Lower Lid Subciliary Blepharoplasty 

Updated: May 03, 2019
Author: Scott J Rapp, MD; Chief Editor: James Neal Long, MD, FACS 

Overview

Background

The treatment of the aging periorbita is arguably one of the most powerful rejuvenating facial procedures, with the capability of restoring a freshened, more youthful appearance.[1] The eyes, more specifically, the periorbital tissues are vital in the expression of emotion but also are telling of age, gender, and beauty. Unfortunately, the delicate nature of these intricate structures is susceptible to the effects of ultraviolet light exposure, gravity, and repetitive animation. According to the American Society of Plastic Surgeons, eyelid surgery is the third most common cosmetic surgical procedure, with over 204,000 procedures performed in 2012. This represents a 4% increase since 2011. These data do not include adjunctive nonsurgical periorbital procedures such as chemodenervation, the injection of alloplastic materials, phototherapy, and chemical peels.

The variety of surgical and nonsurgical approaches for rejuvenation of the periorbita necessitates keen knowledge of the pertinent anatomy, clinical judgment in the application of these techniques and experience to avoid potential complications. Multiple surgical techniques have been described to address both the upper and lower eyelids, however, the operative goals are universal. When addressing the lower eyelid, the surgeon’s aims are to eliminate redundant skin, smooth the underlying musculature, tighten the supporting structures if needed, and to resect or redrape excess retroseptal fat to smooth the transition from the lower eyelid to the cheek.

Transcutaneous lower lid blepharoplasty utilizes a subciliary skin incision coupled with adjunctive surgical maneuvers to accomplish these goals. Although this is a powerful procedure for patients seeking periorbital rejuvenation, it must be tailored to the individual to address their anatomical problems.

History of the Procedure

The history of blepharoplasty dates back to more than 2000 years ago when Susruta described eyelid surgery in the Susruta-tantra.[2] Arabian surgeons later in the 10th century cauterized redundant eyelid tissues to restore a more youthful appearance.[3] Ambrose Pare described functional upper blepharoplasty for visual obstruction in the 16th century.[4] In the early 19th century, several aurthors described the resection of excess upper eyelid skin; however, it was Von Graefe in 1818 who coined the term blepharoplasty to describe eyelid surgery.[5, 6, 7] Expanding upon Sichel’s description of herniated retroseptal fat, Bourget described the separate compartments in the eyelids and the transconjunctival approach for excision of lower lid fat.[8, 9, 10]

Based upon these previous contributions, Costañares precisely detailed the anatomy of the eyelid fat compartments, describing what may be considered the modern blepharoplasty.[9] Costañares’ contemporary, Sir Archibald McIndoe was the first to perform a transcutaneous approach to the retroseptal fat utilizing a skin-muscle flap. This technique gained popularity because of the ease of dissection, increasing the margin of safety for the procedure.

In the 1970s, Furnas further characterized the components of the aging lower lid, recognizing the contribution of redundant orbicularis oculi muscle.[11] While prior techniques focused upon resection to restore a more youthful appearance, Loeb recognized that fat preservation and translocation rather than resection, was effective for blending the transition between the lower eyelid and cheek.[12] Hamra championed the cause of fat preservation and expanded the concept with complete release of the arcus marginalis with fat translocation to soften the lid-cheek junction.[13]

The increasing popularity of aesthetic surgery and adjunctive non-surgical options lead to changes in the approach to periorbital rejuvenation in the 1990’s. Surgeons coupled laser and chemical skin resurfacing techniques with transconjunctival lower lid blepharoplasty, touting the efficacy of the technique and its lowered complication rates compared with other techniques.[14] The proponents of this approach espoused that the surgical manipulation of the orbicularis oculi in transcutaneous techniques lead to its denervation, and secondarily to lower eyelid malposition although these claim were not substantiated in comparative studies.[15, 16, 17] Unfortunately, aggressive rejuvenation procedures incorporating surgical and nonsurgical techniques lead to increasing morbidity with a rise in lower lid malposition and ectropion.

