limited than that of canthoplasty, but no guarantee is given for either method that it will not change over time. Natural ageing also continues to affect the area around the eye.²⁰

What can be expected from the result?

The aim is to carry out the change at the outer corner defined at the examination while preserving the function of the lid; particular attention is paid in planning to preserving the contact with the globe.³ Where there are complaints relating to the upper lid skin, the position of the brow or the cheek tissue, these are assessed as separate structures.⁵⁷

In discussing the result, which structure will be changed and which expectation falls outside this operation are set out clearly. The natural differences in shape between healthy people do not make a single eye shape a medical target.⁴ No promise of complete symmetry is made and no particular appearance is guaranteed.²⁰

Where a request rests on a preference about appearance alone, not having the operation is also among the options that can be discussed.

When should you contact a doctor?

Do not wait for the scheduled check-up in the following situations:

• Sudden reduction in vision, loss of vision or newly developed double vision
• Severe eye pain, rapidly growing tight swelling or the eye protruding forwards
• The eye not closing, the lid margin moving away from the eye, or marked stinging
• Fever, spreading redness or discharge from the incision line
• Separation of the wound or bleeding that does not stop
• Pain that increases rather than settling, or becomes marked despite the pain treatment given

Bleeding within the eye socket can threaten sight.¹⁶ Where there is a sudden visual problem or severe eye pain, urgent assessment should not be delayed while trying to reach the surgeon.¹⁵

One-sided leg pain and swelling, sudden shortness of breath or chest pain are also emergencies. Where there is a sudden breathing problem in particular, urgent assessment is not delayed.

About the numbers in this article

The intervals given for the operation, the hospital stay, stitch removal and returning to activity, and for bruising, swelling, the shape settling and the scar maturing, are a framework of clinical practice. The summary box covers an operation directed at the outer corner of the eye alone; where another procedure is added, the times and the timetable are set again.

The 147 volunteers and 294 eyes are the sample of a measurement study in healthy people; its results do not determine the need for surgery or an ideal measurement.⁴ The number of people and the number of eyes are not used in place of one another.

No frequency rate belonging to cosmetic procedures on the outer corner alone is given in this article. Rates from operations carried out to repair lid malposition and from lower eyelid surgery have not been transferred to this procedure. Because the smoking studies cover different operations, the relative reductions there should not be read as a risk percentage specific to this operation.¹¹¹²¹³

References

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