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Back
Canalicular Obstruction
Upper Eyelid Blepharoplasty
Next
Lower Eyelid Blepharoplasty
Don O. Kikkawa, MD, FACS
Anatomy
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
Patient evaluation
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
Techniques
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
CO
2
erbium:YAG
ablative versus nonablative
Extended blepharoplasty with orbitomalar suspension
Midface lift
Postoperative care
Iced compresses
Antibiotic steroid ointment
Head elevation
Avoid heavy exertion, lifting, bending
Complications
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
References and additional resources
Aakalu VK, Putterman AM. Fat repositioning in lower lid blepharoplasty: the role of titrated excision.
Ophthal Plast Reconstr Surg
. 2011;27(6):462.
Atiyeh BS, Hayek SN. Combined arcus marginalis release, preseptal orbicularis muscle sling, and SOOF plication for midfacial rejuvenation.
Aesthetic Plast Surg
. 2004;28(4):197-202.
Baker SR. Orbital fat preservation in lower-lid blepharoplasty.
Arch Facial Plast Surg
. 1999;1(1):33-37.
Baylis HI, Long JA, Groth MJ. Transconjunctival lower eyelid blepharoplasty. Technique and complications.
Ophthalmology
. 1989;96(7):1027-1032.
Carter SR, Seiff SR, Choo PH, Vallabhanath P. Lower eyelid CO(2) laser rejuvenation: a randomized, prospective clinical study.
Ophthalmology
. 2001;108(3):437-441.
Cohen SR, Kikkawa DO, Korn BS. Orbitomalar suspension during high SMAS facelift.
Aesthet Surg J
. 2010;30(1):22-28.
Collar RM, Lyford-Pike S, Byrne P. Algorithmic approach to lower lid blepharoplasty.
Facial Plast Surg
. 2013;29(1):32-39.
Einan-Lifshitz A, Hartstein ME. Treatment of festoons by direct excision.
Orbit
. 2012 Oct;31(5):303-306.
Epstein JS. Management of infraorbital dark circles. A significant cosmetic concern.
Arch Facial Plast Surg
. 1999;1(4):303-307.
Ghabrial R, Lisman RD, Kane MA, Milite J, Richards R. Diplopia following transconjunctival blepharoplasty.
Plast Reconstr Surg
. 1998 ;102(4):1219-1225.
Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket.
Plast Reconstr Surg
. 2000;105(2):743-748; discussion 749-751.
Goldberg RA, McCann JD, Fiaschetti D, Ben Simon GJ. What causes eyelid bags? Analysis of 114 consecutive patients.
Plast Reconstr Surg
. 2005;115(5):1395-1402; discussion 1403-1404.
Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Incidence of postblepharoplasty orbital hemorrhage and associated visual loss.
Ophthal Plast Reconstr Surg
. 2004;20(6):426-432.
Hoenig JF, Knutti D, de la Fuente A. Vertical subperiosteal mid-face-lift for treatment of malar festoons.
Aesthetic Plast Surg
. 2011;35(4):522-529.
Kim EM, Bucky LP. Power of the pinch: pinch lower lid blepharoplasty.
Ann Plast Surg
. 2008;60(5):532-537.
Korn BS, Kikkawa DO, Cohen SR. Transcutaneous lower eyelid blepharoplasty with orbitomalar suspension: retrospective review of 212 consecutive cases.
Plast Reconstr Surg
. 2010;125(1):315-323.
Korn BS, Kikkawa DO, Cohen SR, Hartstein M, Annunziata CC. Treatment of lower eyelid malposition with dermis fat grafting.
Ophthalmology
. 2008;115(4):744-751.
Kpodzo DS, Nahai F, McCord CD. Malar mounds and festoons: review of current management.
Aesthet Surg J
. 2014;34(2):235-248.
Liao SL, Wei YH. Fat repositioning via supraperiosteal dissection with internal fixation for tear trough deformity in an Asian population.
Graefes Arch Clin Exp Ophthalmol
. 2011;249(11):1735-1741.
Lucarelli MJ, Khwarg SI, Lemke BN, Kozel JS, Dortzbach RK. The anatomy of midfacial ptosis.
Ophthal Plast Reconstr Surg
. 2000;16(1):7-22.
Mack WP. Complications in periocular rejuvenation.
Facial Plast Surg Clin North Am
. 2010;18(3):435-456.
McCann JD, Pariseau B. Lower eyelid and midface rejuvenation.
Facial Plast Surg
. 2013;29(4):273-280.
McCord CD Jr. The correction of lower lid malposition following lower lid blepharoplasty.
Plast Reconstr Surg
. 1999;103(3):1036-1039; discussion 1040.
McCord CD Jr, Shore JW. Avoidance of complications in lower lid blepharoplasty.
Ophthalmology
. 1983;90(9):1039-1046.
McCord CD, Kreymerman P, Nahai F, Walrath JD. Management of postblepharoplasty chemosis.
Aesthet Surg J
. 2013;33(5):654-661.
Patel BC, Anderson RL. Transconjunctival blepharoplasty.
Plast Reconstr Surg
. 1996;97(7):1514-1515.
Sullivan PK, Drolet B. Extended lower lid blepharoplasty for eyelid and midface rejuvenation.
Plast Reconstr Surg
. 2013;132(5):1093-1101.
Trelles MA, Baker SS, Ting J, Toregard BM. Carbon dioxide laser transconjunctival lower lid blepharoplasty complications.
Ann Plast Surg
. 1996;37(5):465-468.
Weinfeld AB, Burke R, Codner MA. The comprehensive management of chemosis following cosmetic lower blepharoplasty.
Plast Reconstr Surg
. 2008;122(2):579-586.
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