In recent years, combining multiple surgical approaches such as using transconjunctival incisions for orbital fat access and preservation paired with a skin-only excision has garnered attention.[18] This technique achieves blending of the lid-cheek junction through re-draping and suspension of orbital fat while avoiding denervation of the orbicularis muscle. More conservative skin removal or “pinch” technique and lateral tightening may reduce lower lid malposition and changes to the eye aperture.[19]

Moreover, the use of autologous fat injection or hyaluronic fillers to restore volume to the periorbita may be applicable in more difficult cases not amenable to traditional eyelid procedures as a result of soft tissue atrophy.[20, 21] However, complications such as blindness, skin necrosis, and contour irregularities have been reported, necessitating further evaluation of outcomes and refinements in technique.[22, 23]

Huang et al described a modified transcutaneous lower lid blepharoplasty technique in which a subciliary elliptical skin excision is made; the medial, middle, and lateral orbital fat compartments are resected; and microautologous fat transplantation (MAFT, using a MAFT-GUN) is used to recontour prominent nasojugal and palpebromalar grooves.[24]

The recognition of patients who are morphologically susceptible to lower lid malposition has led to an emphasis on lateral canthal support as an adjunctive procedure. Lateral canthopexy and canthoplasty are now commonly incorporated maneuvers in lower lid blepharoplasty to aid in the prevention of lower lid malposition.[25, 26, 27] As more interest arises in periorbital rejuvenation, the surgeon will be required to consider not only the medical and anatomic variations in their patients but also the psychological well being of those being selected for an operative intervention.

Presentation

Preoperative assessment

A prerequisite to the planning and the technical execution of any operation is the implicit comprehension of the patient's concerns. Once the patient and the surgeon have a mutual understanding, a comprehensive plan can be constructed, incorporating the patient’s wishes, their underlying anatomical issues, the surgeon’s observations of the problem and the limitations of the procedure. The consultation should first focus upon the patient’s global medical and surgical history, eliciting any issues that may exclude or increase the morbidity of the surgical plan. Chronic medical conditions such as heart disease, hypertension, diabetes mellitus, hepatic disease, thyroid disease and bleeding diatheses should be elicited. A more focused surgical and medical history should be obtained, focusing on prior eye surgery such as photorefractive keratectomy and underlying ophthalmologic conditions such as blepharochalasis.

Subsequent to the patient’s history, a comprehensive review of systems should be conducted, specifically querying the patient about excessive tearing, dryness, frequent blinking, redness and burning of the eyes, and contact lens use.

Of the previously mentioned symptoms, dryness of the eyes deserves special attention. It can have multiple causes including insufficient tear production and excessive tear evaporation. Complaints may include itchy eyes, foreign body sensation, blurry vision, pain, and ocular fatigue. In the general population, 12% of men and 17% of women experience symptoms of dry eyes.[28] If one suspects a patient may have dry eye syndrome or any other ocular complaints, a referral to an ophthalmologist is appropriate.

There are many risk factors for dry eye including environmental, pharmacologic, and systemic illness, however it is important as the surgeon to identify anatomical risk factors on physical examination and to then plan accordingly. A history of previous ophthalmologic surgery such as LASIK, cataract procedures or even prior blepharoplasty also increases the risk for dry eye.[29] Briefly, the Schirmer test has not been shown to be a reliable predictor of patients at risk for dry eye, but rather a detailed history and focused physical examination is a more useful tool.[30]

Chronic allergies, tobacco, alcohol use and current medications including herbal supplements should also be noted. Specifically, aspirin and the use of other anticoagulation medications should be documented. The underlying condition necessitating the use of these medications must be also discerned and the decision made whether withholding these medications is safe for the patient. Bleeding complications can lead to serious morbidity compounded upon the fact that blepharoplasty is an elective surgery. It is our practice to have the patient discontinue aspirin and anti-platelet agents two weeks prior to surgery and for one week afterward if their medical condition will allow this lapse in therapy.

Physical

The physical examination should catalogue the anatomical structures that comprise the lower lid as well as the surrounding periorbital architecture as it pertains to the patient’s concerns. Carefully note the surface anatomy of the periorbital region (see the image below). This survey should also note any anatomical variants that may predispose to postoperative morbidity.

