INTRODUCTION
Lower lid blepharoplasty is one of the most complex procedures performed by plastic surgeons. Here we provide a comprehensive and systematic approach to the lower eyelid, which is critical for lower lid blepharoplasty success.
PREOPERATIVE PLANNING
A thorough ophthalmic history must be taken, specifically as it relates the to use of corrective lenses, glaucoma, allergic reactions, excess tearing, and dry eyes.1 No periorbital aesthetic surgery should take place within 6 months of refractory surgery. Evaluation should include facial proportions, skin type, skin excess, snapback, palpebral fissure size/shape, fat herniation, tear trough, canthal position, extraocular muscle function, Bell’s phenomenon, levator function, margin reflex distance, brow and eyelid ptosis, and globe position relative to malar prominence. (See Video 1 [online], which displays facial analysis.)
Video 1. Facial analysis. Video 1 from “The Five-Step Lower Blepharoplasty Technique Refined”.
OPERATIVE TECHNIQUE
Step 1: Deep Malar Fat Compartment Augmentation
Fat is injected into the deep malar space from the alar base as an entry point, using a 2-mm blunt single side–hold cannula approximately one fingerbreadth below the orbital rim, correcting malar deflation and the inverted-V deformity.2,3 (See Video 2 [online], which displays deep malar fat compartment augmentation.)
Video 2. Step 1: Lower Blepharoplasty Technique. Video 2 from “The Five-Step Lower Blepharoplasty Technique Refined”.
Step 2: Transconjunctival Removal of Lower Lid Fat (If Indicated)
Only a small amount of fat is removed, proceeding from the medial to the lateral side, in most cases. In general, the amount of fat removed decreases as you proceed from the lateral to the medial. The lateral deep lower eyelid fat tends to be fuller, more robust, and more vascular. The lateral fat pad is also most likely to be missed.2,3 (See Video 3 [online], which displays transconjunctival removal of lower lid fat.)
Video 3. Step 2: Lower Blepharoplasty Technique. Video 3 from “The Five-Step Lower Blepharoplasty Technique Refined”.
Step 3: Lateral Retinacular Canthopexy
An absorbable 5-0 Vicryl (Ethicon, Inc., Somerville, N.J.) suture is used for the lateral canthopexy to prevent scleral show and lower-lid malposition without affecting the long-term lateral canthal shape. A 5-0 Mersilene (Ethicon, Inc.) suture may be necessary in men with secondary lax eyelids, in cases of dry eyes, and in negative vector patients.2,3 (See Video 4 [online], which displays lateral retinacular canthopexy.)
Video 4. Step 3: Lower Blepharoplasty Technique. Video 4 from “The Five-Step Lower Blepharoplasty Technique Refined”.
Step 4: Skin Pinch Removal
Fine forceps are used to pinch the excess skin, creating a linear partition to be excised. Curved scissors are then used to carefully excise the skin, maintaining the underlying orbicularis muscle.2,3 (See Video 5 [online], which displays skin pinch removal.)
Video 5. Step 4: Lower Blepharoplasty Technique. Video 5 from “The Five-Step Lower Blepharoplasty Technique Refined”.
Step 5: Fractionated Fat Injection and Release of the Orbicularis-Retaining Ligament
Fat is harvested from the inner thigh with a small multiport cannula. The harvested fat is centrifuged for no more than 1 minute, with the supranatant and infranatant discarded. The remaining fat is then run through a tulip connector at least 50 times to allow for fractionation. This leads to fragmentation of adipose tissue structure. Using a fine 1-mm cannula with a single port, fractionated fat is injected above the periosteum and below the muscle with 50% overcorrection. The medial portion of the orbicularis-retaining ligament needs to be released from its maxillary attachments to blend this transition zone. Release is gently performed laterally using the same fine 1-mm cannula in a blunt manner in the supraperiosteal plane.4,5 (See Video 6 [online], which displays fractionated fat injection and release of the orbicularis-retaining ligament.)
Video 6. Step 5: Lower Blepharoplasty Technique. Video 6 from “The Five-Step Lower Blepharoplasty Technique Refined”.
CONCLUSION
A comprehensive and systematic ophthalmic history and examination is critical in establishing goals and formulating a precise surgical plan for lower blepharoplasty.
PATIENT CONSENT
Patients provided written consent for the use of their images.
Footnotes
Published online 14 July 2020.
Disclosure: Dr. Rohrich receives instrument royalties from Eriem Surgical, Inc., and book royalties from Thieme Medical Publishing. The other authors have no financial interest to declare.
Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.
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