Lower Blepharoplasty Research Articles

Minimal Incisions Vertical Endoscopic Lifting and Fat Grafting as a Systematic Approach to the Rejuvenation of the Periocular Esthetic Unit

The forehead/brow complex, the temporal region, the upper eyelid, the zygomatic area, the lower eyelid, and the cheek comprise the periocular esthetic unit. The combination of variable degrees of tissue descent and fat deflation of the component parts of the unit determine its appearance with age. The authors report the results of tissue repositioning through a minimal incisions vertical endoscopic lift and volume restoration used in combination to restore the natural youthful appearance of the periocular esthetic unit. The authors retrospectively reviewed the charts of patients who underwent minimal incisions vertical endoscopic lift and fat grafting over a 12-year period in 3 different centers. Patients results were evaluated with standardized pre- and postoperative pictures graded by masked observers in a scale from poor, fair, satisfactory, to very satisfactory results. Patient satisfaction was self-graded in the same manner. The study consists of 400 patients, of whom 337 (85%) were women and 63 (14.8%) were men, with a mean age of 46 years (range 38-67) for women and mean age of 53 years (range 48-65) for men. Mean follow up was 16 months (range 6 months-8 years); in 180 patients follow up was 2 years or longer. Additional procedures included lower blepharoplasty in 205 patients (51%), neck lift in 102 patients (26%), upper blepharoplasty in 63 patients (15.7%), lateral canthoplasty in 9 patients (2.3%), and upper eyelid ptosis in 6 patients (1.5%). The results were graded as satisfactory or very satisfactory by 95% of patients and by 91% of observers. On the basis of the anatomical changes that occur in the periocular esthetic unit, tissue repositioning is indicated to address the descent of the superior complex and in minor part of the inferior complex, while volume restoration is indicated to address the volume depletion of the inferior and the lateral complexes and for refinements of the superior complex. The authors propose a systematic combination of lifting and filling to naturally restore the youthful appearance of the periocular esthetic unit. Conservative blepharoplasty can be associated in selected cases for result optimization.

Transconjunctival Lower Blepharoplasty With Fat Repositioning

Differences in technique and outcome between fat transposed to the subperiosteal and supraperiosteal planes during transconjunctival lower blepharoplasty remain to be elucidated. To provide a single-surgeon comparison of transconjunctival lower blepharoplasty with fat repositioning (TCBFR) to the subperiosteal vs the supraperiosteal plane. A retrospective medical record review of patients who underwent TCBFR to the subperiosteal or the supraperiosteal plane by a single surgeon from January 1, 2009, through December 31, 2011. Differences in surgical technique, postoperative course, complications, patient satisfaction, and aesthetic results (by blinded assessment of preoperative and postoperative photographs) are reviewed using a 4-point scale. An ophthalmic plastic surgical practice. The first 20 consecutive patients who underwent TCBFR to the supraperiosteal plane and the previous 20 who underwent TCBFR to the subperiosteal plane. Transconjunctival lower blepharoplasty with fat repositioning. Intraoperative findings, postoperative course, complications, and aesthetic results. We included 40 patients (27 women and 13 men) with a mean age of 57 years and mean follow-up of 10 months. Subperiosteal TCBFR was more meticulous and less disruptive of normal anatomy and resulted in less bleeding. Supraperiosteal surgery was faster yet more traumatic, leading to more bruising, swelling, and with more clinically evident temporary postoperative contour irregularities. All patients expressed a high level of satisfaction (100%). Blinded assessment of results demonstrated no statistically significant difference (P = .45) between the 2 surgical approaches with regard to the final aesthetic result. Transconjunctival lower blepharoplasty with fat repositioning can be performed safely and effectively, whether fat is translocated to the subperiosteal or the supraperiosteal plane. Aesthetic results are comparable between the 2 approaches. 4.