Topographic anatomy of the eyelid. 1.Superior tars Topographic anatomy of the eyelid. 1.Superior tarsal fold 2.Inferior tarsal fold 3.Palpebromalar groove 4.Nasojugal groove 5.Nasolabial fold. Adapted from Jelks, 1993.

In order to devise a comprehensive operative plan to treat the patient’s concerns, the surgeon must have an astute understanding of facial and periorbital aging. The youthful face is grossly characterized by elastic skin without dyspigmentation, well-supported fat and smooth transitions between aesthetic subunits.

In contrast, superficial evidence of aging in the lower periorbita includes changes secondary to actinic damage such as varying degrees of rhytids, the development of keratoses and dyschromias. In general, there is not an over-abundance of excess lower eyelid skin and over-resection can lead to lid malposition.

The supporting structures of the lower lid also succumb to age and gravity, as the tarsus and the canthal ligaments become less elastic causing increased scleral show and lid displacement. The orbicularis oculi and the septum orbitale also become more lax and redundant, permitting the formation of festoons and the pseudoherniation of the orbital fat. To demonstrate this laxity, the lid snap-back test should be performed to ascertain the need for lid support. A positive test is confirmed when one second or more has elapsed before the lid returns to its resting position on the eye after being maximally distracted anteriorly.

Quantitative measures that are clinically significant for lower lid laxity include intraoperative lid distraction of greater than 3 mm of over the lateral orbital rim or 6 mm of anterior distraction away from the globe.[31] If lower eyelid laxity is confirmed upon examination, an adjunctive procedure should be incorporated into the operative plan to provide lower eyelid support.

The surrounding architecture of the periorbita is equally important in determining the indication for lower eyelid support. Notably, the relationship between the anterior projection of the globe, lower lid, and malar eminence, as described by Jelks and Jelks, is a key element in the preoperative evaluation (see the image below).[32] The patient with a negative vector relationship is predictably, morphogenically prone to postoperative lower lid malposition. This relationship exists when the most anterior projecting point on the globe lies anterior to the inferior orbital rim. Thus, a negative vector relationship is an indication to include operative maneuvers for lower eyelid support.

A. Positive vector B. Neutral vector C. Negative v A. Positive vector B. Neutral vector C. Negative vector relationships between the globe and orbit.

The patient with a prominent globe is also morphogenically prone to lower lid malposition postoperatively unless it is recognized preoperatively and addressed intraoperatively.[33] Similar to the assessment of the negative vector relationship, globe prominence is determined by evaluating the position of the globe relative to the orbit. Multiple systems are available, however the Hertel exophthalmometer is most commonly used. It measures the distance between the most anterior projecting point of the globe and the lateral orbital rim. Although ethnic differences exist, globe projection between 15 to 17mm is considered within normal limits.[34] In cases where globe projection is greater than 18mm, special considerations and surgical maneuvers are necessary when addressing the lateral canthus to avoid lower lid malposition, scleral show and ultimately dry eye syndrome. Hirmand et al., provides an excellent description of the management of these challenging cases.[35]

Amongst other important factors to assess is the relative paucity or excess of retroseptal fat. With the patient in an erect position, the quantity of retroseptal fat can be observed, coupled with gentle ballotment of the globe to determine which compartments contain excess fat. While a paucity of fat will exclude fat excision from the operative plan, excess fat can be excised or repositioned to smooth the transition of the lid cheek junction.

A limited ophthalmologic exam should also be performed including visual acuity, evaluation for visual field deficits and extraocular motor function. If any significant deficits exist, the patient should be referred for ophthalmologic evaluation.

Finally, a photographic record should also be established documenting the preoperative periorbital anatomy. We recommend acquiring an anterior and lateral full-face view along with close-up views of the periorbital area with the eyes in neutral and upward gaze. Not only are these photographs an important part of the medical record, but they can facilitate a discussion about the patient’s anatomical problems and what can be realistically addressed.

