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

CO₂
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

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