eMedicine Specialties > Plastic Surgery > Eyelids

Blepharoplasty, Lower Lid Subciliary

Author: W John Kitzmiller, MD, Chief, Division of Plastic Surgery, Program Director, Plastic Surgery Residency Program
Coauthor(s): Lauren P Archer, MD, BA, Staff Physician, All Children's Hospital-St. Petersburg, FL, Largo Medical Center, Largo, FL
Contributor Information and Disclosures

Updated: Apr 2, 2008

Introduction

Rejuvenation of the orbital area is one of the most sought-after procedures in aesthetic surgery. According to the American Society of Plastic Surgeons, eyelid surgery is the fourth most common cosmetic surgical procedure, with at least 233,000 procedures performed in 2006. Numerous approaches to rejuvenation of the lower eyelids have been described in the literature. A successful surgeon must have intricate knowledge of the periorbital anatomy, sound training in the various approaches to the periorbita, and a healthy respect for the potential complications.

Transcutaneous lower blepharoplasty is defined as a process of improving the appearance of the lower eyelids by using a subciliary skin incision. The technique of lower lid blepharoplasty has evolved dramatically over the past 50 years. With careful observation, it becomes evident that a single procedure cannot correct all undesirable features caused by aging and individual anatomic variations. Progress in this area has occurred after critical review of results by practitioners who have accumulated large series of patients and by careful anatomic studies in the cadaver laboratory and the operating room.

History of the Procedure

As described in the Indian document Susruta-tantra, the origins of eyelid surgery are believed to date back to 400 BCE.¹ The term blepharoplasty was coined by Von Graefe in 1818 to describe eyelid surgery. Based on contributions from Miller,² Bourguet,³ and Noel,⁴ Castañares defined the pathology of orbital "bags" from pseudoherniation of orbital fat.⁵ He described what may be considered the modern blepharoplasty, in which skin was elevated from the orbicularis muscle and postseptal fat was resected.

Bourguet is credited with the first description of separate retroseptal fat compartments and the transconjunctival approach to its removal.³ Transconjunctival blepharoplasty is suited for patients with bulging fat in the lower lids, with little or no skin excess.

Sir Archibald McIndoe was the first to perform elevation of the skin-muscle flap with resection of retroseptal fat in the 1950s. The technique gained popularity because of its use of dissection, which afforded an increased margin of safety. This technique is ideal for patients with excesses of both fat and skin of the lower lid.

Furnas, perhaps as a precursor to current approaches in midfacial elevation, recognized that bags in the aging lower lid may be more than lax skin and fat.⁶ He focused on the contribution of laxity of the orbicularis oculi muscle in the aging lid in certain individuals and demonstrated that addressing the lax orbicularis muscle improved results in these individuals.⁶ Loeb described the concept of fat preservation and translocation rather than resection to soften the transition between the lower eyelid and cheek in the nasojugal fold.⁷ Hamra championed the cause of fat preservation and expanded the concept with complete release of the arcus marginalis with fat translocation to soften the prominent orbital rim and nasojugal fold in the aging orbit.⁸

In the early 1990s, skin resurfacing with chemical peels and carbon dioxide laser resurfacing combined with transconjunctival lower lid fat resection radically changed the approach to lower lid rejuvenation.⁹ In general, the transconjunctival approach to fat removal has been associated with reports of faster recovery and a lower occurrence rate of lower lid malposition, though this was not substantiated in a comparative study.^10,11 Proponents of this technique cite denervation of the orbicularis oculi muscle after transcutaneous blepharoplasty as an etiology of lower lid malposition. Recent studies using electromyography and videography dispute this assumption.¹²

In recent years, emphasis has been given to adding lateral canthal support as an important adjunct to lower lid blepharoplasty. Lower lid malposition and ectropion are among the most feared complications following lower lid blepharoplasty. Lateral canthoplasty and lateral tarsal strip procedures were initially used to correct established lid malposition; however, more recently, it has become an accepted and useful prophylactic measure against lid malposition in cosmetic blepharoplasty.^13,14,15

The 1990s was also a time of intense interest in alternative approaches to midfacial rejuvenation. Just as the brow contributes to the aging changes in the upper lid, cheek descent in the midface commonly accompanies aging changes in the lower lid. Improvement in the aesthetic results has been achieved through a number of alternative methods of addressing the midface along with the lower eyelid. The transcutaneous lower eyelid incision became a popular approach for lifting the soft tissues of the cheek through a subperiosteal or preperiosteal approach.¹⁶ Cheek lifting through a subciliary incision is not in the scope of this chapter.

