Is Traditional Lower Blepharoplasty a Superior Technique?

Abstract

Sir:FigureWe read with interest the article entitled “Traditional Lower Blepharoplasty: Is Additional Support Necessary? A 30-Year Review” by Maffi et al. (Plast Reconstr Surg. 2011;128:265–273). This article describes the senior author's experience with traditional blepharoplasty and concludes that external incision with fat removal has a low complication rate and that routine support procedures are unnecessary. We have used both the traditional lower blepharoplasty and the fat-preserving technique1 for over 30 years and have only used the latter for the past 20 years. This technique consists of reducing the fatty hernia and approximating the capsulopalpebral fascia to the arcus marginalis1–5 (Fig. 1). Prospective studies comparing the “traditional” method with the “fat-preserving” method show that hernia repair is simple, safe, and reproducible, with very low morbidity and superior long-term results2,5 (Table 1).Fig. 1: (Above) Intraoperative photograph of fat hernia before reduction and capsulopalpebral hernia repair. (Below) The fat hernia is shown after reduction and repair by approximating the capsulopalpebral fascia to the arcus marginalis with interrupted 5-0 absorbable monofilament sutures.Table 1: Preoperative Tests Recommended for Selecting Patients for “Tightening/Anchoring” Procedures*Although we agree with Maffi et al. that a tightening procedure is not indicated when the eyelid tone is “adequate,” we disagree with their concept of concomitant “canthopexy” when the preoperative distraction test is “less than 6 mm” and “canthoplasty” when it measures more. We have found that both the values that reflect the muscle tone (snap-back test) and the degree of stretching of the canthal ligaments (distraction test) are necessary in selecting patients for lower lid support procedures and that over 80 percent of our patients qualify for such an intervention in contrast to their very small percentage. We define “adequate/normal tone” when the snap-back test and the distraction test are less than 1 second or less than 2 mm, respectively. In “mild” and in the majority of “moderate” and “severe” cases, we perform a tightening/anchoring procedure we call musculoplasty, as shown in Figure 2. Only in a small percentage of moderate and severe cases (<5 percent) do we perform other procedures in addition to musculoplasty. Musculoplasty consists of a single stitch of 5-0 absorbable monofilament that approximates the lower lid's orbicularis muscles to the dense fibrous tissue of the lateral orbital rim. No soft-tissue dissection and no undermining is performed in the lateral canthal region, and chemosis is typically either minimal (<5 percent of patients) or absent and, when present, subsides within 7 to 14 days without the use of steroid preparations. We have observed that chemosis is absent when the lateral canthal area is not invaded, and we attribute postoperative chemosis to surgical trauma to this region and not to lower blepharoplasty per se because in our experience chemosis is absent in these instances.Fig. 2: Musculoplasty consists of approximating the pretarsal and preseptal orbicularis to the dense fibrous tissue of the lateral canthal region.Finally, we disagree with Maffi et al. that the “traditional” approach of fat removal is easier to teach. We have found that surgeons in training who have been exposed to the basic principles of hernia repair in general surgery understand and learn readily the principles of hernia repair in the lower eyelids and are impressed by its simplicity2,5 (Fig. 1). In addition, the procedure requires less sedation, and no intraorbital bleeding/blindness has ever been reported because fatty tissue is not injected or manipulated.1–5 Fereydoun Don Parsa, M.D. Daniel Murariu, M.D., M.P.H. Alan Ali Parsa, M.D. Michael Cyrus Siah, B.A. Jennifer Armstrong, B.A. John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.