Dacryoadenopexy as a recognized factor in upper lid blepharoplasty

The recognition of a herniated lacrimal gland is done by simple examination; it is not usually taught to plastic surgeons. Fullness in the superotemporal aspect of an upper eyelid in younger patients often represents a ptotic gland. Suspension of the glands improves the surgical result of upper-lid blepharoplasty without compromising lacrimal outflow.     

Expanded applications for transconjunctival lower lid blepharoplasty.

There has been a recent upsurge in interest in the transconjunctival approach for lower lid blepharoplasty. Initial reports have focused on the young patient with isolated fat prominence. We describe our experience with transconjunctival lower lid blepharoplasty in 104 patients over the past 2 years. There have been no instances of prolonged lower lid retraction problems, presumably related to leaving the skin, orbicularis, and orbital septum intact. Our experience with expanding the indications for the transconjunctival approach to include patients with fine skin wrinkling as well as frank skin excess has been extremely favorable. We conclude that the skin excess is often more apparent than real, with the skin being necessary to recontour the lower eyelid after fat excision. Although skin excision may be required during the initial procedure or at a later stage, patients with apparent skin excess need not be excluded from consideration for transconjunctival lower lid blepharoplasty.     

Transconjunctival lower lid blepharoplasty for removal of fat.

Our experience with 7 transconjunctival lower lid blepharoplasties is reported, and the technique is described. It is an excellent operation for patients with prominent lower lid fat who do not need skin resection.     

The prevention and treatment of lower lid ectropion following blepharoplasty

Ectropion and scleral show are the most common complications following lower lid blepharoplasty. Certain conditions predispose patients to ectropion, and these should be evaluated. In some cases, the addition of a wedge tarsectomy or tarsal strip procedure to a blepharoplasty in association with careful technique and postoperative measures is important in prevention of postblepharoplasty ectropion. Postoperative ectropion should initially be treated conservatively with massage. This may be effective up to 6 months postoperatively. If conservative measures fail, the etiology of the ectropion should be addressed. Laxity of the tarsus and canthal ligaments benefit from a horizontal lid-shortening procedure. Where there is vertical shortening from excessive skin resection or scarring of the orbital septum, there should be release and grafting of the deficiency.     

The tarsal tuck procedure: avoiding eyelid retraction after lower blepharoplasty

Eyelid retraction and ectropion are the most common complications of lower blepharoplasty. These complications often occur as a result of removing excessive skin and muscle in the face of a lax lower eyelid. The tarsal tuck technique tightens and stabilizes the lower eyelid, thereby minimizing these complications. The lateral canthus and lower eyelid are elevated with the tarsal tuck, which reduces the amount of skin removal required and avoids the "round eye" appearance.     

Tarsal fixation in lower blepharoplasty

Proceeding from the premise that a "youthful" eyelid has a pretarsal bulge while a "senile" eyelid has a pretarsal flatness, the tarsal fixation technique for lower blepharoplasty has been introduced--to reposition part of the orbicularis in front of the tarsus to produce a pretarsal bulge. The technique is presented as a suggested adjunct to the usual types of lower blepharoplasty.     

Use of a muscle flap in lower blepharoplasty.

An adjunctive technique for lower lid blepharoplasty is presented. This operative procedure uses the principle of anchoring the upper margin of the lower lid by suturing a triangular muscle flap from it to the lateral-superior part of the orbital rim. This more effective support for the lower lid margin permits one to excise more redundant tissue without getting an ectropion.     

Gold weight lid load as a secondary procedure

This paper discusses the use of gold weight lid load as a secondary procedure. By using three representative patients, I emphasize the following points: First, the dominance of the eye must be determined so that postoperative changes in the eyelid height can be anticipated. Second, in order to obtain an accurate weight of the implant needed, the restrictive effect on the eyelid from the previous surgery (a tarsorrhaphy or an encircling band) must first be eliminated. Third, to ensure the best result and the patient's comfort, lacrimal function, Bell's phenomenon, and levator function must be assessed.