Rejuvenating the Face by Lower-Lid Blepharoplasty: Slideshow

Intricate knowledge of the periorbital anatomy and sound training in the various approaches to the periorbita contribute to successful blepharoplastic surgery. The skin of the lower eyelid is relatively thin and closely attached in the pretarsal area and becomes thicker and more loosely attached as the lid blends into the cheek. This region is susceptible to engorgement by edema fluid. The muscle is densely adherent to the overlying skin.

The orbital septum is a fibroelastic membrane that contains orbital fat. The attachment of the septum to the orbital rim is referred to as the arcus marginalis. The orbitomalar ligament, which is the fibrous attachment running from the orbital rim to the skin in the area of the lid-cheek junction, often contributes to a sharp definition between the cheek and lower lid that becomes more pronounced with aging.

Atrophy of subcutaneous fat destroys the youthful, smooth transition between the lid and cheek and, combined with cheek descent, may result in prominence of the orbital rim and so-called skeletonization of the orbit. The orbicularis oculi muscle may become flaccid and redundant and contribute to the formation of festoons. Fat herniation contributes to subocular bulges. The image shows the relationship of the lower-lid structures to the malar fat pad, superficial musculoaponeurotic system (SMAS), and suborbicularis oculi fat (SOOF).

Preoperative photography is essential for documenting existing eyelid and periorbital anatomy. The recommended preoperative views include lateral and full-face views of the periorbital area with the eyes in neutral and upward positions. The surgeon should carefully note the surface anatomy of the periorbital region. Pictured is the topographic anatomy of the eyelid: (1) superior eyelid fold; (2) inferior eyelid fold; (3), malar fold; (4) nasojugal fold; and (5) nasolabial fold. (Adapted from Jelks and Jelks.^[1])

Hester's^[2] classification of midfacial aging is helpful in the choice of surgical procedure used for correction. A procedure confined to the lower lid is appropriate for types 1 and 2 aging. A lower-lid procedure applied in aging types 3 and 4, if not accompanied by other procedures, results in limited improvement and dissatisfaction. The presence or absence of excess orbital fat is best assessed while the patient is in the erect position.

The relationship between the anterior projection of the globe, lower lid, and malar eminence represents a key element in the preoperative evaluation. The views (left to right) show the positive, neutral, and negative vector relationships between the globe and orbit. A negative relationship (far right), which occurs when the globe lies anterior to the lower lid and malar eminence, is an indication to include a technique for lower-lid support in the treatment plan.

The procedure may be performed with the patient under local or general anesthesia. If local intravenous anesthesia is chosen, sedation with appropriate monitoring is recommended. The skin is prepared with povidone-iodine and dried. The incision line is marked, as shown, with a fine-tip marker approximately 2 mm below the ciliary margin in the first natural crease below the lash line, and the incision is extended laterally in a natural crease but not past the orbital rim.

To access the suborbital pockets of fat, the surgeon may incise either a skin flap or a skin-muscle flap. The sketch depicts a skin-muscle flap, which is elevated with an attachment of 4 mm of pretarsal orbicularis muscle. Scissors are used to develop a subcutaneous plane across the subciliary margin. A suture of 5-0 silk is placed in the gray line lateral or medial to the limbus to facilitate retraction and protect the globe. In the lower image, the fat is exposed and ready for excision, repositioning, or both.

Once the flap is elevated, the suborbital fat can be exposed. If a skin flap has been elevated, the orbicularis should be opened by incision over the medial, central, and lateral fat compartments. The inferior oblique muscle separates the medial and central components of fat. The lateral compartment is slightly higher than the central component. The orbital fat is mobilized using fine forceps, and any extra fat is resected. Hemostasis is achieved by using fine-tip cautery under low power. The fat is positioned over the orbital rim and secured using interrupted 5-0 Vicryl sutures.

An alternative means of eliminating suborbital bulges, as proposed by Huang,^[3] entails restoring the functional integrity of the orbital septum by plicating the attenuated orbital septa with 5-0 absorbable sutures. Comparable aesthetic results with arguably less morbidity have been demonstrated with this technique, but long-term follow-up observation and more widespread application are needed to confirm the efficacy of this approach.