Indications

Before a patient may be considered a candidate for lower lid blepharoplasty, a thorough preoperative history and physical examination should be obtained. A patient’s appropriateness for surgery should also include the feasibility of achieving their goals and meeting their expectations regarding the surgical outcome. In a sequential fashion, lower lid blepharoplasty can successfully address redundant skin and muscle, laxity of the septum, excess fat, lower lid malposition and prominence of the nasojugal groove. Problems related to exophthalmos, blepharochalasis and eyelid dyschromias are not surgically correctable with lower lid blepharoplasty and thus are not surgical indications for this procedure.

Relevant Anatomy

Detailed descriptions of the anatomy and innervation (see the image below) of the lower eyelid is described in numerous articles and texts.[17, 25, 27, 35, 36]

Anatomy of the periorbital region. Anatomy of the periorbital region.

Anatomic topography

The lower lid margin commonly rests 1-2 mm above the inferior border of the limbus, making a gentle S curve. This border represents the lower half of the palpebral fissure. When the lower lid rests below the limbus, the patient exhibits scleral show.

Skin

The delicate skin of the lower eyelid is closely adherent to the underlying tarsus superiorly, becoming thicker in quality over the more caudad preseptal region. The youthful lower eyelid has a smooth transition into the malar eminences. A hallmark of periorbital aging is an abrupt transition between the lower eyelid and cheek, defined by the radial expansion above and below the orbitomalar ligament (see the image below).[35]

Cross sectional anatomy of the lid-cheek junction. Cross sectional anatomy of the lid-cheek junction.

Muscle

The orbicularis oculi muscle is closely adherent to the overlying periorbital skin and is designated into three zones: the pretarsal, preseptal, and orbital regions. The preseptal orbicularis oculi muscle splays into two heads. The anterior head coalesces into the anterior crus of the medial canthal tendon, which inserts on the frontal process of the maxilla. The posterior head inserts dorsally onto the posterior lacrimal crest. The orbicularis muscle is segmentally innervated primarily by the zygomatic distribution of the facial nerve laterally and secondarily by the buccal branches medially.

Septum/fat

The orbital septum is a fibrous membrane that confines the intraorbital fat to the orbit. The arcus marginalis is the insertion of the orbital septum onto the osseous orbital rim. The retroseptal fat is divided into the medial, central and lateral fat compartments. The medial and central fat compartments are separated by the inferior oblique muscle, which can be injured during transcutaneous fat excision secondary to its anatomic location.[37] The lateral fat compartment is frequently under-resected in aesthetic lower lid blepharoplasty and can be approached from either a lower or upper lid approach, depending upon the patient’s anatomic concerns.

Lateral Canthal Tendon

The lateral canthal tendon (LCT) has been a controversial area of periorbital anatomy, however recent reports of cadaveric dissections in the literature have attempted to clarify its nature.[38, 39] The LCT attaches the tarsal plate to the orbital rim via a fascial support system and can be separated into a superficial and deep component. The LCT is bordered anteriorly by adipose tissue (Eisler’s pocket) and posteriorly by the check ligament of the lateral rectus muscle. The term “tendon-ligament” has been used to describe the anatomic connections between the tarsal plate and the pretarsal orbicularis oculi muscle medially to the orbital tubercle laterally, which provides structural fixation of both the upper and lower lids. The LCT also allows for mobility of the lateral canthal angle by its posterior fibrous attachments to the check ligament of the lateral rectus muscle, which is evident upon extreme lateral gaze. It is this structure that must be addressed topreventlowereyelid malposition and sequelae when the patient presents with underlying lower lid laxity, a negative vector relationship or a prominent eye.

Contraindications

Patient selection is of paramount importance when deciding who is an appropriate candidate for any elective aesthetic procedure. Conditions that would preclude a patient from undergoing periorbital rejuvenation include patients with unrealistic expectations and/or significant medical comorbidities. Specifically, patients with underlying endocrinological or conditions such as dry eye syndrome should be carefully evaluated. An ophthalmologic evaluation should be strongly considered if these patients are being considered for periorbital rejuvenation.

