Lower Eyelid Blepharoplasty: A Procedure in Evolution

Abstract

The commonly perceived aging changes in the lower eyelid are a natural consequence of the anatomic attachments and age-related changes in the periorbital tissues. A variety of techniques have evolved to address cosmetic concerns in the lower eyelid including subtractive blepharoplasty techniques, elevation of ptotic eyelid and midface tissues, and the injection or implantation of autogenous or alloplastic materials to diminish lower eyelid “bags.” Greater anatomic understanding of the pathogenesis of aging changes in the lower eyelid has led to more anatomically conservative and appropriate cosmetic surgical treatments. The decline in purely subtractive surgical techniques in blepharoplasty surgery and the advent of fat repositioning and other volume enhancement techniques has improved surgical outcomes.

Introduction

Lower eyelid blepharoplasty has evolved since the early 1900s when Charles Conrad Miller published the first photograph showing the resection of excess skin from the lower eyelids in an approach very similar to that sometimes used today.¹ In 1924, Julien Bourguet of France first described a transconjunctival approach to the resection of herniated periorbital fat.² This combination of skin and fat resection has been an integral part of cosmetic lower eyelid surgery. The modern technique of “subtractive” blepharoplasty was codified by Salvador Castañares in 1951.³ As our understanding of the aesthetic and anatomic sequelae of aging and these subtractive surgical techniques has advanced, techniques of periocular rejuvenation have evolved to include volume enhancement of the lower eyelid to soften the “tear trough” or line that demarcates the eyelid and cheek.⁴

Understanding Aging Changes in the Lower Eyelid

The desire to defer the consequences of aging and maintain youth are as old as human consciousness. Characteristic age-related changes in facial shape occur from infancy through youth, middle-age and senescence. These morphologic changes provide clues to youth and sexual maturity which closely interface with societal perceptions of “beauty.” For over a century surgeons have attempted to surgically modify facial shape to restore youthful morphology.

In the lower eyelid and midface, a series of age-related changes occur that patients commonly wish to modify on a cosmetic basis. These changes include a deepening of the fold running along the orbital rim (“tear trough” defined below), increased prominence of the orbital fat pads with an apparent “dark circle”, an increase in relaxed and dynamic wrinkling of the lower eyelid skin along with actinic and other aging changes in the face, and the loss of facial volume in the temple, cheek and other facial sites resulting in flattening and sagging of the face.

The line that defines the junction between the eyelid and cheek was defined by Duke-Elder and Wybar in 1961 as the “nasojugal fold.”⁵ Flowers re-named this sulcus the “tear trough deformity” in 1969 given the observation that tears will track along these groove.⁶ Age-related changes in the contour of the periorbital soft tissues results in deepening of this tear trough deformity that creates a tired appearance. The shadow created by this groove is commonly perceived as a dark circle under the eye that is difficult to conceal with makeup. Osseous atrophy with aging may further contribute to the loss of soft tissue support and descent of the cheek which deepens the tear trough.

Anatomy

The current understanding of the anatomic attachments producing a prominent “tear trough” rely on the cadaveric dissection studies of Kikkawa and Muzaffar, et al.^7,8 They describe the ligamentous attachment between the orbicularis muscle and the underlying orbital rim and deeper midfacial structures. The central portion of this attachment is skeletonized the most and distends more with age allowing for greater descent of the central fat pad. See Figure 1. Greater laxity of the lid-cheek junction with age contributes to the tear trough deformity by accentuating the apparent herniation of orbital fat.

Figure 1.

Schematic overlay showing the pathogenesis of a double convexity deformity in the eyelid and prezygomatic area due to laxity of the orbicularis retaining ligament (small arrow) with a prominent tear trough (large arrow).

Treating the Tear Trough Deformity

Surgically Invasive Techniques: Drawbacks of Traditional Blepharoplasty

Historically, surgeons have removed prominent prolapsing orbital fat in an attempt to level the preseptal portion of the eyelid with the orbital rim. Such approaches are generally performed transconjunctivally as an evolution of Bourquet’s technique², or via an external approach, as an evolution of the techniques described by Castañares.³ Excessive fat sculpting is now well known to increase the relative prominence of the tear trough and to accentuate hollowing and a skeletonized eyelid appearance along with eyelid retraction in the post-blepharoplasty patient. See Figure 2. The poor long-term results of excessive fat sculpting in attempting to cosmetically improve eyelid appearance has led to more conservative techniques which generally involve the repositioning of tissues and augmentation along the orbital rim attempting to mask the prominence of the tear trough.

