Beyond Blepharoplasty: Almond Eye surgery to modulate lower lid contouring
What is Almond Eye Surgery?
Almond eye surgery is a procedure used to correct sagging of the lower lid contour, which is a common feature in many individuals and can result in a tired, sad, and withdrawn appearance. This procedure is a specialised form of blepharoplasty and must be carried out by a highly skilled oculoplastic surgeon.
Almond-shaped eyes are characterised by a slightly raised outer corner or canthus, and a lower eyelid that sits at the lower edge of the iris. Many people have this eye shape naturally due to ethnicity or genetics, while others may have a different shape altogether.
Appearance can have an enormous psychological impact and the eyes in particular play an important role in perceived attractiveness and communication. Studies have shown that in some cultures and ethnic groups around the world, certain eye shapes are considered to be an indicator of beauty. For this reason, some people may wish to undergo almond eye surgery to achieve what they perceive to be a more attractive or less tired looking eye shape.
While there is wide variability in the contours of the eyelids, resulting in many different eye shapes, this is only partly due to the nature of the eyelids themselves. Eye shapes are often determined by the shape of the midface, the depth of the eye sockets and, importantly, the size of the globes (eyeballs).
Why is Almond Eye Surgery Carried Out?
Conventional blepharoplasty is effective at reducing excess tissue but is not able to correct changes in the shape of the lid contours. Almond Eye Surgery, on the other hand, focuses on changing the shape of the eye, rather than the reduction of skin and eye bags. The procedure, therefore, appeals to those seeking specialist aesthetic treatments, which is particularly the case for younger patients.
A variety of eyelid shape parameters can be changed using established treatments such as:
What Causes Lower Lid Sag?
There are many causes for lower lid sag and retraction, which can either be due to diseases or simply constitutional. The pathological causes include a variety of conditions affecting the skin, such as dermatitis, burns and skin tumours.
Moreover, in specialised oculoplastic aesthetic practice, there is a significant number of patients with post blepharoplasty retraction - a complication as prevalent as up to 20% in some studies. Thyroid eye disease and other forms of inflammatory orbital conditions can also cause this.
Most patients with constitutional lower lid sag are typically seen in the context of myopia (widely known as short-sightedness). Myopic eyes have a larger diameter and tend to protrude forward in what is described as a “negative vector” eye configuration. In these settings, the lower lids have less support and often appear to be sagging. It is also associated with canthal dystopia (the drooping of the outer corner of the eye), which can give rise to a lethargic or sad appearance.
How is Almond Eye Surgery Performed?
Almond eye surgery and the correction of lower lid sag requires complex procedures with very narrow margins of error. Such procedures should only be performed by highly skilled oculoplastic surgeons, who will carry out meticulous planning and examination of the eyes themselves. The eyelid is a complex multi-layered structure (see figure 1) so as with all eyelid surgery, this procedure requires a detailed biomicroscopic assessment of the ocular surface before proceeding.
Almond Eye Surgery is performed under local or general anaesthetic and involves three critical parts: lower lid septo-retractor recession, mucograft implantation, and lateral canthoplasty. The precise details of the surgery are complex, but essentially, the surgery is performed through the inside of the eyelid, leaving no noticeable scars. Through the conjunctival incision, the natural retractor bands within the eyelid itself are released, and then the spacer graft is sutured in to elevate the eyelid and prevent retractor re-attachment. A canthoplasty procedure resets the lateral canthal position, to provide further support for the eyelid and ensure that the canthal tilt (angle between medial and lateral canthi) is improved.
Mucograft is commonly used in dental reconstruction. It is a highly versatile component allowing for full integration into the inner eyelid. This lower eyelid procedure represents a novel application for this material.
If patients have skin and muscle shortage (anterior lamella), this procedure is less likely to work, as raising the lower lid in the context of skin shortage is more complex, requiring midface elevation and is generally not recommended as a primary aesthetic procedure.
Does Almond Eye Surgery Leave Scars?
Scarring is rarely a problem, as the Almond eye procedure is undertaken through internal incisions on the inside of the eyelid.
Is Almond Eye Surgery safe?
Yes, almond eye surgery is safe. It is a very delicate procedure that can be even more complicated in patients who have had prior eyelid surgery or who have protruding eyes, so consulting a specialist oculoplastic surgeon is vital.
What Happens During Post-Surgical Recovery?
Recovery after Almond Eye Surgery is usually between 2-3 weeks. Patients will be able to go home after the procedure but should get plenty of rest and refrain from strenuous activity for the first couple of weeks. It is common to notice some bruising and swelling for 7-10 days.
For some patients, recovery may be longer as they can experience chemosis (also known as conjunctival oedema), which is a type of swelling/inflammation of the eye, particularly prevalent in myopic patients.
After surgery, until the mucograft integrates into the lower lid tissues, it maintains a hard and roughened surface. Bandage contact lenses are used in the meantime to allow for comfort, along with prophylactic antibiotics to reduce pain and swelling.
Although patients can return to work and resume normal activities after 2-3 weeks, complete healing can take several months.
What are the Results of Almond Eye Surgery?
When performed by an experienced surgeon, the results of almond eye surgery are natural and long-lasting, avoiding any drastic changes to the eyes or facial appearance. As such, most patients are happy with the outcome of the surgery.
Typically, the elevation of the lateral and central parts of the eye can be as much as 2-3mm. Although this seems like a small amount, the normal palpebral aperture is between 8-9mm, which means the change after surgery represents a remarkable improvement.
What Factors Need to Be Considered for Almond Eye Surgery?
When counselling a patient for this surgery, a meticulous examination of the eyelids and eyes is required. The Almond eye procedure will not work for all patients. Several factors need to be considered when deciding if this procedure is right for you:
- Patients with a negative vector eye configuration (meaning that the eye is further forward than the cheek) are less likely to maintain the postsurgical elevation, due to limitation in lateral support of the new eyelid position.
- Patients with existing ocular surface disease, particularly blepharitis or dry eye, can experience long-term discomfort after this surgery, and a thorough examination is required to identify if this is a problem.