 

Treatment

Intraoperative Details

Patient preparation, marking, and incision

Anesthesia routes for the procedure should be carefully considered before the operation, balanced with the desires of the patient and the complexity of the operative plan. The procedure can be performed under local, monitored anesthesia care with local anesthesia or general anesthesia.

The face is prepared with povidone-iodine paint and a subciliary incision is designed approximately 2mm below the ciliary margin. If possible, a natural crease should be selected to aid in camouflaging the scar (see the image below). It is important that the extension of the lateral incision is not carried past the orbital rim to prevent surgical stigmata.

Subciliary incision design as reported by Rees and Subciliary incision design as reported by Rees and Dupuis.

After the administration of MAC or general anesthesia, a 30-gauge needle on a small-volume syringe is used to infiltrate along the designed incision in the subcutaneous, pre-muscular plane with 1% lidocaine with 1:200,000 epinephrine buffered with 8% sodium bicarbonate, mixed in a 1:5 ratio. The lateral and inferior orbital rim should also be infiltrated at the level of the periosteum if a canthopexy/canthoplasy or arcus marginalis release is planned. A period of 7-10 minutes is allowed to elapse to maximize the vasoconstrictive effects of the epinephrine. The contralateral side can be addressed after completion of the first side.

Flap elevation

The lateral portion of the incision is made along the predetermined marking, leaving the orbicularis oculi muscle beneath the skin intact. A curved iris scissor or tenotomy scissor is then employed to develop a subcutaneous plane along the subciliary marking and the skin is cut accordingly, avoiding the eyelashes.

A Frost suture (5-0 nylon or silk) may then be placed in the gray line lateral to the limbus, to protect of the globe and to facilitate retraction. In addition, a well-lubricated corneal shield may also be inserted.

Depending upon the anatomical correction required, a skin only or skin-muscle flap is then elevated. If a skin flap is chosen, it is elevated down to the level of the inferior orbital rim or the last skin wrinkle. Electrocautery under low power is used to achieve hemostasis throughout the course of dissection.

A skin-muscle flap may be elevated using the same incision. When this approach is utilized, a skin flap is elevated, preserving the most cephalad 4 mm of pretarsal orbicularis oculi muscle. Once completed, the orbicularis oculi muscle is then divided. The avascular retro-orbicularis plane is then developed down to the level of the inferior orbital rim, between the overlying muscle and the orbital septum. Special care should be taken not to perforate the septum (see the image below). Castro recommends a skin-muscle flap if there is orbicularis oculi muscle redundancy or flaccidity.[40]

Technique of skin-muscle flap elevation from Rees Technique of skin-muscle flap elevation from Rees and Dupuis.

Management of orbital fat

The management of orbital fat is best determined before entering the operating room. Preoperatively, the presence or absence of excess orbital fat is assessed while the patient is sitting erect. With this information, clinical decisions can be made regarding the volume and location of fat excision or whether retroseptal fat should be preserved. This is more difficult to do in a supine position, however, balloting the globe can aid in judging whether excess retroseptal fat has been adequately excised. The negative effects of over-resection of lower lid retroseptal fat include a hollowed-out, cadaveric appearance.

In the event that a skin flap has been elevated, button-hole type incisions can be made in the orbicularis muscle through the septum over the medial, central and lateral fat compartments, depending on which compartments contain excess fat. A skin-muscle flap affords the surgeon exposure to all of fat compartments. After injecting the target of excision with local anesthetic, the septum is incised. Excess orbital fat can then be teased out with fine forceps and a cotton-tip applicator, and subsequently resected with a fine-tip insulated electrocautery (see the image below). Routine identification of the inferior oblique muscle prior to fat resection of the medial and lateral compartments is not necessary.

Depiction of retroseptal fat compartments and fat Depiction of retroseptal fat compartments and fat resection.