Effacing the Orbitoglabellar Groove With Transposed Upper Eyelid Fat

An age-related depression can develop over the superonasal orbital rim, which the authors have called the "orbitoglabellar groove (OGG)." It is, in part, related to volume loss over the rim as is seen at the lower eyelid/cheek interface (nasojugal groove). An upper eyelid fat pedicle can be transposed over the OGG during standard upper blepharoplasty surgery to reduce this depression. The charts of patients who underwent fat transposition to the OGG during upper blepharoplasty over a 20-month period (2010-2012) are retrospectively reviewed. Only primary eyelid surgery patients are included in the study. The procedure, its results, and complications are presented. Seventeen patients are included in this study. Eleven patients (65%) are women and 6 (35%) patients are men. The average patient age is 56 years (range 47-80 years), and the average follow up is 10 months (6-14 months). Two patients (12%) developed a transient induration over the transposed fat pedicle in the postoperative period which resolved with a combination 5-fluorouracil/kenalog injection. There were no cases of postoperative infection, prolonged swelling, motility disturbance, diplopia, or eyelid malposition. Clinical effacement of the OGG was noted in all cases, and physician and patient assessment of surgical results are equally good. The OGG is an involutional periorbital hollow present over the superonasal orbital rim. The depression can be reduced with native eyelid fat transposition during upper blepharoplasty in a similar way that lower blepharoplasty with fat repositioning effaces the nasojugal groove. The learning curve for the procedure is quick, especially for those who have experience with its lower eyelid counterpart.

Acellular Dermal Grafts for Tear Trough Deformity in Revision Lower Blepharoplasty

Acellular Dermal Grafts for Tear Trough Deformity in Revision Lower Blepharoplasty

Anthropometry of Pretarsal Fullness and Eyelids in Oriental Women

In Chinese physiognomy, lower-lid pretarsal fullness is considered a sign of beauty in women. However, there are no data regarding the normal measurements of pretarsal fullness. The purpose of this study was to evaluate the average appearance of lower-lid pretarsal fullness in oriental women of specific age groups with the intention of obtaining data that surgeons could use when performing lower blepharoplasty. The effects of the orbicularis oculi muscle on pretarsal fullness are also discussed. A total of 260 oriental women were included in this study. The parameters of the eyelid, including the size of lower-lid pretarsal fullness, upper-lid crease, and palpebral fissure, were measured. The changes in these parameters with age, the ratio of lower-lid pretarsal fullness to palpebral fissure height, and the effect of the orbicularis oculi muscle on pretarsal fullness were analyzed. Two-hundred sixty women (520 eyes) were analyzed in the study. The average age of the participants was 39.3 years (range 21-60 years). The prevalence of static and dynamic pretarsal fullness was 19.2 and 74.0 %, respectively. The prevalence was higher in subjects in the fourth and fifth decades of their lives and lowest in subjects in their sixth decade. In the younger group, the average size of static pretarsal fullness was approximately 6.1-6.5 mm, and the static pretarsal fullness ratio was approximately 0.4. The vertical dimensions of static and dynamic pretarsal fullness increased with age. The changes were significantly higher in subjects over 20 years of age. This study provided data about the size and prevalence of pretarsal fullness, and allowed us to provide reference data for doctors to utilize when treating patients seeking lower-eyelid pretarsal fullness. Patients may appear younger when their new static pretarsal fullness falls within the range of 6.1-6.5 mm in the vertical dimension and when the pretarsal fullness ratio is about 0.4. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Anatomic Predictors of Unsatisfactory Outcomes in Surgical Rejuvenation of the Midface

To aid the aesthetic surgeon in midface analysis and selection of treatment plans offering the greatest likelihood of success in midface rejuvenation. We performed a retrospective review of all patients who underwent surgical midface rejuvenation by a single surgeon. We recorded demographics, history, procedures, outcomes, and complications. Results of physical examination and photography were used to classify patients by volume loss, midface ptosis, skin elasticity, and skeletal anatomy. Outcome was determined by patient satisfaction at the 12-month follow-up; unsatisfactory results were further analyzed by a blinded independent expert with more than 15 years' experience. We included 150 patients. Mean patient age was 51 years; 93.3% were women, and 20.7% had undergone previous procedures, including malar implants, autologous fat grafting, rhytidectomy, midface-lift, and extended lower blepharoplasty. Multimodality treatment was used in 34.0%. Patient dissatisfaction was encountered in 14.0% of cases; the expert concurred in each case. Autologous fat grafting alone demonstrated the greatest propensity for dissatisfaction (4 of 12 cases [33%]). Rate of dissatisfaction was significantly higher with malar hypoplasia (41% vs 7%; P < .001) or loss of elasticity (16% vs 3%; P = .01) but was not highly correlated with age (r = 0.15). Successful midface rejuvenation requires accurate diagnosis and avoidance of anatomic pitfalls. Many patients require multimodality therapy, including lifting and volumizing techniques. Unsatisfactory results are most common when midfacial aging is accompanied by skeletal insufficiency or loss of elasticity. Respective consideration of these defects should be given to placement of malar implants and rhytidectomy approaches targeting the midface.

