Skin

• Fitzpatrick skin types
• I pale white; always burns, never tans
• II fair; usually burns, tans minimally
• III darker white; sometimes mild burn, tans uniformly
• IV light brown; burns minimally, tans easily
• V brown; rarely burns, tans darkly
• VI dark brown to black; never burns, always tans
• True dermatochalasis versus rhytids (static or dynamic)
• Active orbicularis oculi contraction is required to distinguish.
• Dynamic rhytids are more amenable to neurotoxin injections.
• Festoons
• Typically develops between potential space between the orbitomalar ligament and the zygomatic cutaneous ligament
• Can develop as a true festoon or interstitial edema

Orbicularis

• Hypertrophic pretarsal orbicularis
• Occurs in pretarsal region
• Common in Asian patients

Orbital fat

• Clinically apparent fat compartments
• Medial
• Central (divided from medial by inferior oblique)
• Lateral (divided from central by arcuate expansion of inferior oblique

Bone

• Infraorbital rim projection
• Negative vector with anterior globe projection
• Patients with negative are at higher risk for lid retraction following lower lid blepharoplasty.
• Malar and nasojugal fold
• Tear trough develops inferomedially due to unmasking of inferior orbital rim
• Contributing factors include genetics, the aging process, and soft tissue deflation.

Ligamentous structures

• Tarsoligamentous band
• Midfacial supporting ligaments
• Orbitomalar ligament
• Zygomatic cutaneous ligament
• Masseteric ligament

Subjective complaints by patient

• Careful understanding of concerns: Review with mirror.
• Set realistic expectations.
• Patient complaint of bags must be differentiated by surgeon as to which treatment modality is best for the problem.

Clinical examination

• Assess subtleties of each anatomic region
• Presence of orbital fat protrusion beyond inferior orbital rim and pseudoherniation of each clinical fat pad
• Presence of dermatochalasis, skin tone and festoons
• Presence of tear trough and inferior orbital rim unmasking
• Relationship of inferior orbital rim (negative vector)
• Lid position: pre-existing lid retraction present?
• Lid laxity (snap back and forward traction test)
• Look for "long eyelid" — lengthening of the distance of the lid margin to the malar fold (cutaneous insertion of the orbitomalar ligament — this indicates some midfacial descent.

Decisionmaking

• Choice of operation depends on goals and patient's anatomy.
• The surgeon must be familiar and clinically adept at performing multiple lower lid procedures: One operation cannot accomplish all clinical objectives.
• Clinical experience will help to guide the surgeon with the proper operation.
• For patients with fat protrusion and minimal infraorbital hollowing, consider transconjunctival blepharoplasty; skin pinch or laser resurfacing can be performed as an adjunct if necessary to address skin laxity and/or mild dermatochalasis.
• For patients with fat protrusion and moderate infraorbital hollowing, consider transconjunctival fat redraping; skin pinch or laser resurfacing can be performed as an adjunct if necessary to address skin laxity and/or mild dermatochalasis
• For patients with descent, fat protrusion, and infraorbital hollowing, consider transcutaneous fat redraping with orbitomalar suspension; conservative skin removal can be performed with adjunct lid tightening, if necessary, with canthopexy or canthoplasty.
• For some patients, additional concomitant or sequential procedures such as autologous fat grafting, midface lift, filler injections, or orbital rim implants might be appropriate.

Preoperative considerations, informed consent

• Thorough medical history and physical with documentation of cardiac, renal, thyroid, pulmonary and autoimmune disease.
• Preoperative medical testing is guided by the age of the patient and medical condition; medical clearance should be obtained if indicated.
• If possible avoid anticoagulants for 7–10 days prior to surgery.
• Smoking avoidance
• Informed consent
• Risks:
• hemorrhage
• infection
• scarring
• dry eyes
• need for possible revision
• vision loss (remote)
• Benefit: improved cosmetic appearance
• Alternatives:
• nonsurgical approaches
• observation

Transconjunctival blepharoplasty

• Incision through conjunctiva and lower lid retractors several millimeters beneath inferior tarsal border
• Preseptal or postseptal dissection
• Conservative fat removal in clinically distinct areas of medial, central and lateral orbital anatomic regions.
• Take care to avoid inferior oblique.
• Keep remaining fat level with inferior orbital rim.
• Residual lateral orbital fat is common complication.
• Hemostasis is key.
• Reinsertion of conjunctiva and lid retractors: optional
• Adjunct lid tightening, canthopexy if necessary
• Adjunct treatment of skin if necessary: laser resurfacing, skin pinch, or chemical peel

Fat redraping

• Transcutaneous or transconjunctival incision
• Preseptal or postseptal dissection
• Fat placement below inferior orbital rim
• Preperiosteal or subperiosteal dissection below inferior orbital rim; avoid infraorbital nerve.
• Preserve fat pedicles; many ways of fixing of orbital fat have been described:
• direct suturing with 5-0 polyglactin suture
• externalized pull out sutures
• subperiosteal placement
• tissue adhesives, "curtain of fat"
• Adjunct treatment of skin: laser resurfacing, skin pinch or chemical peel.

Transcutaneous blepharoplasty with orbitomalar suspension

• Infraciliary incision 1 mm below lash line
• Both skin-only versus skin-muscle dissection have been described.
• Increased risks with skin muscle dissection include possible denervation of orbicularis
• Opening of orbital septum with resection or redraping of fat
• Lifting component and vertical support created by orbitomalar suspension
• Release of orbitomalar ligament is performed with sharp and blunt dissection, inferior to orbital rim in the preperiosteal plane.
• Ensure that more lateral stout component is released.
• Suspension of cheek tissues can be performed to lateral orbital rim through lower lid incision or upper lid crease incision.
• Adjunct lower lid tightening:
• Canthopexy versus canthoplasty depending or pre-exiting laxity
• Consider precautionary lid tightening to lessen risk of postoperative lid retraction.
• Conservative skin excision with skin closure with absorbable or nonabsorbable 6-0 suture

Festoon management

• True festoon versus interstitial edema
• Options
• Direct excision
• Laser resurfacing
• CO₂
• erbium:YAG
• ablative versus nonablative
• Extended blepharoplasty with orbitomalar suspension
• Midface lift

• Iced compresses
• Antibiotic steroid ointment
• Head elevation
• Avoid heavy exertion, lifting, bending

Vision threatening complications

• Retrobulbar hemorrhage with vision loss; risk < 1:20,000
• Ruptured globe from anesthetic injection or direct globe injury

Adnexal involvement

• Extraocular muscle damage or incarceration of inferior rectus or inferior oblique during redraping procedure
• Ciliary ganglion damage
• Lacrimal system injury
• Chemosis
• Inflammatory chemosis is more common in the early postoperative period and responds to anti-inflammatory topical medication.
• Lingering interstitial chemosis can result from lymphatic disruption or lid retraction with loss of squeegee effect from lid distraction and might require revisional surgery or direct excision.

Lid malposition

• Lower lid retraction
• Middle lamellar shortening
• Lower lid ectropion
• Anterior lamellar shortening
• Lower lid entropion
• Posterior lamellar shortening
• Canthal dystopia
• Canthal rounding

Undercorrected or overzealous fat resection

• Revisional procedure will enable correction of residual fat with additional excision
• For overcorrection, consider volume replacement
• Dermis fat graft can be helpful to correct lid retraction and volume deficit.

Suture-related

• Granuloma
• Inclusion cysts
• Canthal webbing

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