Lower Eyelid Blepharoplasty Techniques
Bryan Sires
INTRODUCTION
Aging changes of the lower eyelid have been better defined over the past decade as the result of increased understanding of the anatomy. This has led to an evolving approach to rejuvenation of the lower eyelid. Two main factors are part of this evolution. These include the recognition that the lower eyelid has an anatomic relationship with the adjacent cheek region. There is a continuum from one area to the other, and what affects one will affect the other. They exist in a symbiotic relationship. One region cannot be adequately addressed unless both regions are considered in the treatment plan. The abundant suborbicularis oculi adipose tissue (SOOF) spans both structures in youth, but with age, it atrophies and descends (Fig. 4.1). The second factor is that with aging, there is not only descent, redundancy, and prolapse of tissue over time but also deflation of the facial and periorbital regions. This has led to tissue additive procedures to the lower eyelid rather than just tissue subtractive or redraping techniques. Additionally, there has been the recognition that supporting structures exist in the face (Fig. 4.2). With time, these ligaments stretch. To rehabilitate the face and eyelid, the ligaments require release in order to allow the soft tissue structure to slide over the bony hard tissue and to be anchored in an elevated and supported position, which secondarily supports the lower eyelid.
Up until the mid-1970s, lower eyelid blepharoplasty was usually performed through a skin incision in the infraciliary line. Dissection proceeded through the orbicularis oculi muscle and orbital septum if excision of adipose tissue was required. The skin and/or muscle would then be redraped and trimmed, thereby removing excess tissue. In 1950, the transconjunctival or internal approach was recognized but limited in its use. This was due to the thought that the excess skin could not be addressed via this approach. However, the combination of transconjunctival removal of adipose tissue and addressing mild to moderate excess skin with either chemical peels or laser allowed for the increased use of the transconjunctival approach. The two techniques of chemical peels and laser resurfacing that lead to skin contraction are beyond the scope of this chapter. In cases of severe amounts of excess skin, transcutaneous excision remains the procedure of choice.
Over time, there is a loss of facial volume that can create a skeletonized and aged appearance. Early efforts in facial volumization were limited by the available technologic, material, and even conceptual resources that we take for granted today. It was not until the 1980s when tumescent liposuction techniques were described that widespread use of adipose tissue and its various applications could be used. Through the continued advancement of liposuction techniques, the harvest and production of “fat pearls,” which could be passed through narrow cannulas to the site of interest, became realized. These advances, along with the more complex understanding of facial volume, converged into what is considered modern facial rejuvenation.
The rationale behind using adipose tissue for volumization of the face is that you have a living autologous tissue that could potentially provide a lasting effect without repetitive injections. If the adipose tissue survives the transfer, then you have a basis for a long-lasting treatment. The adipose tissue is also readily accepted by the body as it is the patient’s own autologous tissue. Typically, there is an ample supply of adipose tissue. It is unclear what cells survive and what conditions are ideal. It is known that both preadipocytes and adipocytes are transferred. Both may survive, but the transfer of preadipocytes supposes that
regeneration of new cells plays a role. It is becoming apparent that the long-term volume effect is more likely the result of regeneration of adipose tissue rather than tissue transfer. This is brought about by the transfer and differentiation of stem cells or preadipocytes. It has been shown that volume retention will often dip in the first 3 to 4 months with resolving edema and as vascularization occurs. This is followed by a rebound and improved facial volumes at 1 year or later. The delayed volumetric effect is secondary to either the uptake of fatty acids into the cytoplasm of the surviving adipocytes or the differentiation of the stem cells into adipose tissue cells that mature and grow. It is also unclear what percent of the transferred cells survive. This is important in deciding how much adipose tissue to place considering the anticipated loss. Access of the “fat pearls” to the surrounding blood supply also plays a critical role. Most surgeons are overcorrecting due to the anticipated loss. An unknown critical maximum volume exists whereby additional “fat pearl” volume will lack adequate exposure to blood supply nourishment. This will lead to cell death and atrophy due to inadequate oxygenation and nutrition. To ensure adequate blood supply, no more than a 1.5-mm layer of adipose tissue should be injected into any plane. The placement of optimal total volumes of adipose tissue rather than overfilling to get the desired effect is also crucial for adipose tissue survival. The goal is to place a total of 30 to 50 mL of adipose tissue into the facial regions compared with the 100 to 150 mL some authors advocate. Five to six mL of adipose tissue per lower eyelid/cheek interface is ideal. This helps retention and avoids contour issues as well. If further research can enhance “fat pearl” survival, then overcorrection will become less important.
