Lower Eyelid Blepharoplasty Research Articles

Comprehensive Treatment of Lower Eyelid Plasty Based on Intraoral Fixation and Redistribution of Lower Eyelid Fat.

Eye bags especially give an impression of aging and mental exhaustion. At present, the surgical methods of bags mainly include conjunctival approach and lower eyelid skin approach. With the continuous upgrading of the concept of facial esthetics, the lower eyelid pouch surgery for middle-aged and elderly patients pays more attention to reducing surgical trauma, improving tear trough deformity along with the effacement of lid‑cheek junction. This paper discusses the clinical effect of the lower lid blepharoplasty involved orbital septum fat repositioning based on oral fixation via conjunctival approach combined with relaxation skin resection in the treatment of eye bags in elderly patient. Fifty elderly patients underwent blepharoplasty between January of 2021 and June of 2021 at our hospital. The lower eyelid orbital septum fat was released along with the prezygomatic space and the premaxillary space were stripped through the conjunctival approach. The released cellulite was redistributed in the prezygomatic space/premaxillary space and fixed in the oral vestibular with 5-0 Polysorb through the middle facial tunnel. Finally, the appropriate skin was finally removed. After operation, 48 patients were satisfied with the operation results, with tight lower eyelid skin and natural lid‑cheek junction. One patient with conjunctival infection was cured after 7 days of antibiotic eye drops. One patient felt foreign body when chewing, and the symptoms disappeared naturally after 5 days without treatment. For middle-aged and elderly patients with bags, the surgical method in this study not only has good postoperative effect, but also has small damage to the lower eyelid orbicularis muscle. The appearance is natural and the lower eyelid skin is tight. The effacement of lid‑cheek junction and recreating a smooth transition of lower lid cheek interface, which can correct lacrimal groove deformity. The patients have high acceptance and satisfaction, which can be widely used in clinical practice.

Vertical V-Y Advancement Lifting Based on Fat Compartments: A New Approach for Lower Eyelid and Midcheek Rejuvenation.

Lower blepharoplasty techniques continue to improve over time. With discovery of the numerous fat compartments of the face, surgeons noticed that the appearance of the lower eyelid area through aging could be improved through midface lifting. This article introduces a vertical V-Y advancement lifting technique using the concept of fat compartments for lower lid and midcheek rejuvenation. Eighty female patients were categorized into four age groups at 20 patients each from 20 to 59 years old. The average measurement for the lower lid length in each group was recorded. An additional 318 patients who underwent lower eyelid blepharoplasty combined with fat compartments advancement lifting for lid-cheek junction rejuvenation from April of 2015 to May of 2018 were included in this study. The postoperative effect was evaluated based on preoperative and postoperative photographs, lower lid length measurements, and three-dimensional facial analyses. Lower lid lengths gradually increased with age, with the greatest increase occurring in the 30- to 39-year-old group. A total of 318 Asian female patients (age range, 35 to 58 years) underwent the surgical procedure. Measurements of lower lid length showed an average reduction of 0.31 cm 6 months after surgery. Three-dimensional facial analysis indicated that midcheek volume increased at varying degrees after surgery. Lower eyelid blepharoplasty combined with vertical V-Y advancement lifting makes it possible to restore facial fat compartments. This procedure improves projection in the midcheek without fillers, thus achieving a more youthful appearance of the lower lid and lid-cheek contour in middle-aged women. Therapeutic, IV.

Role of fractional carbon dioxide laser resurfacing in post-operative transconjunctival lower eyelid blepharoplasty

