Lower Lid Blepharoplasty by Skin–muscle Flap Approach
The traditional lower blepharoplasty is indicated for patients who have aging changes, with underlying skin laxity and some gravitional descent of structures. It is also indicated for some males with aging changes who want a conservative approach.
The procedure starts by placement of a 4-0 silk as a traction suture over the central portion of the lower eyelid margin. An incisional line is marked approximately 1mm below the cilia from the medial canthus towards the lateral canthus; it is then slanted inferolaterally for approximately 6–8mm after reaching the lateral canthal angle. Ideally, the inferolateral incision would merge with one of the crow’s-feet lines there ( Fig. 8.1A & B ).
The initial skin incision starts over the inferolateral portion and is best performed using a No. 15 Bard-Parker blade. Small amounts of capillary bleeding are controlled using bipolar cautery. A cutting Bovie cautery is then used to incise through the orbicularis layer to fashion a myocutaneous flap, starting at the lateral canthal area. Once a small space is initiated, a small Blair retractor is inserted and turned laterally so that the traction is lateral. Straight sharp scissors are then inserted beneath the skin over the pretarsal region, undermining the skin beneath the lashes. The incision over the infraciliary region is then completed using the straight scissors. Next, the orbicularis is undermined, and incised approximately 2–3mm below the inferior border of the tarsus, thereby avoiding the inferior tarsus arcade. The orbicularis muscle overlying the tarsus in the pretarsal region is not incised – this helps in preserving the lower lid tone. The myocutaneous flap is retracted with the Blair retractor inferiorly, while the lid margin is retracted superiorly with the traction suture or the surgeon’s finger on a gauze pad.
Gentle pressure on the globe allows any fat to protrude forward. A needle-tipped Bovie cautery is then used to incise the septum ( Fig. 8.2 ). Incision into the central fat pocket is done first. Prolapsing and redundant fat may be excised using a combination of bipolar cautery first, followed by excision using the Bovie needle on coagulation mode. The retractor is then repositioned towards the nasal direction, retracting the medial edge of the lower lid incision nasally, and with downward pressure the nasal fat pad is made to protrude. The capsule is incised and the nasal fat pad, which is usually pale white, may protrude. The fat is similarly excised using bipolar cautery as well as the Bovie needle on coagulation mode. Any visible blood vessels should be carefully cauterized before allowing them to be reposited. Between the central and nasal fat pads lies the inferior oblique muscle and this should be protected. The lateral fat pocket is removed, if necessary, after the lateral canthoplasty procedure is performed.
Surgical technique of lateral canthoplasty
Often a patient will exhibit age-related laxity of the lower lid margin as well as lateral canthal dehiscence. The addition of this maneuver allows the surgeon to stabilize the eyelid fissure, correct for horizontal laxity of the lower eyelid, as well as adjust for the prominent-eye patient as seen in thyroid eye disease. This is performed before the lateral fat pad excision because it will affect the prominence of the lateral fat pad.
A lateral canthotomy is performed using scissors, connecting the incision with the inferolateral extension of the skin incision line. An inferior cantholysis is performed over the superficial and deep portion of the lateral canthal tendon. The freed lower lid segment is draped under mild tension against the globe and directed towards a point just above the lateral orbital tubercle in the area of the lateral orbital rim. A redundant segment of the lower lid, measuring between 2 and 4mm, may be excised, depending on individual findings. Capillary oozing from the inferior tarsal arcade is easily stopped with bipolar cautery. The reanchoring of the lateral portion of the tarsus may be performed using either a 5-0 Vicryl or an 5-14 needle or 4-0 Prolene suture on a P-2 needle (Ethicon) ( Fig. 8.3A & B ). The needle is inserted through the inferior portion of the tarsus, taking an intratarsal bite and then exiting through the upper portion of the tarsal plate, just below the lid margin so that it will remain buried when tied. This upper end of the suture is then passed through the inner periorbita just above the lateral orbital tubercle and brought from inside the lateral orbital rim outward. It is then reinserted from outside the lateral orbital rim inward and tightened with a double throw until the lower lid margin rests along the lower corneal limbus with the desired tension. Lid tension is tested intraoperatively to confirm appropriate tightness. In persons who do not show any horizontal laxity and in whom lower lid tightening is not performed, the tied suture may even contain slack. When the knots are tied, care is taken to make sure that the suture knot will not protrude and irritate the overlying skin.
