11.1 Goals

• 
  

  Transcutaneous lower blepharoplasty facilitates surgical removal of excess skin on the lower lids through a subciliary incision.

  
  
• 
  

  When necessary, orbital fat prolapse can be addressed via the subciliary surgical approach. This may include fat excision and/or fat repositioning below the inferior orbital rim to address infraorbital hollowing and to create a smooth transition at the lid-cheek junction.

11.2 Advantages

The primary advantage of the transcutaneous approach is the ability to excise excess skin on the lower eyelids, which is not feasible from a purely transconjunctival approach. When performed correctly, the incision is hidden just beneath the lash line on the lower lid and blended into a crow’s feet line at the lateral canthus. ^{1 ,​ 2}

11.3 Expectations

• 
  

  Patient expectations are aesthetic rejuvenation of the lower eyelids while maintaining an anatomically correct position and function of the lower eyelids.

  
  
• 
  

  Every patient’s lower eyelids age differently, but common goals are to address excess skin and wrinkles on the lower lid, address any orbital fat prolapse, and to create a vertically short lower lid that transitions gracefully into the cheek.

  
  
• 
  

  If there are any pre-existing lid malpositions such as ectropion, entropion, or eyelid retraction, these should be discussed and addressed simultaneously.

11.4 Key Principles

A customized lower blepharoplasty evaluation should provide an individualized assessment of the patient’s lower lid anatomy and a surgical plan that addresses specific issues. There are various approaches to lower blepharoplasty (transconjunctival, transconjunctival with skin pinch excision, and transcutaneous), and various adjuncts such as fat repositioning, mid-face lifting, autologous fat grafting, and laser resurfacing. Every patient deserves consideration as to which technique would be most appropriate.

Transcutaneous lower blepharoplasty involves a subciliary incision for surgical access as well as for removing excess skin. When performing subcutaneous dissection, preservation of the pretarsal orbicularis neuromuscular anatomy by incising the orbicularis and septum more inferiorly down the lid helps to minimize weakening the orbicularis oculi muscle, which can lead to ectropion, lagophthalmos, and exposure keratopathy.

Management of fat should include reducing any prolapsed orbital fat but should not be overaggressive such that the patient looks hollowed or “skeletonized.” Fat repositioning can be performed to address infraorbital hollowing along the orbital rim and to smooth the transition zone of the lid-cheek junction.

11.5 Indications

• 
  

  Dermatochalasis of the lower eyelids.

  
  
• 
  

  Desire for aesthetic rejuvenation of the lower lids and lid-cheek junction.

  
  
• 
  

  Orbital fat herniation on the lower eyelids.

  
  
• 
  

  Periorbital hollowing along the lower lids.

11.6 Contraindications

• 
  

  Paralytic lagophthalmos due to facial nerve palsy or multiple prior surgeries.

  
  
• 
  

  Pre-existing cicatricial ectropion or eyelid retraction.

  
  
• 
  

  Unrealistic patient expectations.

  
  
• 
  

  Inability to stop blood thinners.

11.7 Preoperative Preparation

To minimize intraoperative bleeding and reduce the risk of postoperative bruising and bleeding complications, the surgeon should discuss stopping anticoagulants, vitamins, and supplements with patients, pending approval by the patient’s cardiologist or primary physician. Ideally, blood thinners such as aspirin, ibuprofen, and other vitamins and supplements can be stopped 7 to 14 days prior to surgery, although certain anticoagulants can be stopped safely within 2 to 5 days prior to surgery. Before surgery, patients should receive a thorough history and physical and medical clearance from their primary care physicians.

In the preoperative area, with the patient sitting in an upright position, the periorbital grooves can be marked along the inferior orbital rim, above which the orbital fat prolapse can be visualized (Fig. 11‑1a). Having patients supraduct their eyes helps to accentuate orbital fat prolapse. The surgeon can annotate on the eyelids which fat pads are most herniated to help guide an individualized approach to fat reduction and redraping (Fig. 11‑1b).

A subciliary incision can be marked, if desired, prior to injection of local anesthetic. Some surgeons prefer to mark the amount of skin to be excised preoperatively, whereas others prefer to determine the amount of skin to be excised after undermining, managing the orbital fat, and redraping the skin. Local anesthetic containing epinephrine is infiltrated into the lower lids and lateral canthal regions with sufficient time given for hemostasis.

11.8 Operative Technique

Prior to making the subciliary incision, it can be helpful to place a 6–0 silk traction suture through the lower lid margin for superior lid traction. A subciliary incision is performed with Westcott scissors 1 mm below the lashes. Subcutaneous dissection is performed over the pretarsal orbicularis (Fig. 11‑2). Below the pretarsal orbicularis, the orbicularis is incised and dissection is continued inferiorly in a preseptal plane down to the orbital rim (Fig. 11‑3).

At this point, the orbital septum is opened across the eyelid, and the medial, central, and lateral fat pads are pedicalized and prolapsed outward. Care is taken to avoid injury to the inferior oblique muscle located between the medial and central fat pads (Fig. 11‑4). The fat pads are conservatively debulked as needed. To determine the amount to be excised, the eye can be manually retropulsed and the fat pedicles trimmed flush with the surface of the lower lid. To treat infraorbital hollowing, the fat pads can be redraped after creating a preperiosteal dissection plane below the orbital rim (Fig. 11‑5). The fat pedicle is redraped below the orbital rim using a 5–0 monocryl suture that is passed in a horizontal mattress fashion through the fat pedicle, through a slip of periosteum below the infraorbital rim, and back up through the fat pedicle (Fig. 11‑6). The suture is tied off, and this preperiosteal fat redraping results in correction of infraorbital hollowing and blending of the lid-cheek junction (Fig. 11‑7). Alternatively, the fat can be redraped in a subperiosteal plane. In this technique, a subperiosteal dissection plane is created below the orbital rim. A double-armed 5–0 prolene or gut suture can be passed through the fat pedicle, and the needles are externalized through the skin below the orbital rim and tied off on the skin or over a bolster. ³ Finally, the orbital septum is evaluated and any necessary further septal release is performed to ensure the septum and lower lid retractors are not being tethered downwards by the redraped fat pads.

After addressing the fat, any further lid tightening or supportive procedures can be performed as needed or desired. Options include a simple canthoplasty for horizontal lid tightening, or additional adjunctive measures that can provide more robust support, such as orbitomalar ligament release with orbicularis-pexy or a sub-orbicularis oculi fat (SOOF) lift. The orbicularis-pexy and SOOF lift are helpful in preventing post-blepharoplasty eyelid retraction in patients with significant mid-face descent or who are at high risk of eyelid retraction due to a negative vector. ⁴

Finally, the skin is redraped, and a conservative amount of skin is excised. Typically, more skin is excised laterally than medially along the subciliary incision. After ensuring hemostasis, the subciliary incision is closed in running fashion using 6–0 fast-absorbing gut suture from lateral to medial. This concludes the transcutaneous lower lid blepharoplasty procedure (Fig. 11‑8, Fig. 11‑9).