Background: Transconjunctival blepharoplasty is the management of lower eyelid structures via the conjunctival approach and is usually applied to the cosmetic improvement of the lower eyelid using this approach. Aim and objectives: The study aimed to evaluate and compare the aesthetic result for residual fine wrinkles after transconjunctival lower eyelid blepharoplasty alone or combined with post-operative fractional CO2 laser. Subjects and methods: The present study was carried out on 20 patients with lower eyelid puffiness without skin redundancy just fine wrinkles who were selected from patients that were admitted to department of plastic and reconstructive surgery, AL-Azhar University hospitals. Results: Skin tightening and residual wrinkles improvement in group (A) show that 9(90.0%) were improved and 1(10.0%) were not improved while in group (B) 6(60.0%) were not improved and 4(40.0%) were worsen. There was highly statistically significant differences between groups where P<0.001 with better result in group (A) in comparing with group (B). Conclusion: Our results demonstrated that both lower eyelid transconjunctival blepharoplasty alone or with combination with postoperative fractional CO2 laser were safe and effective in the treatment of lower eyelid puffiness. Both of the investigated methods had comparable outcomes in terms of complications and satisfaction.

Long-term stability of transconjunctival midface lift surgery for postblepharoplasty lower eyelid retraction

Lower eyelid retraction occurring as a complication of lower eyelid blepharoplasty may give rise to symptoms of exposure keratitis as well as cosmetic considerations. This retrospective longitudinal study describes our clinical experience with 74 patients with bilateral lower eyelid retraction postblepharoplasty (148 eyes) undergoing a transconjunctival subperiosteal midface lift with the implantation of a hard palate spacer graft over the period 2002 to 2019. All patients had a forced-up traction test result of less than or equal to 2mm, indicating a significant fibrosis of the middle lamellae. Margin reflex distances (MRD2) were examined at follow-up visits scheduled for 2 weeks, 1 month, and 1, 3, 6, 9, and 12 years. Mean follow-up duration was ± 102 months (range 6 to 144 months). In all patients, MRD2 varied up until 1-year postsurgery and stabilized thereafter. Last follow-up MRD2 values indicated retraction improvements of 1.4, 2.4, and 3.2mm, respectively, for those with mild: MRD2 6.3mm [5.5 - 6.6], moderate: 7.0mm [6.7 - 7.8], and severe retraction: 8.5mm [7.9 - 9]. This improvement was statistically significant in patients with severe baseline retraction (p=0.04). This approach proved to be safe and functional, and cosmetic results were excellent and remained stable over time.

Discussion: Vectra 3D Simulation of Lower Eyelid Blepharoplasty: How Accurate is it?

Discussion: Vectra 3D Simulation of Lower Eyelid Blepharoplasty: How Accurate is it?

A new modified internal fixation method of transconjunctival lower blepharoplasty

AbstractIn transconjunctival lower eyelid blepharoplasty with pedicled fat transposition, internal fixation of the septal fat is always the most difficult step. We describe a new modified method that makes this procedure less time‐consuming and specific instruments unnecessary.

Surgical Treatment of Proptosis due to High-axial Myopia During Lower Eyelid Blepharoplasty in Identical Twins.

Unilateral high-axial myopia can be associated with amblyopia and relative proptosis due to elongation of the eye and staphyloma formation. It is important to consider addressing any relative proptosis at the time of a lower eyelid blepharoplasty as the proptotic eye often creates a significant negative vector and increases the likelihood of postoperative retraction and scleral show. We present twin sisters who presented for a lower eyelid blepharoplasty evaluation; each sister had unilateral proptosis with high-axial myopia. Both underwent bilateral lower eyelid blepharoplasty and unilateral fat decompression in the proptotic eye. One sister required additional medial wall bony decompression to resolve the proptosis at the time of the aforementioned surgery. Therefore, it is important to consider globe position and degree of proptosis at the time of lower eyelid blepharoplasty surgery to optimize surgical results.

The Aging Midface and the Role of Lower Lid Blepharoplasty

Aging of the midface has been described to involve soft tissue descent as well as volumetric change. A simplified grading system for midfacial ptosis ranging from mild to severe has recently been proposed. Midfacial ptosis results in exposure of the orbital rim and the creation of a more acute orbital rim angle, especially in conjunction with orbital fat pseudoherniation. In the authors' opinion, the best surgical approach to address severe midfacial ptosis is the transtemporal subperiosteal midface lift in combination with a fat-modifying transconjunctival lower lid blepharoplasty with skin pinch.

