PR49 LOWER LID BLEPHAROPLASTY

Abstract

Introduction Lower lid blepharoplasty traditionally is considered a more complex procedure than upper lid blepharoplasty. More factors effect the success of the procedure and complications are more frequent. In lower lid blepharoplasty the following anatomic features are observed pre‐operatively and are often modified surgically: Lateral canthus position, interpalpebral slant, lower lid position, size and shape of the lateral scleral triangle, lower lid fat pad buldes, lower lid tone, lid‐cheek junction, and tear trough deformity. The following findings significantly effect surgical execution but are not modified surgically: presense of dry eyes/tear quality and the presence of relative enophthalmos or exopthalmos.Methods/Techniques Lower lid blepharoplasty is performed with the patient in a supine position and with conscious sedation or general anesthesia. Corneal protection lenses are placed. Local anesthesia is injected for hemostasis in the lower lid, along the infraorbial rim, and at the lateral orbital rim. A scalpel is used to make an incision from the lateral canthus in a lateral direction one cm long. The angel in changed infero‐obliquely to travel in a subcilliary location for one cm. The bovie is used to incise to that lateral orbial rim taking care to preserve the periosteum. Scissors are used to create a plane in the subcilliary location between the muscle and the skin. A subcilliary skin incision is made with the scissors. An incision is then made in the orbicularis oculi muscle inferior to the skin incision in order to preserve at least 4 mm of pre‐tarsal muscle. A skin muscle flap is then raised in the pre‐septal plane. The orbito‐malar ligament released and small portion of the lateral superior cheek is raised in a pre‐periosteal plane. Scissors are used to perform a septectomy. If the preoperative inspection demonstrated fat bulges and an absent tear trough, a conservative amount of fat is resected at the level of the orbital rim. If a prominent lid cheek junction is present and if a medial tear trough is present the fat is reposition over the infra‐orbital rim. In the case of medial tear trough correction, the medial origin of the levator labii superioris alaque nasae is elevated. Fat pads are repositioned beneath the tear trough and sutured in place to the periosteum of the superior maxilla using 6‐O vicryl.Attention is then turned to the lateral canthus. A canthopexy or lateral canthoplasty is performed in almost every lower lid blepharoplasty in order to shape the lower lid margin and the lateral scleral triangle. If the lower lid has minimal laxity defined by less than 6 mm of lid distraction from the globe with forcep retraction, a canthopexy is attempted in order to avoid a lateral canthotomy and the potential associated morbidity. If there is significant lower lid laxity, a lateral canthotomy and lateral canthoplasty is performed. 4‐O mersiline suture is used to the suture the lateral canthus to the lateral orbital rim. If lid tightening does not occur sufficiently, the lower lid is too long. In this case a lower cantholysis in performed and the lid is shortened laterally using scissors. 4‐O mersiline is used to re‐construct the lateral canthus by suturing the lower lid lateral cut margin to the lateral orbital rim in a posterior position. The vertical position and the depth of the canthoplasty or canthopexy suture placement is determined by the preoperative assessment of globe prominence using a Hertel exophthalmeter.Subsequent to management of the lateral canthus, skin‐muscle flap is redraped, trimmed and fixed in place at and lateral to the lateral orbital rim. Conservative resection of skin in important for the avoidance of complications.Results 485 patients underwent lower blepharoplasty with the technique described. The average age of the patient was 52 years. 90% patients were women and 10% were men. 73%% underwent canthopexy and 27% underwent canthoplasty. 185 were secondary lower bleaphroplasties. Satisfaction rates were high. Minor complications included chemosis, lateral canthal webbing, and excess skin requiring revision. Major complications included hematoma, lid malposition or ectropion. 3% required re‐operation for lower lid retraction.Conclusions Lower lid belpharoplasty is an important procedure in order to achieve a balanced natural appearance. Complications, while more common than those in upper lid belpahroplasty, occur at relatively low rates. Satisfaction rates are generally high. The keys to success are proper canthal positioning for lid shape and support bolstered by an orbicularis flap properly placed and firmly fixed to the lateral orbital periosteum in order to correct lower lid laxity.