The muscle-suspension lower blepharoplasty.

The muscle-suspension (or muscle sling) lower blepharoplasty is a technique that can be used to some extent for all lower lids in which tightening and smoothing is desired. It seems to provide an extra degree of support by counteracting the natural tendency of gravity to produce scleral show or ectropion when the lid skin is tightened. It consists of anchoring a sling of orbicularis muscle to the periosteum of the lateral orbital rim, with an upward and lateral pull--while the skin is pulled in a more medial or upward direction.     

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.     

Restoring palpebral fissure shape after previous lower blepharoplasty

The youthful palpebral fissure can be described as long and narrow. Both the aging process and transcutaneous lower blepharoplasty can cause descent of the lower lid margin and medial migration of the lateral canthus, resulting in a rounding of the palpebral fissure. This article presents a technique to correct significant postsurgical lower lid malposition and palpebral fissure distortion without the use of outer or inner lamellar grafts. In overview, subperiosteal dissection frees scarred lid structures and cheek soft tissues, creating a continuous composite flap. Elevation of the cheek soft tissues recruits deficient outer lamellae and allows the sub-orbicularis oculi fat to be positioned between the orbital rim and scarred lid structures, filling this space and helping to support the repositioned lid margin. Titanium screws placed in the lateral orbit provide a point for secure fixation of elevated cheek tissues. Transosseous wire fixation securely repositions the lateral canthus. This procedure not only restores lower lid position and the vertical height of the palpebral fissure, but it also restores the palpebral fissure's horizontal length and the lateral canthal angle. It has been effective in correcting palpebral fissure distortion after lower blepharoplasty in 15 patients during a 6-year period.     

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.     

Experience with tarsal suspension as a factor in lower lid blepharoplasty

The bowed lower eyelid, with scleral show, is a common but untoward result following blepharoplasty with even minimal skin excision. A number of conditions, unrecognized preoperatively, can predispose a patient to scleral show. These include eyelid laxity with or without atrophic orbicularis muscle tone, lax canthal tendons, hypoplastic malar eminences, unrecognized Graves' ophthalmopathy, unilateral high myopia, or the secondary blepharoplasty. Suspension of the tarsus of the lower eyelid, concomitant with or following blepharoplasty, can straighten bowed lids and provide 2 to 3 mm of elevation, if desired. A classification of patients likely to develop scleral show is presented along with a revised technique of tarsal suspension.     

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.