Damage from periorbital ageing to the multilayered structures and resilience of the skin in Chinese population

Ageing dynamically disrupts the multilayered supporting components of the skin that are held together by cell adhesion molecules (CAMs). Skin specimens from 33 female Chinese patients undergoing lower blepharoplasty were divided into three age groups and examined by haematoxylin and eosin (H&E) staining, immunohistochemistry (IHC) and Elastica-van Gieson (EVG) stains, western blotting, surface electron microscopy (SEM) and biomechanical tension analysis. The SEM density (skin surface topology) showed a negative linear relationship with age. The triangular pattern of the skin surface in the younger group gradually broke down into quadrangular and irregular patterns in the older group. Collagens and elastic fibres in the dermis showed anisotropy and decreased density in the older groups compared with the younger group, especially in the papillary dermis. Anisotropy means that physical properties differ according to the direction of measurement. E-cadherin and integrin αv (whose functions are to bind epidermal and dermal elements respectively) increased and decreased, respectively, in the oldest group. Skin resilience decreased significantly in this group under repetitive stress. In conclusion, a loss of skin surface textures, integrin αv expressions, epidermal-dermal connections and dermal compactness led to the multilayered structure of the skin becoming separated. This in turn decreased resilience during ageing. These findings may therefore explain why aged skins cannot tolerate repetitive facial expressions, and why this action produces further dynamic wrinkles.

Complications in Periorbital Surgery

Comprehensive rejuvenation of the periorbital region commonly involves management of the brow, as well as the upper and lower eyelids. Browlifting, upper and lower blepharoplasty, fat transfer, and neuromodulators are frequently utilized with excellent results. However, surgery in this region can be fraught with potential complications ranging from a poor cosmetic outcome to orbital hematoma and vision loss. Although avoidance of complications is preferred, it is incumbent on the surgeon to have a detailed understanding of the pathophysiology, prevention, and management of these complications. The authors examine the more common complications of periorbital surgery.

In This Issue of JAMA Facial Plastic Surgery

JAMA Facial Plastic SurgeryVol. 15, No. 1 Free AccessIn This Issue of JAMA Facial Plastic SurgeryPublished Online:1 Jan 2013AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Nasal Tip Recontouring in Primary Rhinoplasty: The Endonasal Complete Release ApproachHolger G. Gassner, MD, and colleagues describe their approach to the nasal tip and lateral crus of the lower lateral cartilage, which they term the “endonasal complete release approach.” The authors precisely describe their technique and its application to various nasal tip deformities. A retrospective review of 100 consecutive patients undergoing septorhinoplasty in which the authors' technique was used is included, with particular emphasis on patient satisfaction. The authors discuss the advantages and disadvantages of their technique and potential limitations.See page 11Sliding Genioplasty Using Fresh-Frozen Bone AllograftsDario Bertossi, MD, and colleagues report their experience using fresh-frozen human bone allografts as interpositional grafts during sliding genioplasty in 10 patients. The authors present preoperative and postoperative cephalograms and computed tomographic scans in 10 patients and were able to obtain bone biopsy specimens to investigate integration in 1 patient. The authors' technique is described, compared, and contrasted with other methods of sliding genioplasty.See page 51Dry Eye Symptoms and Chemosis Following Blepharoplasty: A 10-Year Retrospective Review of 892 Cases in a Single-Surgeon SeriesJess Pirschman, MD, and colleagues conducted a retrospective medical chart review of all patients undergoing upper and/or lower blepharoplasty over a 10-year period to determine the incidence of dry eye following upper and/or lower blepharoplasty. Multiple risk factors for the development of dry eye following blepharoplasty are identified. The authors also report the incidence of chemosis following blepharoplasty and discuss possible causative factors.See page 39Sulcus Construction in Microtia Repair: A Retrospective Comparison of Different TechniquesShay I. Duvedani, MD, and colleagues performed a retrospective review of 3 different approaches to the creation of a postauricular sulcus in microtia reconstruction in 443 consecutive patients over a 14-year period. Techniques included in the study included the temporal parietal fascial flap, anteriorly based mastoid fascial flap, and a superficial musculoaponeurotic system flap. The authors measured the projection of the reconstructed ear achieved with each technique. The advantages and disadvantages of each technique are discussed, along with the authors' recommendations for the optimal technique.See page 17Deposition of Christ by Michelangelo Buonarroti (1475-1564).See page 68In This Issue was written by Cody Alan Koch, MD, PhD.FiguresReferencesRelatedDetails Volume 15Issue 1Jan 2013 InformationCopyright 2013 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.To cite this article:In This Issue of JAMA Facial Plastic Surgery.JAMA Facial Plastic Surgery.Jan 2013.7-7.http://doi.org/10.1001/jamafacial.2013.935Published in Volume: 15 Issue 1: January 1, 2013PDF download