Alternatively, cheek augmentation either with fat or alloplastic material has been recommended to address the sequelae of midfacial aging.^17,18 As a result of more extensive rejuvenation procedures in the midface and of deep skin resurfacing techniques, lower lid support now is recognized as a critical component of lower lid rejuvenation.

Presentation

Preoperative assessment

Jelks and Jelks have nicely detailed the preoperative evaluation and considerations to minimize postoperative complications and dissatisfaction.¹⁹ First, the surgeon must listen carefully to the patient's description of the problem for which he or she desires correction. Elicit any history of eye surgery or ophthalmologic problems. Query patients about unusual tearing or eye dryness, frequent blinking, redness or burning of the eyes, or contact lens intolerance. Medical disease processes that potentially can result in periorbital problems include hyperthyroidism or hypothyroidism; renal, cardiac, or hepatic dysfunction; and collagen-vascular disorders. Chronic allergies, prior eye surgery, past psychiatric history, tobacco and alcohol use, and steroid usage should also be noted.

The disastrous consequences of perioperative bleeding must be avoided if possible. The use of anticoagulation medications must be discontinued, and the coagulation profile should be normal prior to elective cosmetic surgery in the periorbital area. The patient should discontinue aspirin and antiplatelet agents 3 weeks prior to surgery and for 1 week afterward.

Physical

The goals of the physical examination are to determine the relative contribution of the anatomic components of the lower lid and periorbital area to the patient's complaint and to screen for preexisting ophthalmologic conditions that may affect the surgical approach. Carefully note the surface anatomy of the periorbital region (see Image 4). Preoperative photography is essential for documenting existing eyelid and periorbital anatomy. The recommended preoperative views include full-face close-up views of the periorbital area with eyes in neutral and upward gaze and lateral views. Photographs should be of such quality that valid comparisons can be made between the preoperative and postoperative conditions.

Jelks and Jelks described the relationship between the anterior projection of the globe, lower lid, and malar eminence as representing the key element in the preoperative evaluation (see Image 6).¹⁹ A negative relationship exists when the globe lies anterior to the lower lid and malar eminence. A negative relationship has a high risk of postoperative lid malposition and is an indication to include a technique for lower lid support in the treatment plan.

Perform the lid snap-back test for excess lower lid laxity. If the lid can be distended more than 10 mm from the globe or if the lid does not briskly return to its natural resting state, include a lower lid support procedure in the treatment plan. Document and demonstrate to the patient existing scleral show and lagophthalmos. Record visual acuity for best-corrected vision to screen for unrecognized deficits. Test each eye separately.

McKinney and Byun reported that the Schirmer test and tear film breakup analysis have not been as predictive for postoperative dry eye problems as the preoperative history and physical examination, and they are not performed routinely.²⁰

If the patient has a history of ophthalmologic problems or concerns are identified in the preoperative history and physical examination, preoperative consultation with an ophthalmologist is recommended.

Again, standardized preoperative photographs should be a routine part of the surgeon's preoperative assessment. Fine lines, crow's feet, dyschromias, and telangiectasias should be pointed out to the patient preoperatively. Discussion about adjunctive procedures to address these problems should occur before surgery.

Indications

Candidates for lower lid blepharoplasty should undergo a thorough preoperative history and physical examination. Psychological stability with regard to clearly defined goals and expectations preoperatively is the cornerstone for successful results and satisfied patients in eyelid surgery. Lower lid blepharoplasty can successfully correct excess skin, excess fat, and hypertrophied muscle. Problems such as exophthalmos, eyelid edema, eyelid dyschromias or other lesions, and prominent orbital rims are not correctable by blepharoplasty alone.