Release of the arcus marginalis and the orbicularis oculi muscle attachments at the medial and central aspects of the inferior orbital rim is a useful adjunct that can blunt a prominent tear trough/nasojugal groove.[13] Our practice is to mark the nasojugal groove in the preoperative setting with the patient sitting. Once adequate exposure is achieved whether the approach is transcutaneous or transconjunctival, the medial and central attachments of the arcus marginalis are released along the previously marked line. After hemostasis achieved, blunt dissection in a supraperiosteal plane is performed along the inferior orbital rim with a Freer elevator to create a pocket for the transposed fat. The retroseptal fat in the medial and central compartments is then gently transposed over the inferior orbital rim and secured with several interrupted 5-0 Vicryl suture to the base of the pocket.

Liapakis et al described a subciliary technique that uses fat redraping blepharoplasty and a midface lift to address tear nasojugal groove deformity and midface laxity. The procedure includes a subciliary incision in which fat removed from the nasal fat pad is repositioned, with suturing performed at the inner canthus, followed by a canthopexy to secure the lower eyelid. The technique also utilizes a cheek flap, which is suspended through a tunnel at the periosteum of the upper-lateral orbit. The study reported on 35 procedures, with stable results seen at 4-year follow-up.[41]

Alternative techniques have also been described to manage the pseudoherniation of retroseptal orbital fat. Huang proposed suture plication of the orbital septum to blunt the transition of the lower lid into the malar eminence by smoothing redundant septum (see the image below).[42] Hamra later described a septal reset procedure to address redundancy whereby the orbital septum is released from the arcus marginalis and re-sutured over the inferior orbital rim, smoothing the transition between the lid-cheek junction.[43]

Huang's technique for plication of the septum. Huang's technique for plication of the septum.

Stevens et al described a triple-layer midface lift procedure, performed in 512 patients, in which postseptal fat, suborbicularis oculi fat, and the musculocutaneous layer of skin and orbicularis oculi are repositioned through a subciliary incision.[44]

Orbicularis oculi muscle

After management of the orbital fat is completed, elevation and fixation of the orbicularis oculi muscle has been utilized to smooth redundant muscle and to aid in support of the lower lid. Hamra described using a laterally based pendant of redundant orbicularis oculi muscle and suspending it to the lateral orbital rim through an upper lid incision (see the image below).[13] McCord et al. proposed a similar maneuver in which the pretarsal orbicularis oculi muscle and overlying skin are affixed to the internal lateral orbital rim in superolateral vector.[45] If extra support is not indicated, 1-2 mm of orbicularis oculi muscle may be excised from the skin muscle flap.

Hamra's lateral orbicularis suspension. Hamra's lateral orbicularis suspension.

Lower lid support

Lower lid malposition including lower lid retraction, scleral show and ectropion is a potential complication especially in the morphogenically prone patient. Lower lid laxity as determined by excess anterior distraction of the lid, prolonged snap back testing, a negative vector relationship and prominence of the globe are all preoperative risk factors and in the opinion of many authors, definitive indications for lateral canthal tightening.[25, 26, 27, 45]

Multiple algorithms to determine the appropriate technique used for lateral canthal support have been described and are beyond the scope of this review.[25, 26, 27, 45] In our practice, we perform a canthopexy in patients with a negative vector relationship and mild-moderate lower lid laxity as defined by an abnormal snap back test (greater than 1 second) and in patients with less than 6mm of anterior lower lid distraction.[46]

Many different techniques utilizing various sutures and fixation methods have been published.[25, 26, 27, 45] It is our practice to approach the lateral retinaculum from the lateral aspect of an upper blepharoplasty incision similar to Fagien’s technique (see the image below).[27] The lateral retinaculum is grasped through the upper lid incision with fine tip forceps and manipulated to confirm its anatomic identity. A 5-0 vicryl suture is then passed through the lateral retinaculum from the upper lid incision into the lateral aspect of the lower subciliary incision. From the lower subciliary incision, the lateral retinaculum is captured again with the suture and brought out the upper lid incision. While protecting the globe, the suture is then passed into the periosteum approximately 4mm internal to the lateral orbit rim at the caudad border of the pupil. The suture is tightened to visualize the superoposterior movement of the lateral canthal angle, coapting thelowerlidtotheglobe.

Fagien's simplified lateral canthopexy. Fagien's simplified lateral canthopexy.

