Three-Step Technique for Lower Lid Blepharoplasty

130 J.A. Mauriello, Jr.

lateral aspect of the lower lid and prevents postoperative lower lid retraction. A subciliary incision is made with a #15 blade 5 mm medial to the lateral commissure and 5 mm lateral to it (Figure 41.1A). The initial dissection in the eyelid region involves skin only inferiorly, as much as technically feasible, to the level of the lower tarsal border in order to preserve pretarsal orbicularis muscle. The dissection is continued between the skin–muscle layer and the underlying orbital septum. The carbon dioxide laser is used as a cutting device to dissect inferiorly over the inferior orbital rim, laterally over the lateral orbital rim and under the malar fat pad (subcutaneous thickening of fat). Areas of redundant lower eyelid tissue including the malar folds may be treated focally with the defocused laser in order to effect immediate tightening of the overlying anterior lamella. In addition, gradual tightening continues for 6 months after surgery. 1–5 Subcutaneous fat should be treated judiciously in order to avoid fat necrosis. In patients with minimal redundant skin or negative vector orbits, the laser should only be used as a cutting device. Use of the defocused laser in such patients is avoided in order to prevent contracture and lower lid pulldown. The medial aspect of the lower eyelid skin muscle dissection is completed with a Stevens scissors since the laser cannot be visualized in this area. The entire skin–orbicularis oculi muscle flap is raised with a portion of the malar fat pad. Orbital fat excision can be reassessed once the skin–muscle flap is elevated. When the skin–muscle

ap is pulled superiorly and pressure is placed on the globe, residual fat becomes evident.

The “v” suture technique involves two bites of a double-armed horizontal mattress 5-0 polydiaxanone (PDS) suture (Figure 41.1B). The two bites form a “v” so that the eyelid margin is tightened more than the lower tarsal border (Figure 41.1B). The first vertical bite creates the medial arm of the “v.” A bite is taken approximately 4–5 mm medial to the lateral commissure and penetrates partial thickness tarsus by entering and exiting its anterior surface from inferior (at the tarsal base) to superior. This bite exits 2 mm below the eyelid margin and should not incorporate the superior skin edge of the subciliary wound. The bite of the second arm of the suture is taken from superior to inferior through the anterior tarsus and lateral to the first bite to form the “v.” The distance between the open arms of the “v” is determined by the amount of horizontal laxity. Rarely, two such sutures are necessary to sufficiently tighten lax lower lids. In such cases, a tarsal strip for enhanced tightening should be considered. The “v” suture traverses partial thickness tarsus and exits adjacent to the initial bite of the first arm of the suture at the base of the tarsus to create the apex of the “v.” Angling this second bite inferiorly towards the lower tarsal border creates the modified “v.” When the arms of the suture are tied at the base of the tarsus, the arms of the “v,” a “wave,” or puckering of the lateral lower eyelid margin is evident (Figure 41.1C). The lateral eyelid hugs the globe, elevates the lateral lower lid margin to prevent lower lid retraction, and corrects mild to moderate horizontal eyelid laxity. The suture is tied at the bottom of the “v” to prevent prolapse or erosion of the knot through the subciliary wound.

Chapter 41 Three-Step Technique for Lower Lid Blepharoplasty 131

Step 3: Resuspension of the Anterior Lamella and Adjacent Malar Fat Pad to the Lateral Orbital Periosteum

The previously undermined skin–orbicularis muscle and malar fat flap are now mobilized superiorly by grasping the superior edge of the orbicularis muscle (Figure 41.2A,B). A horizontal bite of the orbicularis muscle is taken with a 5-0 Vicryl (polygalactin) suture to resuspend the ap. The fl ap is suspended to the orbital periosteum laterally (Figure 41.2C). When this suture is properly placed, the skin appears flattened with minimal tension and the upper cheek is mobilized superiorly. Additional undermining may be necessary, and the suture may be replaced. Any excess skin is excised from the superior edge of the skin muscle flap.

The amount of skin that is necessary to excise is usually only 1–2 mm of skin measured vertically. Any redundant orbicularis muscle at the superior edge of the skin–muscle flap that now overlies the tarsal plate just medial to the placement of the 5-0 Vicryl suture is then excised to avoid bunching. The skin edges are closed with an absorbable 6-0 plain catgut.

Steri-strips are placed while the recumbent patient looks up in order to support the lower lid, effectively “dam” the fat back into the orbit, and tamponade any postoperative edema. Steri-strips maintain the lower lid and cheek structures in a superior overcorrected position for 7–14 days after surgery. After the steri-strips are applied, there appears to be redundant lower lid skin, but the edema eyelid and laser tightening over time assures an improved result. Intravenous corticosteroids (8 mg of dexamethasone) the day of surgery and oral corticosteroids (prednisone,

60 mg/day) for the first 3 postoperative days reduce edema and facial distortion. Postoperative head elevation and liberal use of ice compresses allow the lateral canthus to heal in a relatively upward position.

Rationale for the Three-Step Procedure

Horizontal tightening by the “v” suture lateral lower eyelid technique elevates the lower eyelid margin by creating the “wave.” This upward enhancement is complemented by the skin–orbicularis oculi and adjacent malar fat pad resuspension that reduces downward traction on the lateral canthus. Elevation and repositioning of this sphincter-like orbicularis muscle supports the lower lid, and malar fat and serves to reposit the orbital contents posteriorly. During the 6 months after surgery, a tug of war occurs between the lower eyelid margin and the undermined eyelid/cheek skin interface. The eyelid margin always wins if the above steps are performed appropriately and conservatively. The thermal damage induced by the laser affords gradual elevation of the eyelid/ cheek skin interface (Figure 41.3).

132 J.A. Mauriello, Jr.

Pearls

1.Avoid use of laser with thin skin because of possible thermal damage to overlying skin.

2.Avoid overzealous use of defocused laser in patients with mild to moderate skin redundancy to prevent postoperative anterior lamellar contracture and consequent lower eyelid retraction.

3.Chemosis is unusual with this technique and, if present, resolves with a short course of topical corticosteriods.

4.The technique may be learned and gradually improved with conservative performance of each step until experienced is gained by the surgeon.

5.Final results require 6 months. Patience is required.

A

Figure 41.1. (A) Skin muscle flap is undermined through a small lateral subciliary incision that extends beyond lateral canthus. (B) The “v” horizontal mattress suture horizontally shortens the lower eyelid and also serves to elevate the lower eyelid margin. (C) Note the “wave” that gradually flattens, usually within 2 weeks after surgery.

Chapter 41 Three-Step Technique for Lower Lid Blepharoplasty 133

B

C

Figure 41.1. ( Continued)

134 J.A. Mauriello, Jr.

A

B

Figure 41.2. (A,B) The optimum point to fixate the skin–muscle flap is assessed.

(C) Resuspension of skin–muscle layer to lateral orbital rim just beyond the lateral canthus is accomplished with a 5-0 Vicryl suture. Any residual redundant lower lid skin tightens over time due to thermal damage to the orbicularis muscle from the defocused CO2 laser.

Chapter 41 Three-Step Technique for Lower Lid Blepharoplasty 135

Figure 41.2.

( Continued)

C

A B

C

Figure 41.3. (A) Preoperative photograph of patient undergoing lower blepharoplasty using three-step technique as well as upper blepharoplasty. (B) Result 3 months after surgery. (C) Note increased elevation of the eyelid skin and cheek skin interface 6 months after surgery compared to result 3 months after surgery in (B).