Relevant Anatomy

The anatomy and innervation of the lower lid (see Image 1) has been described in detail previously in numerous articles and texts.^{15,13,21,12,22}

• Superficial anatomy: The lower lid margin ideally rests 1-2 mm above the lower level of the limbus and makes a gentle S curve; it defines the lower half of the palpebral fissure.
• Skin: The skin of the lower eyelid is relatively thin and closely attached in the pretarsal area and becomes relatively thicker and more loosely attached as the lid blends into the cheek. This region is susceptible to engorgement by edema fluid. Hester et al named the fibrous attachment from the orbital rim to the skin in the area of the lid-cheek junction the orbitomalar ligament (see Image 2).²¹ This attachment often contributes to a sharp definition between the cheek and lower lid that becomes more pronounced with aging.
• Muscle: The 3 components of the orbicularis oculi muscle are pretarsal, preseptal, and orbital. The muscle is densely adherent to the overlying skin. Medially, the preseptal orbicularis has 2 heads, of which the anterior head becomes the anterior crus of the medial canthal tendon and inserts on the frontal process of the maxilla. The posterior head inserts onto the posterior lacrimal crest. The orbicularis muscle is innervated primarily by the zygomatic branch of the facial nerve laterally and by the buccal branch of the facial nerve medially. These branches join to form a plexus of nerves that penetrate the deep surface of the muscle in a segmental fashion.
• Septum/fat: 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. From a surgical perspective, orbital fat is approached in 3 compartments: the lateral compartment rests slightly above the other 2 compartments, the central compartment and the medial compartment, which are separated from the lateral by the inferior oblique muscle. The lateral compartment is the most frequently missed fat compartment in aesthetic procedures of the lower lid. Resection of the lateral compartment alternatively may be performed through an upper lid approach. The relationship of the lower lid structures to the malar fat pad, superficial musculoaponeurotic system, and suborbicularis oculi fat is depicted in Image 3.

Signs of aging in the lower lid and midface include laxity and loss of elasticity of the skin that results in variable degrees of fine and coarse wrinkling and dyspigmentation, laxity of the tarsus with inferior displacement of the lid margin, pseudoherniation of orbital fat, and descent of the lid-cheek junction and the soft tissues of the cheek. 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.

The classification of midfacial aging by Hester et al is quite helpful in the analysis and choice of surgical procedure for correction (see Image 5).²¹ As a general rule, a procedure confined to the lower lid is appropriate for types 1 and 2 aging but results in limited improvement and dissatisfaction if applied alone to types 3 and 4 aging. Aging beyond the lower lid requires treatment by cheek lift or face lift or perhaps fat injections or malar implants and is beyond the scope of this article. For expert viewpoints and journal articles on additional aesthetic procedures, visit Medscape's Aesthetic Medicine Resource Center. Click here for a CME activity on injectable fillers.

Contraindications

The major contraindication to this surgery is unrealistic patient expectations about the effect of lower lid blepharoplasty on facial appearance.

Patients with endocrinological and other medical conditions that lead to the appearance of lax and bulging lids are generally not candidates for surgical correction.

Patients with dry eye syndrome should be approached with great care, and consultation with an ophthalmologist is recommended for these patients. Only rarely should skin be resected at a secondary blepharoplasty if skin had been resected previously.

• Search for CME/CE on This Topic »

• Blepharoplasty, Lower Lid Transconjunctival (Plastic Surgery)
• Blepharoplasty, Transconjunctival Approach (Otolaryngology and Facial Plastic Surgery)
• Blepharoplasty, Upper Lid (Plastic Surgery)
• Blepharoplasty, Lower Eyelid Laxity (Otolaryngology and Facial Plastic Surgery)

• Eyes Wide Open: Surgery to Westernize the Eyes of an Asian Child
• Facial Resurfacing With Coblation Technology
• Complications of Eyelid Surgery