eMedicine Specialties > Plastic Surgery > Eyelids

Blepharoplasty, Lower Lid Subciliary: Treatment

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

Treatment

Intraoperative Details

Patient preparation, marking, and incision

• The procedure may be performed with the patient under local or general anesthesia. If local anesthesia is chosen, intravenous sedation with appropriate monitoring is recommended.
• Prepare the face with povidone-iodine (Betadine) paint. Dry the skin and mark the incision with a fine-tip marker approximately 2 mm below the ciliary margin in the first natural crease below the lash line (see Image 7). Extend the incision laterally in a natural crease but not past the orbital rim.
• Using a 27-gauge needle on a small-volume syringe, carefully infiltrate 1% lidocaine (Xylocaine) with 1:200,000 parts epinephrine and 8% sodium bicarbonate combined in a 1:5 ratio subcutaneously in the area of the incision and subcutaneously down to the orbital rim. No deep injections are made. Repeat the method on the contralateral side and allow at least 5-7 minutes for the local anesthetic to take effect.

Flap elevation

• If a skin flap is chosen, score the incision across the lower lid as marked and deepen the incision laterally through the skin.
• With a small hook for retraction, use scissors to develop a subcutaneous plane across the subciliary margin, with care to protect the lashes. Then use sharp scissors to complete the incision and skin hooks to retract the flap.
• The Frost suture of 5-0 silk placed in the gray line lateral or medial to the limbus facilitates retraction and protects the globe. Alternatively, a lubricated corneal shield may be inserted (see Image 8).
• Elevate the flap off the orbicularis muscle down below the last wrinkle or to the orbital rim. Obtain hemostasis using fine-tip cautery under low power.
• If a skin muscle flap is chosen, the original incision is the same. Raise the skin flap to preserve attachment of 4 mm of pretarsal orbicularis muscle (see Image 8).
• Divide the orbicularis muscle; the retro-orbicular plane is identified readily and raised down to the orbital rim.

Management of orbital fat

• The presence or absence of excess orbital fat is a critical determination. This is best assessed by examining the patient preoperatively while he or she is in the erect position and by studying preoperative photographs. Once the patient is supine, judgment regarding excess fat is much more difficult. Gentle pressure on the globe with the eyelids closed causes excess fat to bulge anterior to the orbital rim.
• If a skin flap has been elevated, open the orbicularis by incision over the medial, central, and lateral compartments. If a skin muscle flap is chosen, the exposure of all the compartments is in plain view. Open the compartments and tease out orbital fat with fine forceps and a small cotton-tip applicator.
• If the patient is under local anesthetic, inject a minute amount of local anesthetic before resection. Fine-tip insulated cautery has proven to be an effective tool for resection of excess retroseptal fat (see Image 9).
• The inferior oblique muscle is identified readily, separating the medial and central components, and it is protected easily. The lateral compartment is slightly higher than the central component and should be identified carefully because it is the most common compartment to be overlooked.
• In the case of a prominent nasojugal fold and/or malar fold, an arcus marginalis release may be performed, as described by Hamra in 1996 (see Image 9).⁸
• Open the periosteum along the orbital rim; a small amount of the septum may be resected. Mobilize the orbital fat and resect any extra fat. Preserve the lateral fat in particular. Attach the fat over the orbital rim with interrupted 5-0 Vicryl sutures.
• Alternative means of management of pseudoherniation of orbital fat have been described. Huang proposed supporting pseudoherniation of orbital septum by plication (see Images 10-11).¹⁶ Comparable aesthetic results with arguably less morbidity have been demonstrated. Long-term follow-up observation and more general application of this technique are awaited.

Orbicularis muscle and modified cheek lift

• After management of orbital fat, elevation and fixation of the orbital orbicularis muscle and soft tissue have been used to improve the aesthetic appearance of the lid 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 (see Image 13-14).⁶
• Hamra described using a laterally based pendant of orbicularis and suspending this pendant through an upper lid incision to avoid mass scar effect underneath the lateral skin closure (see Image 15).⁸
• Hester et al expanded the use of the subciliary incision for rejuvenation of the lower lid and midface.²¹ Division of the orbital malar ligament and mobilization of the upper cheek soft tissues in the preperiosteal or subperiosteal plane allow for more complete release of the lateral cheek soft tissues and vertical elevation. The orbicularis muscle and soft tissue are suspended to the lateral orbital rim and temporalis fascia (see Images 16-17). Secure suspension of this tissue along with lower lid support with a canthopexy or canthoplasty; conservative lower lid skin excision is emphasized to avoid complications.