Undermining of the skin–muscle flap
It is important to undermine the skin–muscle flap over the malar area separating the septal strands and periosteum from the myocutaneous flap ( Fig. 8.4A & B ). This allows for further smoothing of the malar area. Failure to do this will cause anterior distortion of the lateral fat pocket, requiring more resection. Once the myocutaneous flap is dissected free, the lateral fat pocket may be resected if necessary.
Lateral fat pad excision
The lateral fat pad may be trimmed with a combination of bipolar and Bovie cautery following horizontal tightening and undermining of the skin–muscle flap. It is important to preserve the arcuate portion of the orbital septum laterally, to prevent recurrence of the lateral fat pad prolapse. The lateral fat and the central fat are connected and can be teased from behind this portion of the septum without severing it.
Resection of the skin–muscle flap and periosteal fixation
The tip of the skin–muscle flap is stretched towards the superior tip of the ear to determine how much the lateral portion of the flap overlaps the underlying incision ( Fig. 8.5A ). The first triangle of excess tissue is excised from the lateral portion of the skin–muscle flap. The flap is sutured at the lateral canthal angle’s lateral periosteum to create a desired level of tension over the cheekbone and correct for any hollowing effect in the lower lid. Trial positioning of the flap to the lateral rim may be performed until the desired level of tension is obtained. For this maneuver, a 4-0 silk suture is used: it passes through the anchoring point located on the skin–muscle flap, then into the lateral periosteum at the desired position, and is then brought out through the skin–muscle layer of the upper edge of the incision at the lateral canthal area ( Figs 8.5B & 8.6 ). The second triangle of excess skin–muscle flap is then trimmed along the infraciliary incision line. This is usually a long and thin triangular strip.
Trimming of the orbicularis muscle fibers from beneath the skin–muscle flap may be performed if there seems to be excess, to further thin the lid down. These are orbicularis fibers that overlap the muscle fibers preserved on the pretarsal area from the original incision. This is more applicable to women, to give a smooth look; in men, it is often left in place, to avoid an overly thinned appearance. The flap is everted and examined for bleeders; any vessels that are actively bleeding are cauterized with bipolar cautery.
Wound closure
Closure of the skin flap is performed using 7-0 silk sutures. The inferolateral region of the incision is best closed using a vertical mattress suture, taking care that both the skin edge and the deeper orbicularis are closed. An alternative to this is the utilization of a ‘far–near near–far’ type of baseball stitching using 7-0 silk, which gives good wound approximation as well as tension control ( Fig. 8.7 ). Meticulous closure is essential in this conspicuous area in order to avoid scarring. A small dog-ear may be seen laterally and can be trimmed off.
The Primary Cheeklift
The traditional lower blepharoplasty has only limited value in addressing anyone with significant gravitational ptosis of the midface or cheek, which is present in the majority of middle-aged patients. The lower eyelid should not be considered as a structure that ages in isolation and behaves independently of the supporting contiguous structures beneath it. It is therefore best evaluated as part of the midface structure which is subjected to the same involutional laxity, ligamentous dehiscences, and atrophy, as well as gravitational sagging. Lower blepharoplasty can therefore be performed as part of the midface rejuvenation made possible through a cheeklift.
The cheeklift addresses the aging changes that occur in the triangular area from the nasolabial fold to the eyelids:
- ▪
eyelid fat protrusion;
- ▪
laxity and sagging of eyelid skin and midface skin; and
- ▪
descent of subcutaneous face fat and midface structures.
Subcutaneous sagging of orbicularis muscle and dropping of the malar fat pad cause a good part of the changes that occur with age – when they are repositioned, this restores the face to a more youthful appearance (see Fig. 2.14 ).
The trans-lid cheeklift ( Fig. 8.8A ) repositions the cheek in a more anatomically correct vector than the facelift. The traditional facelift ( Fig. 8.8B ) should be more properly called a necklift with oblique vectors towards the ear – the vertical-upward vector is the proper direction to restore the cheek and midface contours.