A Case Report of Bilateral Retrobulbar Hemorrhage after Lower Blepharoplasty

Copyright © 2013 The Korean Cleft Palate-Craniofacial Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.e-acfs.org pISSN 2287-1152 eISSN 2287-5603 133 Correspondence: Ji Seon Cheon Department of Plastic and Reconstructive Surgery, Chosun University School of Medicine, 365 Pilmun-daero, Dong-gu, Gwangju 501-717, Korea Tel: +82-62-220-3183 / Fax: +82-62-225-0996 / E-mail: ps9107@naver.com Received August 19, 2013 / Revised September 11, 2013 / Accepted September 12, 2013 Arch Craniofac Surg Vol.14 No.2, 133-136 http://dx.doi.org/10.7181/acfs.2013.14.2.133

An Argument for “Closed Canthal Suspension” in Aesthetic Lower Blepharoplasty

An Argument for “Closed Canthal Suspension” in Aesthetic Lower Blepharoplasty

Dry Eye Symptoms and Chemosis Following Blepharoplasty

To determine the incidence of and risk factors associated with dry eye symptoms (DES) and chemosis following upper or lower blepharoplasty. To examine the outcomes among long-term blepharoplasty data to better understand the incidence of and risk factors associated with dry eye symptoms (DES) and chemosis, to evaluate the known risk factors for DES in the general population, and to analyze intraoperative procedures (such as forehead-lift, midface-lift, canthopexy, and canthoplasty) to determine their effects on DES and chemosis. A retrospective medical record review was performed among all the cases of upper or lower blepharoplasty performed by the senior author during a 10-year period (January 1999 through December 2009). A self-reported dry eye questionnaire was used to collect baseline and follow-up data. Patients with incomplete medical records, multiple (>1) revision procedures, less than 3 weeks of postoperative follow-up data, or a history of Sjögren syndrome, severe thyroid eye disease, histoplasmosis ocular infection, periocular trauma causing eyelid malposition, or radiotherapy for nasopharyngeal cancer were excluded from the study. Binary logistic regression analyses were performed to analyze the relationship between 13 preoperative and anatomical variables and DES or chemosis. χ2 Tests were performed to analyze the relationship between intraoperative risk factors and DES or chemosis. In total, 892 cases met the study inclusion criteria. Dry eye symptoms and chemosis following blepharoplasty were reported in 26.5% and 26.3% of patients, respectively. The incidences of DES and chemosis were significantly higher in patients who underwent concurrent upper and lower blepharoplasty (P < .001) and in patients who underwent skin-muscle flap blepharoplasty (P = .001). Hormone therapy use and preoperative scleral show were associated with DES after blepharoplasty (P < .05). Male sex, preoperative eyelid laxity, and preoperative DES were associated with an increased incidence of chemosis following blepharoplasty (P < .05). Intraoperative canthopexy significantly increased the risk for developing chemosis (P = .009), and postoperative lagophthalmos significantly increased the risk for DES following blepharoplasty (P < .001). Dry eye symptoms and chemosis are common following blepharoplasty, and the risk for developing these conditions may increase with intraoperative canthopexy, postoperative temporary lagophthalmos, concurrent upper and lower blepharoplasty, and transcutaneous approaches violating the orbicularis oculi muscle. Patients with a preoperative history of DES, eyelid laxity, scleral show, or hormone therapy use may be at greater risk for developing dry eyes or chemosis following surgery.