The arcus marginalis release, as developed by Hamra, may be performed in patients who have a prominent nasojugal fold, malar fold, or both. The skin-muscle flap is elevated, exposing the orbicularis muscle, and the arcus marginalis is incised from the medial to the lateral orbital rim. A strip of septum orbitale is removed to prevent potential postoperative scarring and ectropion. Finally, the orbital fat is advanced over the orbital rim and under the repositioned orbicularis muscle.

Furnas'^[4] orbicularis resection, part 1. After management of orbital fat, elevation and fixation of the orbital orbicularis muscle can improve the aesthetic results in selected individuals. Furnas described elevating the skin of the superior rim of the skin-muscle flap, resecting the excess muscle, and attaching or plicating excess orbicularis to the lateral orbital rim. In this image, a split-level dissection is developed, a scissors-spreading dissection exposes the orbicularis for resection, and excess orbital fat is removed before muscle resection.

Furnas'^[4] orbicularis resection, part 2. The extent of orbicularis muscle to be excised is determined, the best pattern for muscle excision (eg, rectangle trapezoid, triangle) is chosen, and the plan is marked out with methylene blue. The orbicularis is excised as marked. The orbicularis fascia and strands of deep muscle fibers are left intact to protect the facial nerve branches. The cut edges of the orbicularis muscle are approximated with simple and horizontal fine monofilament mattress sutures. The skin is closed with a continuous 7-0 monofilament polypropylene suture.

Hamra's^[5] lateral orbicularis orbital suspension. Cheek descent in the midface commonly accompanies aging changes in the lower lid. A number of combination procedures that address midface and lower-eyelid deformities have resulted in improved aesthetic results in selected patients. The image depicts Hamra's lateral orbicularis orbital suspension, in which a transcutaneous lower-eyelid incision is made and a laterally based pendant of orbicularis muscle is lifted and suspended through an upper-lid incision.

Modified cheek lift. Hester^[2] expanded the use of the subciliary incision for rejuvenation of the lower lid and midface. The orbicularis muscle and soft tissue are suspended from the lateral orbital rim and temporalis fascia. A canthopexy or canthoplasty is used to secure suspension of the soft tissue and provide lower-lid support.

Modified cheek lift, lateral view. By division of the orbital malar ligament and mobilization of the upper-cheek soft tissues in the preperiosteal or subperiosteal plane, a more complete release of the lateral cheek soft tissues is achieved, allowing for vertical elevation. However, excision of the lower-lid skin should be conservation to avoid complications. (SMAS = superficial musculoaponeurotic system; SOOF = suborbicularis oculi fat.)

Fagien's^[6] simplified lateral canthopexy. A lateral retinacular suspension with a simplified canthopexy is appropriate as a prophylactic measure in most cosmetic blepharoplasties, and it is appropriate treatment for mild-to-moderate lower-lid laxity.

Fagien's^[6] lateral canthoplasty. If the length of the lower lid is excessive, the horizontal lower lid should be shortened at the level of the lateral canthus and combined with a tarsal strip and canthoplasty.

Skin excision and closure. To avoid malposition of the lower lid, the skin excision should be conservative and the skin fully redraped over the underlying lower-lid structures. If the patient is under local anesthesia, have the patient look up with open mouth to ensure a conservative resection of lower-lid skin. Make a vertical incision at the level of the lateral canthus and place a key suture. Trim the medial and lateral excess skin and place sutures to reapproximate the existing edges. For more information about blepharoplasty procedures and patient management, see http://emedicine.medscape.com/article/1281677-media

References

1. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient: bypassing the pitfalls. Clin Plast Surg. 1993;20:213-223.
2. Hester TR, McCord CE, Nahal F, et al. Expanded applications for transconjunctival lower lid blepharoplasty. Plast Reconstr Surg. 2001;108:271-272.
3. Huang T. Reduction of lower palpebral bulge by placating attenuated orbital septa: a technical modification in cosmetic blepharoplasty. Plast Reconstr Surg. 2000;105:2552-2558.
4. Furnas DW. The orbicularis oculi muscle: management in blepharoplasty. Clin Plast Surg. 1981;8:687-715.
5. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg. 1995;96:354-362.
6. Fagien S. Algorithm for canthoplasty: the lateral retinacular lateral canthoplasty: a simplified suture canthopexy. Plast Reconstr Surg. 1999;103:2042-2058.