Evolving Techniques in Lower Eyelid Blepharoplasty

Evolving Techniques in Lower Eyelid Blepharoplasty, authored by Craig Czyz, Jill Foster, and David Holck.

Downward descent of the cheek fat below the attachments of the orbitomalar ligament creates the appearance of vertical elongation and hollowing of the lower eyelid. Laxity of the lower eyelid may result in downward descent of the lid margin and inferior scleral show. Excess lower eyelid skin may also be present in older patients. Each of these features must be recognized and addressed in lower eyelid blepharoplasty, one of the most intricate and challenging aesthetic surgeries.

Preoperative decision-making includes assessment of the amount of prolapsed fat and its location in the three fat pads, the contribution of the tear trough to the undesired qualities of the eyelid, the degree of laxity of the lower eyelid and canthal tendons, and whether or not there is enough redundant skin to require skin removal.

In patients with no significant horizontal laxity and modest or no redundant lower eyelid skin, a transconjunctival approach with an intact lateral canthal angle is used. A 4-0 silk traction suture is placed in the lower lid, and the skin and orbicularis are reflected anteriorly over a cotton swab. A transconjunctival incision is made through the conjunctiva and lower eyelid retractors at a level about 2 millimeters below the inferior border of the tarsus. When enough separation is accomplished, a traction suture of 6-0 Vicryl is placed through the conjunctiva and lower eyelid retractors and clamped superiorly to the drape. A lacrimal rake is inserted for further retraction as the assistant simultaneously pulls upward on the lid margin and uses a second hand to pull downward on the lower eyelid skin.

The dissection plane remains anterior to the orbital septum until the inferior rim is reached. Once the skin has been safely elevated, the assistant replaces the rake with a Desmarres retractor and places downward tension on the lid instead of anterior traction. This maneuver prolapses the fat anteriorly. Additional local anesthesia is injected into the orbital fat for patient comfort and hemostasis. As shown here, the fat is sculpted using monopolar cautery for increased hemostasis, but Wecott's scissors can also be used.

Protrusion of fat without tear trough hollowing may be addressed with fat sculpting only. In a more typical patient, the presence of fat protrusion with infraorbital hollowing is addressed with a combination of fat sculpting and transposition. Once the desired amount of fat is removed, the remaining fat is pedicalized. This is accomplished by the previously illustrated method of fat sculpting.

A Freer elevator is used to create a plane along the infraorbital rim, either below the periosteum or in the plane of the SOOF. The arcus marginalis is released along the entire inferior orbital rim. The pedicle of fat is imbricated with a double-armed 6-0 Prolene suture. With a transconjunctival incision, it is not possible to rotate the suture back out through the wound. Thus, both arms are passed underneath the cheek tissue and out through the skin, as shown here. A free needle can be used in place of the supplied Prolene needle.

During fat repositioning, the lid position and contour are assessed by replacing the soft tissues and inspecting each. Once satisfactory, the bolster is tied on the skin. The bolster and suture are removed in 5 days. The conjunctiva is then closed using three to four buried, interrupted 6-0 plain gut sutures.

When mild laxity in the skin is also present, orbicularis tightening can be performed without the need for a canthoplasty or cantholysis. An incision is made lateral to the lateral canthal tendon through the skin and orbicularis. The edge of the orbicularis is identified, and a 6-0 Vicryl suture is passed in a buried fashion. The suture is then used to pull the lateral orbicularis up to insert into the lateral canthal tendon and deep temporalis fascia. The skin is then closed with interrupted 6-0 plain gut sutures.

When the preoperative lower eyelid is loose enough to require intervention, better access and visibility are a serendipitous side effect of the lateral canthotomy and cantholysis that are used in conjunction with the transconjunctival or subciliary incisions. Release of the canthus will require more significant lateral repair with resuspension of the lateral canthal tendon. To further address laxity in the skin, the lateral repair may also include resuspension and tightening of the lower preseptal and pretarsal orbicularis.

In orbicularis tightening, a 4-0 or 6-0 Vicryl suture is typically used to pull the lateral orbicularis and SOOF up to insert in the upper lateral canthal tendon and the deep temporalis fascia. Excess skin, up to 2 vertical millimeters, may be removed as a small subciliary incision at the end of the procedure. Larger amounts of skin are addressed intraoperatively with subciliary excision of skin and occasionally orbicularis.

The subciliary incision should be made just below the pretarsal orbicularis using a 15 blade. The skin is then resected with Westcott scissors. Conservative removal of skin is advocated. The skin is then closed with interrupted 6-0 plain gut sutures. In cases where a pinch or skin excision is performed, support of the lower eyelid is improved with a lateral canthoplasty or canthopexy or an orbicularis plication.