Vectra 3D Simulation in Lower Eyelid Blepharoplasty: How Accurate is it?

Estimating the volume of fat to be resected during lower lid blepharoplasty can be challenging. While the excess fat is clearly visible in the upright position, it retracts into the orbital cavity when the patient is in decubitus. Several tools have been developed to predict the volume required for adequate outcomes and to reduce the risk of complications. Among these, 3D photography, in addition to being noninvasive, radiation-free, portable and relatively inexpensive, can be used to make simulations. To assess the level of agreement between Vectra H1 camera simulations and the outcome of lower eyelid blepharoplasties with volume removal based on these simulations. Preoperatively, a 3D camera and simulation software (Vectra H1, Canfield Imaging Systems) was used to estimate the fat pad volume to be resected from the lower eyelids in a sample of 35 patients (female n = 34) aged 55 years on average. Following the procedure, the patients were photographed at 1, 3 and 6 months and the outcome was compared to the simulation. The agreement between the simulated volume and the intraoperative volume was high. While the difference between the postoperative volume and the simulated volume decreased over time, at 6 months the actual volume was still 0.30 mL (right eye) and 0.24 mL (left eye) larger than the simulated volume. A systematic and significant difference was found between the simulation volume and the postoperative volume. The low level of agreement observed suggests that the accuracy of the tested software is insufficient for reliable simulations. 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 .

Outcomes for Cosmetic and Reconstructive Surgeries of the Periorbital Complex from the “Tracking Operations and Outcomes for Plastic Surgeons” Database

GOALS/PURPOSE: Eyelid surgery for both aesthetic and reconstructive purposes are common plastic surgery procedures. However, there is a paucity of data from multi-institutional studies with large sample sizes. The purpose of this study was to utilize a national database and perform a comprehensive analysis of surgical outcomes for blepharoplasty. METHODS/MATERIALS: This is a retrospective cohort review from 2003 to 2018 using the Tracking Operations and Outcomes for Plastic Surgeons database. The dataset was evaluated using Current Procedural Terminology codes for blepharoplasties and its related procedures (15820, 15821, 15822, 15823). These codes correspond to lower eyelid blepharoplasty, lower with extensive herniated fat pad, upper eyelid blepharoplasty, and upper with excessive skin weighting down. The core groups analyzed are those with upper, lower, or combined blepharoplasties. Categorical variables are described as frequencies and compared with Fisher exact or Pearson chi-squared test. Continuous variables, based on normality, are described as means (SD) or medians (IQR) and compared with Student T or Wilcoxon Rank-sum test, respectively. A stepwise backward multivariate logistic regression analysis was performed to assess the effect size of risk factors for adverse events with a P value set at 0.05 for significance. RESULTS/COMPLICATIONS: A total of 20,275 eyelid procedures were included. Mean age was 54.7 years (SD 12.26), female rate was 86.2% (17,466), and mean BMI was 24.77 (SD 5.65). In demographics and comorbidities, 68.4% were Whites, followed by Asians (8.7%), diabetes rate was 2.9%, and 5.9% were smokers. We analyzed 15,720 (77.5%) upper and 13,359 (65.9%) lower eyelids; of those, 8804 (43.4%) were combined. The complication rate was 2.47% for upper, 3.97% for lower eyelid, and 4.68% for combined. Comparing combined blepharoplasties to single eyelid, there was a statistically significant higher rate of hematoma (P < 0.001) eyelid malposition/asymmetry (P = 0.004) and chemosis (P < 0.001) in the combined group. For lower eyelid blepharoplasty, ectropion was more common compared with combined (P < 0.001). On the multivariate regression analysis, combined blepharoplasty (OR 1.49 95%CI 1.08–2.08; P = 0.01), performing over three procedures at the same case (OR 1.80 95%CI 1.34–2.41; P < 0.001), and Hispanic ethnicity (OR 3.1 95%CI 1.17–8.21; P = 0.02) were associated with a higher likelihood to have complications. However, being a non-tobacco smoker (OR 0.56 95%CI 0.36-–0.86; P = 0.009) lowers that probability by 44%. CONCLUSIONS: The results from this study provide insight into the national complication rate for blepharoplasty to be up to 4%, with hematoma and return to the OR as the most common. Risk factors identified for developing complications are performing a combined upper and lower blepharoplasty, having over three procedures at the same time and being of Hispanic ethnicity, while no history of smoking was associated with a decreased probability for morbidity.