The application of undermining orbicularis oculi muscle from orbital rim for the correction of tear trough deformity and palabromalar groove in lower blepharoplasty

To evaluate the role of undermining orbicularis oculi muscle from Orbital rim for the correction of tear trough deformity and palabromalar groove in lower blepharoplasty. 56 cases of lower eye baggy deformity with tear trough deformity and palabromalar groove were treated with the procedure of stripping eye orbicularis oculi muscle from orbital rim by a transcutaneous approach in lower blepharoplasty. The orbital septum was opened along the arcus marginalis for releasing the orbital fat. Some orbital fat was removed if necessary. Then the inferior edge of the orbital septum fat was reset over the orbital rim so as to smooth the infraorbital groove. 56 patients were available for 6 to 18 month's follow-up. 54 patients were quite satisfied with the cosmetic result. One developed lower eyelid retraction and another one showed asymmetrical subcutaneous local uneven after 1 month's. They were all corrected by the second operation after 3 months. Stripping orbicularis oculi muscle from orbital rim plays an important role for the correction of tear trough deformity and palabromalar groove in lower blepharoplasty.

Perceived Age Change After Aesthetic Facial Surgical Procedures

To quantify the degree of perceived age change after aesthetic facial surgical procedures to provide an objective measure of surgical success. Sixty patients undergoing various aging face surgical procedures were randomly chosen for analysis. Preoperative and postoperative photographs were evaluated. Raters were presented with photographs in a random assortment and were asked to estimate the age of the patient. Perceived age difference was defined as the difference between the chronological age and the estimated age, and the change in this value after surgery was the chief outcome of interest. Statistical models were designed to account for any effects of interrater differences, preoperative chronological age, rater group, photograph order, or surgical procedure performed. Our patient population was divided into the following 3 groups based on the surgical procedure performed: group 1 (face- and neck-lift [22 patients]), group 2 (face- and neck-lift and upper and lower blepharoplasty [17 patients]), and group 3 (face- and neck-lift, upper and lower blepharoplasty, and forehead-lift [21 patients]). Adjusted means demonstrated that patient ages were estimated to be 1.7 years younger than their chronological age before surgery and 8.9 years younger than their chronological age after surgery. The effect was less substantial for group 1 patients and was most dramatic for group 3 patients, who had undergone all 3 aging face surgical procedures. Our study is novel in that it quantifies the degree of perceived age change after aging face surgical procedures and demonstrates a significant and consistent reduction in perceived age after aesthetic facial surgery. This effect is more substantial when the number of surgical procedures is increased, an effect unrelated to the preoperative age of a patient and unaffected by other variables that we investigated. The ability to perceive age correctly is accurate and consistent. To provide an objective measure of surgical success, Chauhan et al, conducted a preoperative-postoperative study quantifying the degree of perceived age change after aesthetic facial procedures in 60 patients.

Highlights of Archives of Facial Plastic Surgery

Archives of Facial Plastic SurgeryVol. 14, No. 4 Free AccessHighlights of Archives of Facial Plastic SurgeryPublished Online:2 Jul 2012AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Contemporary Review of RhinoplastyPatrick C. Angelos, MD, and colleagues offer a review of recent advances and trends in primary and functional rhinoplasty. Specific topics addressed in this review include outcomes in functional rhinoplasty and nasal valve repair, outcomes in septal reconstruction, malpositioning of the lower lateral cartilages, nasal tip contouring, osteotomies, grafting materials, and the use of computer imaging.See page 238Perceived Age Change After Aesthetic Facial Surgical Procedures: Quantifying Outcomes of Aging Face SurgeryNitin Chauhan, MD, FRCSC, and colleagues present the results of a retrospective study to quantify the amount of perceived age change that occurs following aesthetic facial surgery, including face- and neck-lift, upper and lower blepharoplasty, and forehead-lift. Preoperative and 6-month postoperative photographs of 60 patients who underwent aesthetic facial surgery were evaluated by blinded raters, who were asked to estimate the subjects' ages. The authors present data on the perceived age change associated with these aesthetic surgical procedures.See page 258Toward a Universal, Automated Facial Measurement Tool in Facial ReanimationTessa A. Hadlock, MD, and Luke S. Urban, MS, describe the use of a novel computer software program designed to provide quantitative measurements of facial anatomic landmarks and facial movement. The authors used this automated tool to analyze facial photographs at rest and with movement of healthy subjects as well as a group of patients with flaccid facial paralysis. Results obtained by the automated software program were compared with those obtained by standard digital photographic analysis using Photoshop. The authors discuss the application of this process to facial nerve rehabilitation.See page 277Biomechanical Properties of the Facial Retaining LigamentsMichael G. Brandt, HBSc, MD, and colleagues present the results of an anatomic study to determine the biophysical properties of osteocutaneous facial retaining ligaments. Ten cadaveric hemifaces were dissected to identify and characterize the orbital, zygomatic, buccomaxillary, and mandibular osteocutaneous ligaments. Measured outcomes are presented, and the authors discuss these findings as they relate to common clinical signs of the aging face.See page 289Madame de Pastoret and Her Son by Jacques Louis David, 1748-1825.See page 304This issue's Highlights were written by Richard J. Wright, MD.FiguresReferencesRelatedDetails Volume 14Issue 4Jul 2012 InformationCopyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.To cite this article:Highlights of Archives of Facial Plastic Surgery.Archives of Facial Plastic Surgery.Jul 2012.235-235.http://doi.org/10.1001/archfaci.2012.668Published in Volume: 14 Issue 4: July 2, 2012PDF download

