COSMETIC OCULOPLASTIC SURGERY
Lower Eyelid Blepharoplasty RUSSELL W. NEUHAUS, MD BACKGROUND.Lower eyelid blepharoplasty is a frequently performed procedure to reverse partially gravitational aging effects on eyelid tissues. Careful planning, proper execution, and appropriate management of potential postoperative complications will generally result in a happy and satisfied patient. However, in any surgical procedure that is primarily aesthetic in nature, the surgeon needs to be constantly aware of factors that may compromise the functional integrity of the eyelid. A patient with altered visual function or ocular discomfort is no longer primarily concerned about the final aesthetic appearance of even the most perfectly executed, technically correct blepharoplasty procedure.
T
he surgical goals in lower eyelid blepharoplasty are directed to improved aesthetic appearance of redundant and displaced lower eyelid soft tissues. Frequently, the preoperativeevaluation of a patient with aesthetic eyelid concerns will reveal latent functional lower eyelid problems as well. Most commonly these include horizontal eyelid laxity with lateral canthal tendon laxity and/or dehiscence from its attachment to the lateral orbital rim. Other latent functional difficulties may include early keratitis sicca (dry eye), mild orbicularismuscle weakness, or pre-existingmedical problems such as thyroid eye disease or other orbital inflammatory conditions. However, with careful attention to detailed preoperative evaluation and planning of the technical aspect of the surgical procedure, the probability of a successful operation with improved aesthetic appearance is enhanced. A single surgicaltechnique is not appropriate for every patient. In fact, every patient requires some modification of the standard surgical procedure to achieve the best possible result. Some of the technical aspects that need to be determined preoperatively include the eyelid skin incision location, amount of excess skin versus excess underlying orbicularis muscle, presence of orbicularis muscle festoons, identification of prominent lower eyelid fat pads, and evaluation of horizontal eyelid laxity. Intraop-
In private practice. Address correspondence and reprint requests to: Russell W.Neuhaus, MD, 3705 Medical Pkwy, Suite 370, Austin, TX 78705.
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OBJECTIVE.To describe the preoperative evaluation, surgi-
cal technique, and postoperative complications of lower eyelid blepharoplasty. Specific attention will be given to lower eyelid retraction and ectropion following blepharoplasty. CONCLUSION. Successful lower eyelid blepharoplasty surgery can be a source of both patient and physician satisfaction. As long as patient expectations are consistent with realistic surgical goals, lower eyelid blepharoplasty is an important aspect of overall facial aesthetic surge ry. J Dermatol Surg Oncol 1992;lB:llOO-1109.
erative surgical attention to meticulous hemostasis and manipulation of delicate eyelid soft tissues will further enhance a pleasing aesthetic result Following surgery, appropriate management of complications if they occur will improve the final result and reassure the anxious patient. Lower eyelid malposition problems -including ectropion, retraction, or lateral canthal deformity- are the most common problems following lower eyelid blepharoplasty. Appropriate supportive medical management including the use of topical lubricating eye drops and ointment is frequently all that is needed. In those patients with persistent lower eyelid malposition problems or acute malposition problems with corneal decompensation, surgical correction can be quite successful in protecting the cornea from further exposure and achieving an acceptable cosmetic result. If residual soft tissue is present after blepharoplasty it can be addressed with secondarylower eyelid blepharoplasty after complete healing has occurred.
Preoperative Evaluation: ”Decision Before Incision” Determining who is an acceptable candidate for lower eyelid surgery requires the evaluation of the patient’s desires in light of what can realistically be accomplished surgically. Frequently the lower eyelid blepharoplasty procedure is performed simultaneously with other aesthetic surgery in the upper eyelid or facial area. It is important that each functional facial unit is considered separately and in concert with other proposed facial surgery.