Clinical Effect of the Anterior Fascia of Tarsus Tightening Combined With Lower Eyelid Blepharoplasty for Senile Entropion.

A majority of patients with senile entropion have a lower eyelid pouch. This study aimed to explore a modified method to correct the entropion and enhance ophthalmic cosmetology. Patients with senile entropion and lower eyelid pouches, who underwent anterior fascia of tarsus tightening combined with lower eyelid pouch plastic surgery from 2018 to 2019, were enrolled in the study. The data on operation time, postoperative effect, degree of eyelid swelling after surgery, patient satisfaction, and recurrence rate were recorded. The lower eyelid entropion was well corrected in all of the 46 patients after the surgery, and the lower eyelid pouch and saggy skin were satisfactorily repaired. After 1-year follow-up, no recurrence of lower eyelid eversion and ectropion was observed. The shape of the orbital areas was natural in all the patients, the incision scar was hidden, and the patient achieved a high degree of satisfaction. In patients with senile entropion and lower eyelid pouch, anterior tarsal fascia tightening combined with lower eyelid blepharoplasty could not only increase the cure rate and reduce the recurrence rate but also achieve good appearance and improve patient satisfaction.

Eyelid Malposition after Blepharoplasty: An Ounce of Prevention.

Upper and lower eyelid blepharoplasty are common procedures performed to provide a more youthful and rejuvenated appearance. However, this seemingly straightforward procedure may result in lid malpositions, frustrating the patient and surgeon alike, which ultimately require further treatment. We review preoperative assessment pearls to avoid these lid malpositions, as well as options for treating any postoperative complications related to lid position. Many of the techniques discussed in this article, in addition to many other oculoplastic procedures, are available to view in Dr. Richard C. Allen's operative video library at: http://webeye.ophth.uiowa.edu/eyeforum/video/plastics/ .

The Selection of Facelift Approach on the Basis of Midfacial Ptosis.

Facial aging in the midface has been described to encompass both soft tissue descent and volumetric change. Currently, there is no established and widely accepted grading system for midfacial ptosis. We propose a simplified grading system for midfacial ptosis ranging from mild to severe in terms of Grades I through III. Using this classification system, we describe an algorithm to help select the facelift approach most appropriate for each patient. The sub-superficial musculoaponeurotic system rhytidectomy, deep plane rhytidectomy, and subperiosteal midface lift techniques are described in detail. The nuances of the selection process also include a discussion on the various approaches to the orbital fat, namely a transconjunctival lower lid blepharoplasty with skin pinch versus a lower lid blepharoplasty with fat transposition, as well as the aging neck. Furthermore, we integrate the addition of postoperative adjunctive procedures which include injectables, chemical peels, and dermabrasion to address facial rejuvenation from not only a gravitational aspect but also the volumetric and textural components.

Ocular surface and tear film changes after eyelid surgery

: Eyelid surgery is widely and extensively used in facial plastic and reconstructive surgeries. There are many categories of eyelid surgeries, the most common of which include blepharoplasty, ptosis surgery, and eyelid reconstruction. In many cases, these procedures are combined, and there are many different techniques for each type of operation. Upper eyelid blepharoplasty usually includes the excision of skin, preseptal orbicularis oculi muscle, and orbital fat. Common methods of lower eyelid blepharoplasty are the skin-muscle flap, the skin flap, and the transconjunctival. Ptosis surgery is mainly divided into three types: transcutaneous, transconjunctival, and sling surgery. Surgeons often used the Hughes or Cutler-Beard Bridge Flaps in eyelid reconstruction. Different types and methods of surgery have their own advantages and disadvantages, and postoperative complications may occur. Therefore, postoperative complications of eyelid surgeries, such as dry eye symptoms, should be taken into serious consideration. Relevant literature involving these complaints can be found in PubMed by searching the terms “dry eye”, “eyelid”, “surgery”, and other related keywords. Moreover, various ocular surface and tear film alterations may be detected using the Ocular Surface Disease Index (OSDI), tear film breakup time, Schirmer test, fluorescein staining, and lissamine green staining after various eyelid surgeries. As dry eye disease is prevalent in the general population, it is more urgent to figure out what we can learn from these complaints. Further exploration in this field may help surgeons to choose a better surgical method and give an accurate evaluation of the postoperative effect.