regeneration of new cells plays a role. It is becoming apparent that the long-term volume effect is more likely the result of regeneration of adipose tissue rather than tissue transfer. This is brought about by the transfer and differentiation of stem cells or preadipocytes. It has been shown that volume retention will often dip in the first 3 to 4 months with resolving edema and as vascularization occurs. This is followed by a rebound and improved facial volumes at 1 year or later. The delayed volumetric effect is secondary to either the uptake of fatty acids into the cytoplasm of the surviving adipocytes or the differentiation of the stem cells into adipose tissue cells that mature and grow. It is also unclear what percent of the transferred cells survive. This is important in deciding how much adipose tissue to place considering the anticipated loss. Access of the “fat pearls” to the surrounding blood supply also plays a critical role. Most surgeons are overcorrecting due to the anticipated loss. An unknown critical maximum volume exists whereby additional “fat pearl” volume will lack adequate exposure to blood supply nourishment. This will lead to cell death and atrophy due to inadequate oxygenation and nutrition. To ensure adequate blood supply, no more than a 1.5-mm layer of adipose tissue should be injected into any plane. The placement of optimal total volumes of adipose tissue rather than overfilling to get the desired effect is also crucial for adipose tissue survival. The goal is to place a total of 30 to 50 mL of adipose tissue into the facial regions compared with the 100 to 150 mL some authors advocate. Five to six mL of adipose tissue per lower eyelid/cheek interface is ideal. This helps retention and avoids contour issues as well. If further research can enhance “fat pearl” survival, then overcorrection will become less important.
 FIGURE 4.1 Anatomy of the lower eyelid-cheek junction during youth and in the aged. SOOF descent is apparent along with orbital adipose tissue prolapse and subcutaneous tissue thinning. |
 FIGURE 4.2 Location of the supporting structures of the face including the orbitomalar ligaments (OL) and zygomatic ligaments (ZL). |
Adipose tissue transfer application to the lower lid and cheek junction is important because there are patients who lose subcutaneous volume in this region. This volume loss occurs in the SOOF and malar adipose tissue pads. At the same time, some patients’ orbital adipose tissue becomes more apparent leading to the impression of adipose tissue prolapse. It is unclear if the adipose tissue prolapses or it becomes manifest as the cheek adipose tissue falls and deflates. Regardless, removing this adipose tissue would lead to deepening of the area and would exacerbate the tear trough deformity. Adding adipose tissue in this region restores the volume lost due to aging with clinical effects that can last years.
HISTORY
A complete history is standard in the evaluation for any patient considering surgery. A detailed past medical history with questions about general medical, ophthalmologic, and surgical events is important. A directed history with regard to the specifics of facial surgery, trauma, congenital abnormalities, autoimmune disease, thyroid disorders, dry eyes, eyelid swelling, ease in bruising, or dermatologic conditions is essential. I ask patients to list all medications that they are taking, including herbal and over-the-counter, to assess for any risks of increased bleeding during and after surgery. I also review tobacco, caffeine, and alcohol consumption. Additionally, I inquire about any placement of neuromodulators (e.g., Botox, Dysport, Xeomin) as well as soft tissue fillers in the regions of interest.
PHYSICAL EXAMINATION
Facial and Eyelid Examination
Understanding the patients’ unbiased goals and expectations of the procedure is the first step of the examination. These should align with the anatomic changes observed on the physical examination, and if so, then a customized treatment plan can be formulated. Standardized photography should be used including full face AP, oblique, and side views when relaxed as well as in positions of facial expression such as smiling and grimacing. The patient should have a good understanding of the financial commitment and the recuperation process. The latter issue may take longer than some patients are willing to tolerate due to the time for resolution of edema. This cannot be overstressed during the preoperative evaluation and discussion.