Canthoplasty is best reserved for patients with significant lower lid laxity as defined by McCord as greater than 6 mm of anterior distraction of the lower lid from the globe.[45] In general, canthoplasty as it pertains to aesthetic blepharoplasty, involves lysis of the lower lid’s contributions to the lateral canthus, excision of the excess lateral lower lid followed by anatomic re-suspension of the lower lid and tarsal plate to the lateral orbital rim (see the image below). Other horizontal lower lid shortening and support techniques have been described such as the tarsal strip canthoplasty and Kuhnt-Symanowski procedures and are beyond the scope of this review.[27, 45, 47, 48]

Fagien's lateral canthoplasty. Fagien's lateral canthoplasty.

Skin excision

Management of the excess lower eyelid skin is performed in a judicious manner, given that overly aggressive skin excision is a contributing factor to lower lid malposition. Under no tension, the skin is gently re-draped over the underlying lower lid structures. A vertical “pilot cut” is made at the level of the lateral canthus and a 6-0 nylon suture is placed approximating the superficial skin edges at this point. Once this point is affixed, the skin medial and lateral to this point is excised at the level of the subciliary incision (see the image below).

Skin excision and closure. Skin excision and closure.

If a skin–muscle flap was elevated, the suture is then removed and the redundant orbicularis oculi muscle is excised so it approximates under no tension to the pretarsal orbicularis that was preserved with flap elevation. The superficial skin edges are then re-approximated using alternating interrupted 6-0 nylon sutures and 6-0 fast absorbing gut sutures.

Postoperative Details

Postoperatively, chilled gel or ice compresses are applied to the periorbita for the first 24-48 hours and for comfort thereafter to control edema. Patients should be observed for at least 1-2 hours in the recovery unit and discharged only after checking their vision. Postoperative instructions should include elevation and avoidance of strenuous activity to decrease edema, lower intraocular pressures and to reduce the likelihood of hemorrhage.

Ocular lubrication with artificial tears and nighttime lubrication with ophthalmic bacitracin ointment is recommended for all patients. This is particularly important if the patient has a preexisting history of dry eyes or if lagophthalmos is present subsequent to edema. While the use of lubrication can prevent corneal abrasions and reduce exposure, prophylactic treatment with an ophthalamic tobramycin and dexamethasone solution can aid in the prevention and hasten the resolution of chemosis.

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 disturbances merit careful attention and evaluation. Sutures are removed 4-7 days following surgery.

Complications

Visual loss/Retrobulbar hemorrhage

The most devastating complication from an aesthetic procedure is the loss of normal physiologic function. Although rare, visual loss is the most feared complication in periorbital rejuvenation, resulting primarily from retinal/optic nerve ischemia secondary to increased intraocular pressure caused by retrobulbar hemorrhage. The frequency of this complication is 0.0045% or one case in 22,000 procedures. A more common complication is the incidence of retrobulbar hemorrhage, which was reported in 1 of 2000 cases or 0.05%. In this series, 96% of the reported hemorrhages occurred within the first 24 hours and more than half within 6 hours of the procedure.[49] Thus, timely recognition and emergent intervention is of paramount importance.

In this circumstance, patients will report a constellation of symptoms including periorbital pain and pressure. These complaints should be taken seriously as these patients may initially present only with periorbital edema and subconjunctival hemorrhage. As intraorbital and intraocular pressures increase, superior orbital fissure syndrome may ensue, defined by proptosis, ptosis and diplopia secondary to paralysis of the extraocular muscles. The addition of visual deterioration defines orbital apex syndrome.

Prevention begins by thoroughly screening the patient at the time of the preoperative assessment for risk factors that may exacerbate hemorrhage. Intraoperative measures are equally important, including perioperative blood pressure control, meticulous hemostasis, retroseptal fat excision under direct vision and the avoidance of deep injections. Postoperatively, antiemetics should be administered and patients are instructed to avoid strenuous activity for 2 weeks.