Figure 2A.

Preoperative photograph of young patient with familial prominent fat pseudoherniation, classically considered an excellent candidate for transconjunctival fat removal.

Fat Repositioning Techniques in Blepharoplasty

In 1981, Loeb reported a novel surgical approach to lower blepharoplasty involving vascularized fat pads from the eyelid “sliding” into the cheek to fill the tear trough.⁹ His technique was performed through a subciliary skin incision with exposure of the medial and central lower eyelid fat pads.

In 1995, Hamra popularized the use of vascularized fat in the filling of the tear trough by modifying Loeb’s fat sliding technique.¹⁰ His technique relies on a subciliary incision with a skin-muscle flap and complete exposure of the orbital septum and malar eminence. The medial and central fat pads are sculpted and advanced over the orbital rim, suturing to the preperiosteal fat of the malar eminence. Hamra further revised his lower eyelid blepharoplasty surgery to the “septal reset” technique in 2004.¹¹ Hamra provided a major improvement of prior techniques, in that they comprehensively deal with the tear trough medially and the aging changes in the inferior eyelid and orbit. His “septal reset” attempts to optimally integrate eyelid surgery into a comprehensive approach to the midface.

Fat repositioning through a transconjunctival approach was described by Goldberg in 1998.¹² The transconjunctival approach, first described in 1924, had been used for fat excision alone. As newer pathophysiologic concepts of the aging face and volume rejuvenation of the face were being discovered, transconjunctival lower eyelid blepharoplasty has continued to evolve. Goldberg described release of the medial and central lower eyelid fat pads with a subperiosteal dissection and fixation of fat in a subperiosteal plane using buried sutures or externalized sutures. Advantages of Goldberg’s approach include avoidance of a skin incision and potential scarring in the middle lamella of the eyelid, with an excellent ability to address the contour changes of the tear trough. Disadvantages include the use of the less anatomic and more difficult subperiosteal plane with potential concerns of fat palpability and survival.

Author’s Current Technique

Our current surgical technique combines the concept of septal reset with a transconjunctival approach in the lower eyelid.¹³ Exposure of the arcus marginalis is achieved through a transconjunctival incision. A CO₂ laser is used in office procedures, mainly due to the minimal discomfort when cutting and excellent hemostasis. The orbital septum is incised at the level of the arcus marginalis. Medial and central fat pads are trimmed minimally if there is excess herniation. More commonly a modest resection of the lateral fat pad is performed. Dissection is then carried inferiorly with blunt scissors in an intrasuborbicularis oculi fat (SOOF) plane. See Figure 3. This dissection is carried 10–12 mm inferior to the orbital rim. A fat transposition at the junction of the medial third and lateral two-thirds of the inferior orbital rim is desirable in the majority of patients, and a more extensive transposition involving the lateral fat pad is necessary in a smaller number of patients. One to three mattress sutures of 5-0 polypropylene are passed from the cheek into the dissected pocket. A robust bite is taken weaving through the central and medial fat pads, repositioning this fat over the orbital rim and and fixating in the intra-suborbicularis oculi fat plan. The polypropylene suture is passed through a foam bolster, tied on the skin and removed in six days. In patients with significant horizontal eyelid laxity the externalized suture may be eliminated in favor of direct suturing of the fat pads into the cheek pocket with 5-0 Vicryl suture.

Figure 3.

Undermining in the intra-SOOF plane after exposure and cautery along the orbital rim. A: Silk traction suture to conjunctiva. B: Kaye blepharoplasty scissors. C: Small Desmarres retractor. The fine dotted line indicates the level of tear trough. The heavy dotted line indicates the exit site of the mattress suture (already passed through bolster on patient’s left eye). Arrows indicate the direction and scope of undermining.

Used with permission.

Most patients undergo light or medium depth Erbium-YAG laser skin resurfacing with a dual-mode Erbium- YAG laser (Sciton®) at the end of the procedure. Lateral canthopexy and direct excision of excess skin via a subciliary incision are performed as needed to address eyelid laxity and skin redundancy.