Perceived Age Change After Aesthetic Facial Surgical Procedures

To quantify the degree of perceived age change after aesthetic facial surgical procedures to provide an objective measure of surgical success. Sixty patients undergoing various aging face surgical procedures were randomly chosen for analysis. Preoperative and postoperative photographs were evaluated. Raters were presented with photographs in a random assortment and were asked to estimate the age of the patient. Perceived age difference was defined as the difference between the chronological age and the estimated age, and the change in this value after surgery was the chief outcome of interest. Statistical models were designed to account for any effects of interrater differences, preoperative chronological age, rater group, photograph order, or surgical procedure performed. Our patient population was divided into the following 3 groups based on the surgical procedure performed: group 1 (face- and neck-lift [22 patients]), group 2 (face- and neck-lift and upper and lower blepharoplasty [17 patients]), and group 3 (face- and neck-lift, upper and lower blepharoplasty, and forehead-lift [21 patients]). Adjusted means demonstrated that patient ages were estimated to be 1.7 years younger than their chronological age before surgery and 8.9 years younger than their chronological age after surgery. The effect was less substantial for group 1 patients and was most dramatic for group 3 patients, who had undergone all 3 aging face surgical procedures. Our study is novel in that it quantifies the degree of perceived age change after aging face surgical procedures and demonstrates a significant and consistent reduction in perceived age after aesthetic facial surgery. This effect is more substantial when the number of surgical procedures is increased, an effect unrelated to the preoperative age of a patient and unaffected by other variables that we investigated. The ability to perceive age correctly is accurate and consistent.

Is Traditional Lower Blepharoplasty a Superior Technique?

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.

The Lift and Fill Lower Blepharoplasty

To evaluate a series of patients who underwent combined lower transconjunctival blepharoplasty with fat repositioning and orbicularis muscle suspension, "The Lift and Fill Lower Blepharoplasty," as a means of improving lower eyelid, and eyelid/cheek interface aesthetics after surgery. The authors retrospectively reviewed the charts of patients who underwent both transconjunctival lower blepharoplasty with fat repositioning and orbicularis muscle suspension over a 4-year period (2007-2010) from the 2 authors' practices. All patients with a history of previous eyelid surgery or trauma, eyelid or orbital inflammatory disease, and those with frank eyelid malposition are excluded. Additional procedures are noted and results and complications are reviewed. The study consists of 54 patients, of whom 42 are women, with an average age of 56 years and an average follow up of 19 months. Thirty patients had fat repositioning performed subperiosteally, and in 24 patients the dissection plane was preperiosteal. A skin excision was added in most patients and canthal suspension in approximately half of the patients. There were no cases of postoperative eyelid malposition or other significant complications. There were no appreciable differences in outcomes between the sub- or preperiosteal fat repositioning approaches. All patients were happy with their surgical outcome. The combination of transconjunctival lower blepharoplasty with fat repositioning, and orbicularis muscle suspension, "The Lift and Fill Lower Blepharoplasty," provides a reliable and reproducible aesthetic rejuvenation of the lower eyelid and its transition to the cheek.

