57

Lower Blepharoplasty with Fat Repositioning Without Sutures

John R. Burroughs and Richard L. Anderson

We seldom perform transcutaneous lower eyelid blepharoplasty due to the high incidence of lower eyelid retraction.

Most patients benefit from lower eyelid fat repositioning as compared to removal of excess skin of the lower eyelids.

To improve lower eyelid wrinkles and skin excess, we recommend a lower eyelid TCA peel (25–35%), which is safer and also helps pigmentation changes.

Fat-Repositioning Procedure

Through a transconjunctival incision, placed approximately at the midpoint between the inferior border of tarsus and the fornix, the septum can be accessed (Figure 57.1). Opening the septum and fat capsules should be done as inferiorly as possible so that the fat will drape inferiorly and fill the tear trough and the lower eyelid hollow areas. We have not found a need to suture the fat pads inferiorly, but an integral component is to release the preperiosteal attachments at the inferior orbital rim. This is best accomplished by blunt dissection and elevation of skin and the underlying tissues with the combination of Stevens scissors and a Sayer elevator (Figures 57.2–57.6). This release is carried below the rim (about 1 cm), which will help the fat fill the tear trough deformity.

Undermining laterally and release of the orbital malar ligament in connection with the midface elevation, via upper blepharoplasty dissection provides opportunity for a more aggressive midface elevation. Fat sculpting should be kept to a minimum, and mostly involves the more superior fat that prolapses after the capsules are opened (Figure 57.7). Excessive lateral fat pads must be more aggressively sculpted as the lower eyelid trough deformity is usually less pronounced laterally, and lateral fat may protrude more after the septum is opened. After ensuring there are no sites of active bleeding, the conjunctiva is closed in the midline with

176

Chapter 57 Lower Blepharoplasty with Fat Repositioning Without Sutures 177

a single 6–0 plain gut to avoid conjunctival adhesions. Excess lower eyelid skin removal, if needed, can be performed as a secondary procedure. The vast majority of patients do not require skin removal. The combination of TCA peel and lower eyelid fat repositioning with lateral canthopexy and/or lateral SOOF elevation provides an excellent aesthetic result and has high patient acceptance with fewer risks.

Figure 57.1. Making of transconjunctival incision with Stevens scissors at mid-fornix.

Figure 57.2.

Opening of fat capsules inferiorly along the orbital rim, allowing fat to prolapse inferiorly.

178 J.R. Burroughs and R.L. Anderson

Figure 57.3. Opening of fat capsules inferiorly along orbital rim. Conservative sculpting of superiorly prolapsing fat may then be performed.

Figure 57.4. Beginning release of preperiosteal attachments along the inferior orbital rim.

Chapter 57 Lower Blepharoplasty with Fat Repositioning Without Sutures 179

Figure 57.5. Utilization of Sayer elevator to release orbital rim preperiosteal orbicularis attachments, allowing inferiorly prolapsing orbital fat to fill the tear trough deformity.

Figure 57.6. Complete release with Sayer elevator to approximately 1 cm below the orbital rim. The cheek fat pad and SOOF have been undermined supraperiosteally, thereby enabling midface elevation.

58

Managing Postblepharoplasty Lower

Eyelid Malposition

Michael T. Yen

Lower eyelid retraction and ectropion remains a challenging complication of cosmetic lower eyelid blepharoplasty. In addition to being cosmetically unacceptable, the eyelid malposition may be associated with ocular irritation, chronic tearing, and lagophthalmos with exposure keratitis.

Most cases of lower eyelid malposition after blepharoplasty are due to either cicatrix formation or an anterior lamellar shortage of the lower eyelid.1 While some patients with mild ectropion and retraction may improve with time and eyelid massage, most patients require surgical correction to achieve acceptable functional and cosmetic improvements. Surgical repair of postblepharoplasty lower eyelid malposition should be graded depending on the severity of the malposition. For most cases that require surgical intervention, the lower eyelid malposition can be corrected by releasing the cicatrix (if present), providing additional support and recruiting anterior lamella to the eyelid with midface elevation, and horizontal tightening of the lower eyelid.

My preferred surgical approach to the midface is through a transconjunctival incision in the lower eyelid fornix.2 A supraperiosteal midface lift is then performed by undermining suborbicularis oculi fat and malar fat pads and elevating the malar tissues with a broad flat elevator. Sharp dissection is avoided to reduce the risk of severing the zygomatico-facial and infraorbital neurovascular structures. The elevation may be extended down to the level of the nasolabial fold. Several 4–0 polyglactin 910 sutures are passed through the malar fat pad, engaging the superficial musculoaponeurotic system (SMAS), and elevated supero-temporally. If the sutures are placed too superficially, unacceptable dimpling of the cheeks will result. If the sutures do not engage the SMAS, adequate midface elevation is difficult to achieve. The sutures are secured to the periosteum along the orbital rim.

For moderate or severe lower eyelid retraction with middle lamellar scarring, a spacer graft is often required in addition to midface lifting and eyelid tightening.1,3,4 This spacer graft provides additional support

183

184 M.T. Yen

and vertical length to the middle lamella of the lower eyelid. My preferred spacer graft material is autogenous hard palate or acellular dermal grafts. Acellular dermis is easily obtained commercially and is less traumatic for patients as there is no separate donor site in the mouth to heal. However, there is less predictability of final eyelid height and position when compared to hard palate grafts. The hard palate graft is the gold standard for treatment of severe lower eyelid retraction or for cases inadequately corrected with acellular dermis. The dense collagen layers give the graft a firm consistency similar to tarsus, and the mucosal lining is less abrasive to the corneal epithelium than acellular dermis.4 The grafts do not shrink, and the results are very predictable. The graft is harvested between the gingiva and the midline, where there is a welldefined submucosa allowing easy separation of the mucosa from the periosteum. The graft should be sized for the entire width of the lower eyelid and approximately 5 mm in height. The graft is dissected in the submucosal plane with a Freer elevator and should stop 3–4 mm short of the soft palate to avoid injury to the greater palatine vessels and to avoid fistula formation in the soft palate.

Lower eyelid malposition after cosmetic blepharoplasty can be very difficult to correct. As we have developed a better understanding of the anatomic relationship between the midface and lower eyelid, we are realizing that both need to be addressed to achieve optimal functional and cosmetic results. With successful midface lifting, eyelid spacer grafts are only required for severe lower eyelid retraction.

Figure 58.1. Retraction and lateral ectropion of the right lower eyelid after transcutaneous blepharoplasty.

Chapter 58 Managing Postblepharoplasty Lower Eyelid Malposition 185

Figure 58.2. Using a broad at (Sayre) elevator, the midface is elevated in the supra-periosteal plane down to the level of the nasolabial fold.

Figure 58.3. Harvesting of the hard palate graft should be between the gingiva and the midline and should stop 3–4 mm short of the soft palate to avoid injury to the greater palatine vessels and to avoid fistula formation in the soft palate.