Reply: Extended Transconjunctival Lower Eyelid Blepharoplasty with Release of the Tear Trough Ligament and Fat Redistribution.

Abstract

Sir: We thank Dr. Ballard and Dr. Few for sharing their thoughts and insights on our article.1 Dr. Few’s technique on the transconjunctival deep plane midface lift is a more extensive procedure for more advanced aging changes, requiring a simultaneous four-lid blepharoplasty with concomitant upper blepharoplasty and transconjunctival lower blepharoplasty with a pinch-type skin excision, canthopexy or canthoplasty, and a midface lift.2 We noted Dr. Few’s opinion that proactively supporting the lower eyelid with either canthopexy or canthoplasty is an important maneuver in preventing postoperative lid malposition. We agree with this thinking with regard to the transcutaneous approach to the lower eyelid, especially with the more extensive procedures such as trans–lower blepharoplasty midcheek lift. Accordingly, we perform routine canthopexy/canthoplasty with our transcutaneous lower eyelid blepharoplasty with midcheek lift as we reported previously in this Journal.3 Certainly, we also agree that in patients with more severe aging changes, such as festoons and large malar bags, the more extensive procedures such as the transcutaneous lower blepharoplasty with strong midcheek lift is the preferred operation. Our purpose with this article was to develop a technique that was effective, simple, and able to deliver the desired aesthetic outcomes with minimal downtime and achieve a quick recovery, as many patients prefer these days. Our technique is a less aggressive procedure that would be suitable for patients with less advanced aging changes. Correction is made possible by using the latest understanding of facial anatomy. We have advocated atraumatic access by using dissection through the facial soft-tissue spaces with precise release of the retaining ligaments that separates them. A previously unappreciated feature of the complex anatomy of the midcheek is the presence of three soft-tissue spaces, the preseptal, prezygomatic, and premaxillary spaces.4 They function to allow free movement of the orbicularis, independent from the underlying lip elevators, the zygomaticus muscles, and the levator labii superioris. These natural gliding planes may be bluntly opened to the boundaries formed by the retaining ligaments. The latter may then be released surgically to achieve the desired effect, either to eliminate tethering from the retaining ligament or to allow mobilization of the superficial fascia.5 With this approach, dissection may be achieved atraumatically, allowing for a quicker recovery. Figure 1 demonstrates a patient (presented in Fig. 8 of our article1) at 5 days postoperatively with no bruising and minimal swelling. A further important advantage of minimizing surgical trauma during surgery is that scarring may be minimized. This has the benefit of not further weakening the lower eyelid tarsoligamentous supportive mechanisms. We did not perform any routine canthopexy for our patients, and have noticed no change in the shape and posture of the lower eyelids in our long-term follow-up. Recovery was quick, with minimal complications; specifically, we did not have any patients with chemosis, as is common with the more extensive periorbital procedures.Fig. 1.: A 40-year-old woman underwent transconjunctival lower blepharoplasty with tear tough ligament release and fat redistribution. She is shown here at 5 days after surgery with minimal swelling and no bruising.The extended transconjunctival lower eyelid blepharoplasty with release of the tear trough ligament with fat redistribution as described in the article is a method ideally suited for a select subgroup of patients (i.e., those who are younger, but have eye bags, tear trough, and minimal skin excess and who want an effective surgical technique with minimal downtime and minimal risks of complications). Finally, this procedure may be performed in isolation, without the need for any concomitant upper blepharoplasty, as is (in general) needed for transconjunctival techniques that need routine canthopexy.2 PATIENT CONSENT The patient provided written consent for the use of her images. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Chin-Ho Wong, M.Med.(Surg.), F.A.M.S.(Plast. Surg.)W Aesthetic Plastic SurgerySingapore Bryan Mendelson, F.R.C.S.(Ed.), F.R.A.C.S.The Centre for Facial Plastic SurgeryToorak, Victoria, Australia