Advantages of this surgical approach include only a moderate increase in complexity from the standard transconjunctival lower blepharoplasty techniques. The majority of patients can undergo this approach as an office procedure with minimal oral sedation plus local anesthetic. Results are generally excellent with almost all of the few cases of ectropion or residual aesthetic deformity occurring early in the authors series of over 200 patients treated with this technique.

Alternate Approaches: Fat Graft Techniques

Autogenous “fat pearls” have been used since the 1980s, with good results reported when used as an adjunct to lower eyelid blepharoplasty. During lower and upper eyelid blepharoplasty, excess herniated fat pads are readily amenable to becoming donor fat grafts to place in areas of depression. Free fat or dermis-fat grafts may also be harvested from other body sites. These fat grafting techniques have special application in the correction of the patient with contour deficits as a result of prior blepharoplasty surgery. Autogenous fat grafting by lipoaspiration and lipoinjection (liposculpture) is a method of small incision filling of facial defects that provides a potentially permanent result.¹⁵ Advantages over collagen and synthetic fillers are the autogenous nature, easy accessibility of fat and potential to place large volumes. Popularized by Sidney Coleman and others, the injection of fat is performed from many different angles and in multiple planes to achieve optimal consistency and contour. See Figure 4.

Figure 4.

Surgical results with authors technique shown preoperatively (left) and three months postoperatively (right). This patient underwent upper and lower blepharoplasty with fat repositioning technique as described and fat transfer (liposculpture) to the midface. Excellent effacement of the tear trough is achieved.

The survival of micro fat globules depends on oxygen diffusion and the proximity of a well-vascularized bed to provide for the nutritional requirements of the grafted fat. Typically multiple treatment sessions are needed. The difficulties with contour, initial overcorrection, replacement by scar tissue, and fat necrosis often requiring multiple procedures are encountered with fat transfer techniques.

Attempting to avoid the complications of free- and pedicled fat grafts, Flowers developed a silicone tear trough implant of differing thickness and contour.⁶ The selection and placement of these implants is performed with the patient supine with careful markings on the skin to delineate the necessary pocket dimensions. Numerous tear trough implants derived from Flowers original concept exist. Problems with these implants including infection, migration, and palpability or visibility have limited their popularity.

Midface Lifting and the Tear Trough

Midface ptosis is a prime causative factor in increasing the prominence of the tear trough with age. Laxity of the eyelid tissues in the preseptal eyelid and pseudo herniation of eyelid fat with age in concert with involutional midface ptosis bares the now thinned skin and orbicularis muscle tethered over the tear trough.

A variety of techniques of surgical midface elevation ranging from transpalpebral approaches advocated by Hester and colleagues¹⁶ to endoscopic techniques advocated by Ramirez¹⁷ and others are employed to address the tear trough, malar fat pad ptosis, the nasolabial fold and aging changes in the eyelid and midface. Midface elevation is integral to the fat repositioning blepharoplasty techniques described, and is often performed as an adjunctive procedure, as the orbicularis muscle and periorbital midface is already released. Additionally, the tension vector on the repositioned fat elevates the midface and appears to contribute to the harmonious results achievable with these techniques.

Minimally Invasive Injection Techniques

Restoring a smooth contour by volume enhancement has been the mainstay of minimally invasive treatment for tear trough deformities. The number of options available speaks to the inadequacy of any one technique in successfully erasing midface aging changes related to volume loss. Minimally invasive transcutaneous injections are utilized with greater success since the advent of hyaluronic acid tissue fillers Restylane (Medicis Pharmaceutical Corp., Scottsdale, AR) and Juvederm (Allergan Pharmaceuticals, Irvine, CA).¹⁸

Summary

The past 50 years have seen significant advances in our understanding of anatomic basis of aging changes in the periorbital area. This combined with a rigorous examination of surgical goals and results has in turn led to improvements in aesthetic surgery of the eyelid and midface. Surgical techniques continue to evolve and yield a more natural and harmonious rejuvenation of the face.

Figure 2B.

Postoperative photograph following transconjunctival blepharoplasty with fat removal only. Note the increased prominence of the tear trough medially and the deeper supratarsal fold.

Biography

John B. Holds, MD, FACS, MSMA member since 1991, is a Clinical Professor in the Departments of Ophthalmology and Otolaryngology-Head and Neck Surgery, Saint Louis University.

Contact: jholds@sbcglobal.net