The lower eyelid should be evaluated for excess skin or dermatochalasis, prolapse of adipose tissue, eyelid laxity, and changes in the relationship between the lower eyelid and the cheek. Dermatochalasis can be determined by gently pulling the skin laterally to determine the excess amount and if skin should be excised. Fine wrinkling needs to be distinguished from tissue excess. Fine wrinkling is dealt with using retinoid, chemical peels, or laser techniques rather than actual skin excision. Prolapse of adipose tissue is determined by observing the prominence of pockets of adipose tissue. This can be accentuated by having the patient look up or by gently retropulsing the eye and noticing the forward movement of the pockets of adipose tissue. The patient is asked to lie in the supine position so that the adipose tissue falls back into the orbit. This will give the surgeon and patient an idea of the result if it is determined that adipose tissue should be removed. This will also help the surgeon determine if there is really descent and loss of SOOF and malar adipose tissue volume. If so, then an additive procedure rather than a subtractive procedure should be considered.
Eyelid laxity is determined using the snap and distraction tests. The snap test is performed while the patient is asked not to blink and the lower eyelid is pulled down and let go. The eyelid should return to its
normal anatomic position in 2 seconds or less. The distraction test measures the distance from the eyelid to the eye when the eyelid is pulled away from the eye to its end point. This should be 7 mm or less. The snap and distraction tests help determine if the lower eyelid should be tightened to avoid postoperative ectropion or retraction.
normal anatomic position in 2 seconds or less. The distraction test measures the distance from the eyelid to the eye when the eyelid is pulled away from the eye to its end point. This should be 7 mm or less. The snap and distraction tests help determine if the lower eyelid should be tightened to avoid postoperative ectropion or retraction.
 FIGURE 4.3 Demonstration of the topography of aging of the lower eyelid-cheek junction. |
Additional signs of aging of the lower eyelid-cheek region have been described consisting of four basic stages made up of two components. The two components of aging include the angle of the line from the lateral to medial canthal angles and the position of the lid-cheek junction. The lateral canthus is typically 2 mm higher than the medial canthus. This provides the natural gravitational slide for tears to be directed toward the nasolacrimal drain. As aging occurs, the lateral canthus can actually descend and be positioned below the medial canthal angle. Many patients will experience tearing in this setting. Along with descent of the lateral canthus, it also moves medially due to stretching leading to acquired blepharophimosis or narrowing of the horizontal palpebral fissure. The patients will describe this as loss of their “almond-shaped” eye.
The lid-cheek junction normally sits 8 to 12 mm below the lower eyelid margin in a young adult. In the aged eye, the lid-cheek junction descends to a distance of 15 to 18 mm and can give way to a tear trough deformity, a malar bag, and deepening of the nasojugal fold (Fig. 4.3). From the side, the youthful transition from the lid to the cheek is smooth, continuous, and convex. However, with aging, a biconvex deformity develops. The elevation in the eyelid is orbital adipose tissue. Inferior to this is the depression or the tear trough deformity. Finally, below this is the cheek mound/malar bag. If these findings are present, then the cheek region, as well as the eyelid, need to be addressed.
INDICATIONS
The indications for lower eyelid blepharoplasty are mostly related to the cosmetic aging changes found in this region. However, in severe cases, insurance will cover the costs of lower eyelid blepharoplasty if it interferes with the functionality of vision in the reading position. This typically occurs when the excess tissue sits on the reading segment of the glasses and obstructs the person’s ability to read.
The signs of aging that would be amenable to lower lid blepharoplasty are prolapsed adipose tissue/mounds, excess skin/dermatochalasis, descent of the lid-cheek junction, deepening of the nasojugal fold/tear trough deformity, and lateral canthal dystopia.
The goal of surgery is to reposition the lateral canthus, redrape the cheek, and fill the tear trough deformity. Transfer of adipose tissue is an additive procedure that has superior longevity compared to industry-produced materials like hyaluronic acid or hydroxyapatite. It should be used in patients with deflation and deepening of their tear trough deformity. The key to planning where to inject the “fat pearls” is based on a thorough understanding of the patient’s expectations along with the physical examination findings and then studying photographs for final decision-making.
An alternative to filling the tear trough with transferred “fat pearl” is to transpose the already presumed prolapsing orbital adipose tissue. This proves to be technically more challenging and invasive; so many surgeons have abandoned this technique in favor of transfer of adipose tissue.
