Lower Eyelid Blepharoplasty
Sulen L. Chi, MD, PhD
DISEASE DESCRIPTION
In the aging face, thinning of the orbital septum and orbicularis oculi atrophy allow orbital fat to prolapse anteriorly, creating a convexity in the lower lid. Patients who find this convexity aesthetically displeasing may seek surgical treatment in the form of lower eyelid blepharoplasty.
MANAGEMENT OPTIONS
Orbital fat prolapse of the lower eyelid may be handled surgically or not at all. A trial of injectable filler may be considered if hollowing of the nasojugal sulcus (tear trough) exacerbates the convexity of the orbital fat prolapse.
PREOPERATIVE CONSIDERATIONS
Evaluate the degree of orbital fat prolapse in each of the three lower eyelid fat pads.
Determine transconjunctival versus transcutaneous approach (Figure 42.1).
Patients with significant lower eyelid skin redundancy may benefit from skin excision, and therefore a transcutaneous approach.
Transconjunctival approach is appropriate for patients concerned about external scars or who have little skin excess.
Combined approaches such as transconjunctival fat removal with a “skin pinch” may also be used in selected cases.
Determine whether sufficient horizontal eyelid laxity exists to require a horizontal lid tightening procedure — typically, greater than 5 to 6 mm of lid distraction.
Evaluate for the presence of festoons.
If present, modify patient expectations for surgical outcome from blepharoplasty alone.
Consider the need for secondary festoonectomy or concomitant CO2 laser resurfacing.
Evaluate the patient’s overall suitability for surgery with respect to realistic expectations, ability to self-care in the postoperative period, tobacco use, anticoagulants, and comorbidities that may be risk factors for anesthesia.
FIGURE 42.1. Surgical approaches for lower lid blepharoplasty — transcutaneous (blue), preseptal transconjunctival (red), and postseptal transconjunctival (purple).
Document preoperative appearance with photographs. Photographs taken with and without camera flash can highlight lower lid convexities and distinguish “dark circles” that result from shadows cast by convexity from true hyperpigmentation or from the purplish skin hue observed as a result of thinning skin.
SURGICAL DESCRIPTION
Transconjunctival Blepharoplasty (Figure 42.2)
Take note of the relative proportions of the herniating lower lid fat pads with the patient sitting upright; mark the belly of the bulge of each on the skin if necessary.
Instill topical anesthetic in the inferior fornix if desired, followed by infiltration of the lower eyelid through transconjunctival or transcutaneous approaches.
Prep and drape the patient allowing both eyes to be appreciated in the sterile field simultaneously.
Place a 4-0 silk traction suture through the lower lid margin.
Place a scleral protector on the globe.
Evert the lower eyelid over a Desmarres lid retractor in conjunction with the traction suture.
Incise the conjunctiva 3 to 4 mm inferior to the inferior tarsal edge utilizing the incisional tool of choice (Colorado electrodissection needle, #15 blade, or incisional CO2 laser)
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