An Update on Subciliary Lower Eyelid Blepharoplasty.

The subciliary lower eyelid blepharoplasty has evolved considerably to create a more harmonious natural appearance with a fuller and unoperated look and also to minimize the complications. While lower eyelid malposition was very common in the past, now this complication is significantly reduced by attention to preoperative evaluation, meticulous surgical planning, precise surgical technique, and postoperative care. Various prophylactic maneuvers maintaining/strengthening lower lid support can be utilized to prevent lower lid malposition including preservation of the pretarsal orbicularis oculi muscle, conservative resection of skin and muscle, and suspension of the orbicularis oculi muscle and/or tarsus to the periosteum of the lateral orbital rim. The release of the orbicularis retaining ligament and surgical transposition of orbital fat over the rim rather than excision allows for smoothing of the lid-cheek junction, filling the tear trough deformity, and reducing the appearance of bulging fat in the lower eyelid. In this article the reader will find a comprehensive approach for achieving a smooth contour with gradual blending at the lower eyelid-cheek junction while maintaining/restoring normal lower lid support. A descriptive outline of postoperative care is also provided to help in optimal healing for the patient.

Comparison of Fat Repositioning Versus Onlay Segmental Fat Grafting in Lower Blepharoplasty.

Lower blepharoplasty is one of the most challenging procedures in aesthetic surgery. In particular, blending the lid-cheek junction and correction of the tear trough are prone to failure and unsatisfactory outcomes. The aim of this study was to combine lower eyelid blepharoplasty with a novel technique of autologous fat grafting, commonly called segmental fat grafting, and to analyze the safety and efficacy of this approach. A retrospective analysis of 339 lower blepharoplasties was performed to compare the novel technique of segmental fat grafting to traditional fat transposition during lower blepharoplasty. Outcomes were assessed objectively by several measurements as well as via online survey of 148 invited experts in plastic surgery. Statistical analysis included t test for unpaired and paired samples as well as 1-way analysis of variance for matched data. There were no differences in baseline characteristics and comorbidities between study groups. After a mean follow-up of 12.9 months (range, 5-120 months), the group that underwent segmental fat grafting had a significant reduction in tear trough width compared compared with the group receiving lower blepharoplasty with fat transposition. Based on an expert (blinded) online survey, segmental fat grafting was superior or equal in 47% and 35% of cases, respectively. Complications (4%) and revision surgeries (9%) did not differ significantly between study groups. The novel technique of transplantation of a segmental fat graft during lower blepharoplasty is a safe and effective way to overcome tear trough deformity and blend the lid-cheek junction.

Transconjunctival lower eyelid blepharoplasty with fat transposition above the orbicularis muscle for improvement of the tear trough deformity.

The tear trough is the hollow concavity of the medial lower eyelid. Surgery can address tear trough deformities and reverse visible signs of periorbital aging. The previous methods of transconjunctival blepharoplasty with fat transposition were first described with subperiosteal placement of fat (Plast Reconstr Surg, 125, 2010,699, Aesthetic Surg J, 32, 2012, 426). This was followed by techniques with submuscular transposition of fat, which overcame certain difficulties associated with the subperiosteal methods (Clin Plast Surg, 20, 1993, 393, Arch Facial Plast Surg, 2, 2000, 16). We present a detailed description, evaluate the efficacy, safety, and advantages of transconjunctival blepharoplasty with fat pedicle transposition above the orbicularis muscle for lower eyelid rejuvenation and improvement of the tear trough deformity. Forty-one patients underwent lower eyelid blepharoplasty with fat transposition above the orbicularis muscle. Clinical and photographic documentation along with patient satisfaction ratings were evaluated for a minimum of 44months postoperatively. Significant improvements of lower eyelid aesthetics and correction of tear trough abnormalities were observed in most patients. At 44months postoperatively, surgical correction was maintained in all patients with a high satisfaction and long-term survival. No contour irregularities or significant long-term complications were detected in any of the patients. Transconjunctival blepharoplasty with the fat pedicle transposition placed above the orbicularis muscle is a safe and effective technique for lower eyelid rejuvenation. Compared to previously described techniques of repositioning fat into the subperiosteal or submuscular plane, this technique of transposing fat above the orbicularis muscle is an alternative technique resulting in long-term improvement of tear trough abnormalities with no major complications.

Recurrence of Lower Eyelid Fat Pads (Herniated Fat) after Blepharoplasty: An Analysis of Different Operative Techniques

Background: Aging changes to the lower eyelids and midface include all but not only these changes: pseudoherniated orbital fat, tear trough deformity, lid laxity, and dermatochalasis. Surgical repair often aims at treating redundant skin or orbital fat malposition with a lower eyelid blepharoplasty. In manipulating the inferior orbital fat pads, a surgeon has many options including excision, repositioning, or augmentation with synthetic dermal filler, autologous fat grafts, or acellular dermal allografts [1]. The aim of this study is to find the best approach in preventing fat herniation reccurnce in lower lid blepharoplasty. Methods: The patients in study were classified into three groups depending on the used surgical technique, to test the most effective technique associated with minimal rate of lower fat pad recurrence after surgery. Two of these techniques include a muscular flap suspension from the orbicularis oculae muscle. Results: The two surgical techniques that include orbicularis oculi muscle suspension are associated with no recurrence of lower herniated fat pads after blepharoplasty. Conclusions: The suspension of orbicularis oculi muscle has an important role in enhancing the lower orbital septum and prevents the recurrence of the lower herniated fat pads.

Lower Blepharoplasty

This review provides an overview of lower eyelid blepharoplasty, with discussion focused on relevant anatomy, the effects of aging on the lower eyelid and lid/cheek junction, patient evaluation, the most common surgical techniques, complications from surgery, and outcomes assessment. Emphasis is placed on tailoring surgical approaches to the specific aesthetic and functional concerns for each patient. Keywords: blepharoplasty, lower lid surgery, transconjunctival blepharoplasty, transcutaneous blepharoplasty, pseudoherniation, cosmetic surgery, surgery techniques, aesthetic surgery, tear trough deformity, orbital fat, eyelid laxity, canthoplasty This review contains 6 figures, 2 tables, and 50 references.

Smoothening the Lid-cheek Junction in Lower Blepharoplasty.

Aim: Transcutaneous lower blepharoplasty is more convenient for its easier learning curve, its better visibility and access to the lower periorbital structures. Conventional techniques entail fat removal to improve the lower eyelid contour. In this study we adopted the extended transcutaneous lower eyelid blepharoplasty that included dissection below the extent of the inferior orbital margin to correct the tear trough deformity that is usually missed in traditional techniques.Methods: From December 2017 to December 2018, 25 patients were subjected to this procedure via a transcutaneous stair-step incision. A retrospective analysis was implemented. On the medial side, palpebral, orbital orbicularis oculi muscle and the orbitomalar ligament were freed with dissection approaching to the premaxillary space. On the lateral side, release of the orbitomalar ligament was done, followed by dissection reaching to the prezygomatic space. Fat pads were dealt with either by excision or redistribution. Results: The mean follow-up was 12 months. High degree of patient’s satisfaction was noted after using this technique. No major complications in term of lid malposition or scleral show or infection.Conclusion: Extended transcutaneous lower blepharoplasty is a safe and effective approach and a very powerful modality for blending the lid-cheek junction and periorbital rejuvenation.Level of evidence: Therapeutic, V.