If retrobulbar hemorrhage or visual changes occur postoperatively, the patient must be evaluated emergently for medical and surgical intervention. Elevated intraocular pressures can be treated with topical and systemic glaucoma medications. Systemic corticosteroids can also be administered. Surgical management consists of suture removal and evacuation of hematoma with subsequent control of any hemorrhage. If no improvement is noted, a lateral canthotomy and cantholysis is performed. In rare circumstances, decompression of the orbital apex is warranted if computed tomographic scan confirms the diagnosis of more posterior hemorrhage.[50]

Lower lid malposition

Lower lid malposition can be an equally devastating complication. In the intermediate postoperative period it is one of the most common complaints, usually attributed to excess skin resection, edema, superficial hematoma, tethering of the orbital septum or failure to provide lower lid support in the morphogenically prone patient. Temporary paralysis of the orbicularis oculi muscle can also result in lid malposition. Mild scleral show and lid malposition can be initially managed with massage and lubrication.[51] Another option is to remove sutures on postoperative day 2 or 3 to allow for a gap in the wound, which is less aesthetically ideal, but decreases the chance of an ectropion.[52] The failure of conservative measures indicates that there is either deficient tissue from overresection, cicatrization or horizontal lid laxity. The first two causes are usually amenable to skin grafting whereas lower lid laxity is addressed with a combination of lid shortening and lateralcanthalrepositioningprocedures.

Corneal abrasion

Corneal abrasion is another preventable cause of vision loss, albeit temporary in most circumstances. Patients will report symptoms of eye pain, complaints of a foreign body sensation, altered vision and light sensitivity that manifests immediately after surgery. If a corneal abrasion is suspected, ophthalmologic evaluation is warranted. The diagnosis is confirmed by examining the eye under a Woods lamp after the application of fluorescein drops. Prevention of epithelial desiccation and intraoperative corneal injury is accomplished with careful attention to technique, lubrication and the use of eye shields. Ophthalmic antibiotic ointment is an effective treatment of superficial injuries, and the patient’s progress should be monitored daily until their symptoms resolve. A prolonged course should prompt a referral to an ophthalmologist for evaluation.

Dry eye syndrome

Postoperative prevention of dry eye syndrome should focus on minimizing edema, maximizing hydration and lubrication, and preventing infection. Head elevation, cool compresses, artificial tears and lubricating ointments should be routinely used. Strategies for reducing the risk of postoperative dry eye in high-risk patients include staggering the timing of the upper and lower procedures, temporary tarsorrhaphy, lateral canthal support and punctal occlusion. Judicious excision of lower lid skin is also extremely important for preventing lid malposition and its sequelae.

Chemosis

Chemosis is defined as edema of the bulbar and fornical conjunctiva which is often associated with inflammation. It is the result of intraoperative dissection resulting in lymphatic dysfunction and edema, which leads to a self-propagating cycle of conjunctival exposure, inflammation and worsening chemosis.[53] As with corneal abrasions, patients may present with complaints of a foreign body sensation, irritation and epiphora. Weinfield et al. presents a comprehensive treatment algorithm for chemosis ranging from conservative measures to surgical intervention. In general, the initial steps for management are similar to the treatment for corneal abrasion and dry eye syndrome, utilizing wetting drops and ophthalmic ointment. More aggressive measures for refractory cases include ophthalmic steroid drops, patching, surgical intervention and systemic steroids.[53]

Other complications

Less common complications include globe perforation during local anesthetic infiltration, central retinal artery embolization, diplopia and infection. While all complex surgical procedures carry some element of risk for complications, transcutaneous lower lid blepharoplasty can performed in a safe, efficient manner as long as proper patient selection, counseling, surgical technique and surgical judgment are exercised.

Outcome

In a study of 100 patients who underwent bilateral skin-muscle flap lower eyelid blepharoplasty, Sultan et al found that the procedure led to a small change in eyelid position, with a mean increase found in the distance from the pupil to the lower eyelid margin of 0.33 mm and a mean increase seen from the lateral limbus to the lower eyelid margin of 0.32 mm. A significantly greater change in both measurements was found in patients who underwent concurrent canthopexy. Revision surgery was need in only two patients secondary to eyelid malposition. New onset of dry-eye symptoms occurred in 25 patients.[54]