Lower lid support

• Understanding of lower lid malposition has evolved significantly over the past 20 years. The following are indications for lower lid support procedures:
  • Lid laxity is noted in the preoperative physical examination
  • A skin flap technique is performed
  • Moderate-to-deep skin resurfacing procedures are performed
  • A modified cheek lift is performed
• Historically, the Kuhnt-Szymanowski procedure with resection of the lower lid just lateral to the limbus was recognized as a straightforward way of improving lid laxity. Occasionally this resulted in noticeable notching of the lid. In individuals with prominent eyes or low position of the lateral canthus, a Kuhnt-Szymanowski procedure actually may worsen lower lid malposition.
• Fagien described an algorithm for management of the lower lid support that summarizes the current approach.¹⁵ The lateral retinacular suspension with a simplified canthopexy is appropriate as a prophylactic measure in most cosmetic blepharoplasties and is appropriate treatment for mild-to-moderate lower lid laxity. The technique has been well described and is illustrated in Image 19. If significant lower lid length excess is present, horizontal lower lid shortening at the level of the lateral canthus with a tarsal strip and canthoplasty is recommended (see Image 18).

Skin excision

• Excess skin excision is traditionally the most common cause of lower lid malposition after lower lid blepharoplasty.
• Perform skin excision conservatively with skin fully redraped over the underlying lower lid structures. If the patient is under local anesthesia, having the patient look up with the mouth open aids in conservative resection of lower lid skin.
• Make a vertical incision at the level of the lateral canthus and place a key suture. Trim medial and lateral excess. Place sutures to reapproximate the existing edges (see Image 20).

Postoperative Details

• Ice compresses are recommended for the first 24-48 hours to control swelling and bruising.
• Patients should stay in an observational area at the surgery suite for at least 1-2 hours, and they should avoid strenuous exertion.
• Ocular lubrication with artificial tears and nighttime lubrication are recommended, particularly if the patient has a preexisting history of dry eyes or if lagophthalmus is present.

Follow-up

• Clear lines of communication should exist between the patient and surgeon, particularly in the first few days after surgery. Any reports of unusual pain or visual disturbance merit careful attention and evaluation.
• Remove sutures 4-7 days following surgery.

Complications

Blindness is the most devastating complication of cosmetic blepharoplasty. Fortunately, this is quite rare, with a prevalence rate of less than 1 case (0.0045%) in 22,000 procedures (Hass, 2005). Retrobulbar hemorrhage and retinal ischemia have been implicated as causative. Although acute orbital hemorrhage does not always result in permanent visual loss, it is always considered a true ocular emergency and requires urgent intervention. The prevalence of orbital hemorrhage after blepharoplasty is approximately 1 case (0.055%) in 2000 procedures and occurs most commonly in the first 24 hours postoperatively.²³ Measures to reduce the risk of acute hemorrhage include (1) intraoperative and postoperative control of blood pressure, (2) strict control of hemostasis intraoperatively, (3) resection of fat under direct vision, and (4) avoidance of deep injections. Patients must avoid aspirin or antiplatelet agents for a minimum of 2 weeks before surgery.

Postoperatively, orbital hemorrhage is recognized by patient reports of pain, swelling, and proptosis. Associated changes in light perception may also be present. This condition is a true emergency that requires an emergency evaluation by an ophthalmologist. Open the incision, evacuate clots, and control bleeding. Usually, no one bleeding point is defined. If increased orbital pressure is suspected, perform a lateral canthotomy with lateral cantholysis. Control hypertension and consider osmotic diuresis.

Corneal injury is preventable by careful attention to technique, adequate corneal lubrication, and use of shields. If injury is suspected, diagnosis can be confirmed with fluorescein staining and illumination with a Wood lamp. Superficial injuries are managed with topical antibiotics. Patients should be reevaluated every 24 hours initially. More extensive or persistent injuries should be referred to an ophthalmologist.

Diplopia following blepharoplasty can be transient, related to edema or hematoma. Permanent diplopia results from injury to the periocular muscles or nerves. The inferior oblique muscle is the most frequently injured structure in lower lid surgery.²⁴ Conservative management is recommended initially. Persistent reports of diplopia should be referred for strabismus surgery.²⁴

Mild lagophthalmos occurs frequently and is usually present in the first week after blepharoplasty. Reports of blurred vision and irritation are associated with early postoperative lagophthalmos. Conservative treatment such as taping, lubrication, and massage are typically used until the problem resolves spontaneously. Persistent lagophthalmos may be due to overresection of skin or anterior lamellar scarring. Definitive surgical correction is necessary to correct persistent corneal exposure due to lagophthalmos. Surgical release of the scar with full-thickness grafts is occasionally required.

Lid malposition can be avoided by recognition of preoperative risk factors and by intraoperatively performing canthopexy and canthoplasty as appropriate. Postoperatively, lower lid support may be improved with taping or a temporary Frost suture during the first 4 days of peak edema.

Aesthetic problems following blepharoplasty include a hollowed-out appearance of the socket from overresection of fat. Conservative fat resection, as advocated by Hamra, can prevent this problem.^8,25 Occasionally, the patient reports underresection of fat. According to Putterman, the lower lateral compartment is most likely to be underresected.²⁶ Patient dissatisfaction resulting from preexisting fine lines and shadows may be addressed with adjunctive laser treatment, chemical peels, fat injections, or selective use of botulinum toxin (BOTOX®-A, Allergan), depending on the individual problem.

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