Tear Trough Deformity: Review of Anatomy and Treatment Options

The lower eyelid can be a challenging area in facial rejuvenation. While lower eyelid bags are commonly the reason that patients present for lower eyelid rejuvenation, a separate entity known as a tear trough deformity may occur in conjunction with lower eyelid bags or alone. In this article, the authors outline the current understanding of the tear trough anatomy; describe multiple classification systems, which provide an objective means of evaluating the deformity and aid the surgeon in choosing appropriate treatment options; and review surgical and nonsurgical techniques for correcting the tear trough deformity. Treatment options include hyaluronic acid filler, fat grafting, skeletal implants, and fat transposition. Each procedure is associated with advantages and disadvantages, and each should be considered more complex than traditional lower blepharoplasty alone. While lower blepharoplasty removes excess fat and may tighten the anterior lamella, tear trough procedures require the addition of volume to the underlying depression. These procedures requiring release of the ligamentous structures and orbicularis (of which the tear trough is composed), as well as fat transposition or fat grafting, are associated with additional complications, which are also reviewed.

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Sir:FigureWe sincerely appreciate Dr. Gradinger's comments and astute observations regarding our study, “The Five Step Lower Blepharoplasty: Blending the Eyelid-Cheek Junction.”1 Dr. Gradinger has raised some interesting points that further underscore the need for enhancing our ability to truly grade our results objectively using evidence-based medicine, and the challenges plastic surgeons face in effective and predictable lower eyelid rejuvenation. Directly correlating quantitative outcomes with clinical improvements in aesthetic surgery continues to be a daunting task. The crux of Dr. Gradinger's comments centers around our computer-generated outcomes. It is important not to distract our readers from the key points of our study with computer-generated data, which only served to confirm the safety of our study. Dr. Gradinger's queries are valid and require clarification. Overall, we saw a cumulative improvement in the aesthetic outcomes and had no complications that required reoperation. This is quite rare in performing lower eyelid rejuvenation surgery. The goal of our study was to delineate a safe and effective method of blending the eyelid-cheek junction without disrupting the orbicularis oculi muscle or performing operative techniques that have excessively high morbidity. The high complication and reoperation rates seen in lower eyelid surgery served as the impetus for the five-step combination and research design. Although our maneuvers may not have had 100 percent desired change in each of the individual data points measured, overall aesthetics were improved. Does a slight increase in pupil-to–eyelid margin distance in 36 of 100 eyelids mean that the technique is ineffective? Is it possible that in many of the same patients who demonstrated an increase in pupil-to–eyelid margin distance there was also a decrease in tear trough width and pupil-to–tear trough distance? If so, then the sum of effects was effective and safe, because the overall improvements did not require further surgical correction. It is the sum of the five steps and the overall combined effect of these individual techniques and their direct morphologic changes that lead to improved eyelid-cheek junction blending. Just as the individual steps should not be isolated, so should the results not be judged on each isolated data point. Rather, these data points were measured to evaluate the spectrum of changes that can be observed, whether it decreased in some respects and increased in others. The orbicularis retaining ligament is a key structure in bringing together the cumulative changes. With that said, we will address all the points raised by Dr. Gradinger. Selective release of the orbicularis retaining ligament is as effective as arcus release because the major significance assigned to the arcus is its translated effects by means of the orbicularis retaining ligament to the overlying skin and soft tissue. Full release is not always necessary. Lateral retinacular support served as prophylaxis against lid malposition during the healing/edema phase and is not meant to be permanent. All eyelids undergo slight to minimal lower lid fat removal, sometimes purely for contour and “smoothing,” not just for debulking purposes. We have not witnessed any posterior and/or middle lamellae contracture with the five-step method. All patients in our study required at least slight skin pinch excision, and no patients demonstrated exophthalmos, which is a contraindication to this technique. The conservative degree of skin removal and avoidance of injury to the septum/orbicularis muscle anteriorly all help to eliminate tension and resultant anterior lamella shortening. Concern regarding exacerbation of tear trough as a result of adjacent augmentation of the deep malar fat pad is valid and is a common source of trepidation. Selective orbicularis retaining ligament release allows migration of native lower lid fat to coalesce with the superficial and deep malar fat compartments. Molding is performed intraoperatively to further blend this region. Reducing skin laxity with pinch removal also helps reduce tear trough appearance. Deep malar fat augmentation also acts to elevate the superficial fat compartments cephalically to meet the now released lower lid fat. We thank Dr. Gradinger for his clear and directed comments on the numerous challenges inherent in lower eyelid rejuvenation. We hope that our five-step technique helps to shed more light on the key principles and techniques in safe and effective lower eyelid-cheek rejuvenation.2–5 Ashkan Ghavami, M.D. Department of Surgery, Division of Plastic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, Calif. Rod J. Rohrich, M.D. Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas