Cosmetic, Plastic, Aesthetic and Reconstructive Surgery:- Lower Lid Blepharoplasty

Lower lid blepharoplasty
The lower eyelid is a common area for patients to notice aging changes. This article describes the anatomy of the lower eyelid and the reasons for aging. It concentrates on the various operative principles and variations in practice including complications and adjunctive procedures

Introduction
The alterations caused by aging are noticeable first around the eyes and then on the neck and lower face. Periorbital rejuvenation continues to evolve with a more detailed understanding of eyelid anatomy and its subsequent affect on the anatomy with aging. Procedures have developed with time, with surgeons striving for a more youthful appearance.

Anatomy of the lower eyelid
The anterior lamella consists of the skin and orbicularis muscle. The middle lamella consists of the orbital septum, which originates from the arcus marginalis and inserts into the inferior tarsal margin. The posterior lamella includes the conjunctiva and lower eyelid retractors.
The orbicularis oculi muscle is immediately deep to the skin of the lower lid and extends from close to the ciliary margin past the infraorbital rim to the cheek. It has both pretarsal and preseptal components. Pretarsally, the orbicularis is tightly adherent to the underlying tarsus. The preorbital portion of the orbicularis oculi has cephalad attachments to the orbital rim along the orbicularis retaining ligament and along its caudal margin to the fascia enveloping the origin of the elevators of the upper lip (zygomaticus muscles). The retaining ligaments that support the orbicularis oculi to the underlying orbital rim and cheek serve to fixate this muscle tightly against the underlying facial framework.
The orbital septum lies deep to the orbicularis. A plane of loose connective tissue, the suborbicularis fascia, lies between the orbicularis and orbital septum. The suborbicularis oculi fat (SOOF) lies in this plane and is the continuum of the malar fat pad14. The triangular malar fat pad has its base at the nasolabial fold and its apex at the malar eminence, and is situated between the skin and the superficial musculoaponeurotic system (SMAS). It is loosely connected to the SMAS and firmly attached to the skin.
The orbital septum fuses superiorly with the tarsal plate and inferiorly with the periosteum of the infraorbital rim; this inferior attachment of the septum is termed the arcus marginalis. The arcus marginalis attaches medially to the anterior lacrimal crest and thins as it extends laterally attaching approximately 2 mm inferior to the rim on the facial aspect of the zygomatic bone. The orbital septum serves to retain orbital fat within the orbit. The fat mass as it encircles the extraocular muscles causes it to be divided into three pads; medial, central and lateral.

Aging of the lower eyelid-cheek complex
The pathogenesis of herniation of lower orbital fat has been debated for decades. Whether excess fat appeared in older age or whether this was shifting of intraorbital contents was unclear. The concepts of Manson et al and Camirand et al attributed lower fat extrusion to a weakening of Lockwood’s suspensory ligament with the presence of intraorbital septation within the fat compartments limiting the degree of protrusion. De la Plaza and Arroyo first proposed the theory that fat protrusion is related to the weakness of the support system of the globe, allowing it to descend and causing enopthalmos and lower lid pseudoherniation (bags).
The most poorly supported part of the orbicularis oculi is the preseptal portion and it is this portion of the orbicularis that shows the greatest tendency toward descent. As the retaining ligaments relax with aging, the herniated lower lid fat becomes situated not only anteriorly but also inferiorly below the orbital rim. This is most apparent along the central fat pad but may be noted medially as well. It is uncommon to note a lateral fat pad inferior to the infraorbital rim. In youth there is no herniation of orbital fat, the lateral orbicularis oculi blends with the malar pad. Malar bags are rarely apparent and there is a smooth contour between the preseptal and preorbital orbicularis. In youth, there is relatively more SOOF in the lower lid and more subcutaneous cheek fat. This helps to make the lower lid appear soft and smooth without the sharp demarcation between eyelid and cheek that become obvious with aging.
Hamra noted that in the youth the eyelid-cheek complex is a single mildly convex line on profile, running from the tarsus inferiorly over the young cheek. Aging causes descent of the globe and subsequent pseudoherniation of intraorbital fat. The inferior and lateral descent of these structures produces an orbit that appears deeper with a wider diameter. This progressive ptosis and an attenuation of soft tissue coverage produce skeletonization of the entire orbital area and reveal the topographical contours of the inferior bony orbital rim. A youthful midface is characterized by a malar fat pad seated over the zygomatic arch, its upper border covering the orbital part of the orbicularis oculi and its inferior border located along the nasolabial fold. With advancing age, the malar fat pad along with the SOOF slides an inferonasal direction and anteriorly over the SMAS. It bulges against the fixed nasolabial crease and exacerbates the appearance of the nasolabial fold.
The combination of descent of the orbicularis oculi, SOOF and malar fat with aging transforms the youthful single convexity to an aging double convex pattern.

Historical correction of lower lid aging
Historically lower lid blepharoplasty was viewed as an operation to remove skin and fat in the lower eyelid. The traditional open blepharoplasty redraped the skin or the skin-muscle flap between the infraorbital rim and the subciliary incision. Orbital fat that appeared excessive was removed, but the “malar crescent” or inferior border of the orbicularis muscle remained undisturbed from its position over the malar eminence.
Postoperatively, the appearance of the lower eyelid became smoother and usually deeper, particularly in patients with a negative vector. The appearance of the "malar crescent" or inferior orbicularis border if present before surgery remained unchanged. Removal of orbital fat caused eventual collapse of the existing skin cover, which created more wrinkling than before. With continuing aging, ptosis and attenuation of the orbicularis oculi led to a typical sunken appearance with possible scleral show.

Repositioning of the orbicularis muscle
The use of the orbicularis muscle as a flap in surgery of the lower eyelid was first described by Adamson et al, Courtiss, Furnas and was first used to treat malar bags/festoons by Furnas advocating lateral tension placed on the orbicularis muscle.
Hamra noted that by elevating the orbicularis muscle off the malar eminence, in a suborbicularis oculi plane, and repositioning it, the axis of the muscle from the medial orbital rim to the lateral raphe could be changed and the muscular ring around the bony orbit could be tightened. Hamra postulated that to negate the vector of aging in the orbicularis oculi, an inferolateral direction off the malar eminence, that the vector of repair should be superomedial. This superomedial vector could either be obtained by either a composite rhytidectomy or by using a lateral based orbicularis muscle flap. The laterally based orbicularis muscle flap was turned superiorly under the raphe and sutured under extreme tension to the periosteum of the lateral orbital rim.
Hamra noticed limitations of this procedure, which included occasional prolonged malar odema and an inability to exert sufficient tension on this skin muscle flap owing to the fear of lower eyelid retraction. He thus adapted the plane of dissection to continue the suborbicularis dissection under the medial portions of the zygomaticus minor and major muscles while maintaining an adequate soft-tissue cover over the periosteum. With this level of dissection he found no need to disrupt the origins of the zygomaticus musculature but could still reposition the orbicularis with even more tension than before. This zygorbicular (zygomaticus-orbicularis) plane offered many advantages. Hamra believes that this zygorbicular dissection plane is preferable to the subperiosteal plane as introduced by Tessier and recommended by Hester.
Following dissection of the zygoorbicular flap he used a 4-0 nylon suture through the longitudinal axis of the lateral canthal tendon and sutured it to the inner wall of the lateral orbital periosteum. This suture stabilized the lower eyelid in yet a higher position ensuring stability of the eyelid when suturing the septum with adequate tension over the orbital rim. He called this a "transcanthal" canthopexy, which required neither detachment of the lateral canthal tendon nor a canthotomy.

Preservation of Orbital Fat/Septal reset
Loeb was first to describe the technique of mobilizing intraorbital fat across the medial infraorbital rim. He used it to fill and thus camouflage the nasojugal groove. Hamra expanded this concept by advocating complete release of the arcus marginalis allowing the subseptal fat to be elevated to the level of the orbital rim. He extended Loeb's concept to include advancement of all of the lower lid fat pads in an effort to conceal the infraorbital rim and to recreate the youthful fullness of the lower lid. As originally described, the arcus marginalis was incised and the orbital fat alone was advanced and sutured to the preperiosteal fat of the upper cheek. Subsequently, Hamra refined his technique leaving the septum orbitale that he once excised intact and resetting the inferior border of the septum after arcus marginalis release over the orbital rim. The septal flap included orbital fat creating a smoother transition of soft tissue covering the bony rim and a firm smooth convex surface for the redraped overlying skin-muscle flap thus diminishing the rhytids. Hamra termed this procedure a septal reset. Hamra observed a marked improvement with the repositioned orbicularis now resting on a firm undersurface of septum, rather than on the concavity created by fat removal, or the soft fullness of fat only.

Surgical Technique
Perioperatievly the dermis of the subciliary incision line is injected with local anaesthesia along with percutaneous injections of a few drops of local anaesthesia with adrenalin layered over the periosteum of the maxilla and zygoma.
Subciliary skin incision is followed by a skin flap dissection to the junction of the preseptal portion with the periorbital portion of the orbicularis oculi muscle. The preseptal orbicularis is opened, leaving the pretarsal muscle undisturbed. After dissecting down to the orbital rim over the septum orbitale, the suborbicularis dissection is continued under the zygomaticus muscles. The origins of the zygomaticus major and minor muscles are left intact and an adequate layer of soft tissue is left overlying the periosteum. Dissection is started with cutting cautery, continued with scissors, or occasionally a "Kitner." This blunt dissection prevents potential nerve injury, and pushes the dissection boundary under the midportion of the zygomaticus minor and major and laterally to the zygomatic arch and a zygoorbicular dissection performed. The arcus marginalis is released by incising the junction of the septum orbitale and the periosteum of the inferior orbital rim with cutting cautery after the zygorbicular dissection has been accomplished. Decisions regarding fat removal and repositioning over the orbital rim are determined preoperatively
Some medial and central fat may be resected whereas lateral fat is in most cases used for repositioning. Before the septal reset is completed, a transcanthal canthopexy, with a 4.0 nylon, is accomplished fixing the lower eyelid position so that the septal reset can then be completed without tension. The inferior edge of the septum is then reset over the orbital rim with multiple 5-0 Vicryl sutures. Usually 5-0 eight to 12 sutures are required for the septal reset to create a smooth transition, with the tension being enough to create a firm undersurface for the orbicularis to rest upon.
After the reset is completed, the zygorbicular midface flap is advanced. Several 3-0 Vicryl sutures are placed between the zygorbicular flap and the preperiosteal tissue to reduce dead space and serum collection. A laterally based orbicularis pedicle is created from the lateral “dog leg” of the blepharoplasty incision. This pedicle is passed under the skin and muscle raphe to be secured with two sutures of 4-0 Monocryl to the periosteum of the lateral orbital rim. The very last manoeuvre is the trimming of skin, in the event that an adjustment needs to be made.

Fat Removal
Before surgery, the surgeon must decide whether fat must be resected or not, and if so, how much. This is a preoperative judgement dictated by the anatomy of each individual patient, which is difficult to assess when the patient is anaesthetized. Positive and negative vector eyelids refer to the axis dropped from the most anterior point of the globe to the cheek. The positive vector eyelid is usually the easiest for achieving a good result when using conventional blepharoplasty, and the negative vector eyelid presents a challenge when using conventional blepharoplasty. In the case of a positive vector eye with no excess fat, the septal reset takes a small amount of fat with the reset. In the case of a negative vector eye, most of the fat is necessary to adequately fill in the depression between the subciliary line and the cheek mound to create the contour of youth. Patients with a negative vector may also present with a congenital excess of fat. In these cases conservative fat removal may be appropriate. In the hollow lower eyelid, whether iatrogenic or natural, all possible fat is recruited from the subseptal space to effectively achieve a correction.

Transcutaneous versus transconjunctival.
The transcutaneous method of lower lid blepharoplasty has been generally met with some resistance. Proponents of the transconjuctival method recommend it as it addresses the lower eyelid fullness attributable to prominent orbital fat with a much lower risk of lid retraction, without visible incisions and can be safely combined with resurfacing techniques. The concerns surrounding transconjunctival blepharoplasty are related to middle lamellar contraction/shortening, lateral rounding, scleral show and ectropion. The causative factors attributed being violation of the orbicularis resulting in denervation of the orbicularis oculi. Hamra admits that with the composite lift combining and repositioning of the orbicularis that partial denervation of the orbicularis can occur. Although this is likely to result in partial denervation long lasting effects have been postulated. Clinical studies however have shown a mixed innervation of the muscle both medially from the buccal branches and laterally from the temporal branch of the facial nerve. Reinnervation to functional normality following surgery has been demonstrated. Even studies of orbicularis myomectomies for the treatment of blepharospasm have not produced any long-term denervation or loss of tone.
Honrado review of 4395 cases showed that patients who may benefit from transconjunctival blepharoplasty include the younger patient with smooth skin, moderate fat pseudoherniation and no muscle swag.
It is generally accepted that the transcutaneous method is required for orbicularis hypertrophy, excessive skin, sagging lower eyelids or where canthopexy is required, although the transconjunctival methods have been further adapted to address these issues. A transconjunctival excision of the excess fat may be followed by a transcutaneous approach leaving the orbicularis/septum complex and removing excess skin. Canthoplasty may also be combined as may adjuvant resurfacing procedures where required. Transconjunctival orbicularis septum tightening using CO2 laser in combination with periocular skin resurfacing has also been postulated. It is proposed that leaving the orbicular/septum complex prevents the problems of middle lamellar tightening. Hester et al have questioned that if so many lid supporting procedures need to be performed via the transconjunctival approach whether the morbidity can be any less than a transcutaneous procedure.
Hamra suggests however that the transconjunctival approach results in a sub optimal result.

Reproducibility
Hamra advocates addressing the lid/cheek complex as part of a composite face-lift. The isolated Hamra lower lid blepharoplasty technique has not been adopted widely although its concepts have proved to be reliable and reproducible by others. Barton et al describe its use in the group of patients they label as the “tear trough triad”.
These patients exhibit “fat herniation, prominent orbital rim depression and malar rim retrusion with negative vector”. They performed the technique in 71 patients showing no middle lamella shortening or contracture. They added that the more extensive infraorbital dissection disrupts more lymphatic channels draining into the cheek resulting occasionally in prolonged oedema. In order to avoid this they used an irrigation solution of triamcinolone into the suborbicularis space before closure and advocate manual lid stretching exercises.
Orbicularis repositioning/transcanthal canthopexy/zygoorbicular dissection plane
The plane of dissection has been debated, Hester recommending a subperiosteal plane based on the work of Tessier. For patients with pseudoherniation of orbital fat with minimal skin/muscle excess and patients with minimal descent of the lid/cheek junction and malar prominence Hester recommends that a preperiosteal cheek dissection is sufficient. This is based on their extensive review of complications in 757 cases of transblepharoplasty approach recommending that it prevents both oedema and downward retraction on the lower lid. They also recommend minimal lower lid skin excision.
Although Hester performed a subperiosteal flap dissection they utilized the arcus marginalis release, transcanthal canthopexy and laterally based orbicularis pedicle flap passed under the lateral raphe. They found improvement on their original canthotomy and canthoplasty technique. Hamra sees this change in practice as the turning point in the author’s quest for a natural look.
Although techniques incorporating orbicularis repositioning provide a vertical lift they generally result in lateral dog-ear formation, especially in patients with excess skin. Maximal skin removal to address the lateral dog-ear as recommended by Hester is required which is tolerated well with minimal complaints.

Fat repositioning and mobilization
Although fat conservation is an increasing trend debate still centers on fat repositioning versus fat mobilization. Repositioning of the subseptal fat into a subperiosteal pocket is advocated by Goldberg. Repositioning is also advocated by Moelleken rather than a septal reset because of the risk of middle lamellar contracture. Rohrich concludes that Hamras technique is useful in the central and outer portion of the lower eyelid but falls short in the medial portion, which requires either autologous fat transfer from the central and lateral compartment or autologous fat injection in the suborbicularis plane to soften the medial portion of the nasojugal groove.

Adjuvant resurfacing procedures
Adjuvant therapies such as laser resurfacing have been used for transcutaneous blepharoplasty including TCA injections/peels laser resurfacing or fat injections. Hester used TCA or laser resurfacing in over 60 percent of cases without complications and also proposed fat injection volume restoration in the nasojugal groove. Hamra postulates that improved results would be the same 1-2 years later with or without adjuvant therapies.

Complications
Complications following lower blepharoplasty techniques include lateral orbital fullness, canthal webbing, minor scleral show, ectropion, lower lid malposition, prolonged oedema, lateral dog ears and recurrence of the nasojugal groove.
For significant scleral show/ectropion Hester recommends canthoplasty. For recalcitrant lower lid malposition usually with dry eye symptoms not corrected by repeated canthoplasty and re-elevation of the lower lid Hester et al recommended the use of lower lid spacers such as ear cartilage and hard palate mucosa. Hamra recommends alloderm as an alternative.

Consultation
For anyone considering blephaoplasty it is important to consult with a surgeon who has experience in all the above techniques. For further information

(c) copyright garyross 2009

About Author
Mr Gary Ross is an NHS consultant plastic surgeon, on the GMC specialist register for plastic surgery, member of BAAPS and BAPRAS. He has trained in Australia, United Kingdom and Canada and has become a leading figure in the highly competitive field of Plastic Surgery. His private practice in Cheshire reflects his interest in head and neck and breast aesthetics. He has been appointed as an honorary senior lecturer at the University of Manchester and has published over 50 peer reviewed articles and a number of book chapters (including face lifts, brow lifts, blepharoplasty). He has presented worldwide over 200 times many as a key note lecturer and moderator. He has organized a number of international conferences and instructional courses and offers non surgical options including laser, botox, fillers and peels. He offers the full range of cosmetic surgery procedures specialising in facial aesthetics, breast surgery and body contouring. Further information available on