0 1992 by Elsevier Science Publishing Co., Inc. 0148-0812/92/$5.00
NEUHAUS LOWER EYELID BLEPHAROPLASTY
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The surgeon needs to be aware that aesthetic and functional changes that occur following upper eyelid blepharoplasty will impact the result of lower eyelid blepharoplasty. Specifically,transient upper eyelid lagophthalmos (inability to close the eyelids) secondary to postoperative upper eyelid edema will exacerbate the corneal exposure secondary to any lower eyelid retraction following lower eyelid blepharoplasty. Pre-existing lower eyelid horizontal laxity may not be functionally evident until increased inferior traction occurs after lower eyelid blepharoplasty. Preoperative lower eyelid laxity can be determined by the eyelid retraction test. After the patient is instructed not to blink, moderate inferior manual traction is applied to the lower eyelid and then released (Figure 1).If normal horizontal tightness is present with good orbicularismuscle tone, the lower eyelid will assume a normal anatomic position with good apposition to the globe immediately. With mild lower eyelid horizontal laxity the lower eyelid will require several seconds to assume its normal anatomic position. With moderate horizontal eyelid laxity the lower eyelid will only assumeits normal anatomicalposition following eyelid blinking. With severe horizontal eyelid laxity the lower eyelid malposition will persist with blinking and will be a functional problem before lower eyelid blepharoplasty is performed. If lower eyelid horizontal laxity is diagnosed preoperatively,intraoperative correction is indicated during blepharoplasty, as discussed below. Because mild keratitis sicca (dryeye) may by asymptomatic, a properly performed Schirmer's test should be accomplished prior to blepharoplasty surgery. The Schirmer's test strip is placed in the inferior cul-de-sac of the eye to determine reflexive tear production (without the use of topical anesthetic agents) and basal tear production (after the use of topical anesthetic agents) (Figure 2). Less than 5 mm of wetting suggests an inadequate tear production. A borderline dry eye may not become symptomatic until stressed by increased corneal exposure following blepharoplasty surgery. Patients with borderline
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dry eyes may still be acceptable blepharoplasty candidates, but a more conservative operation is indicated and the need of either short- or possible long-term topical tear supplementation needs to be discussed with the patient preoperatively. In patients with a history of a previous Bell's palsy or facial nerve dysfunction, it is important to determine whether any residual orbicularis muscle weakness is present. With the patient maximally closing the eyelids, the examiner tries to elevate the upper eyelid (Figure 3). Any asymmetry in the ability to open the upper eyelid manually against the maximally contracted orbicularis muscle signifies sigruficant orbicularis muscle weakness. Although the patient may be compensated prior to blepharoplasty surgery, corneal exposure may become a problem after blepharoplasty secondary to orbicularis muscle dysfunction and lagophthalmos. A history of previous thyroid disease should raise one's suspicion of underlying dysthyroid orbital inflammatory disease (Graves' disease) with secondary soft tissue redundancy and anteriorly prolapsed orbital fat and lacrimal gland into the eyelids (Figure 4). Although patients with Graves' orbital inflammatory disease can successfully undergo blepharoplasty surgery, additional attention needs to be directed to possible globe proptosis, upper or lower eyelid retraction, anteriorly prolapsed lacrimal glands into the eyelid, and engorged blood vessels that may be present. Finally, the general medical health of the patient needs to be evaluated with specific attention to any aspirincontaining compounds or nonsteroidal anti-inflammatory drugs that the patient may be taking. These medications need to be discontinued 10 days prior to surgery so that platelet function can return to normal. Underlying bony skeletal problems will affect overlying soft tissue surgery. Specifically, shallow orbits with relative globe proptosis in association with midfaaal bony hypoplasia of the zygomatic bone predisposes the lower eyelid to a retracted position following blepharoFigure 3. Attempting manual upper
Figure 2. Schirmer's test strip in inferior Figure 1. Lower eyelid retraction test.
cul-de-sac.
eyelid elevation during maximal orbicularis muscle constriction.
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Figure 4. Patient with dysthyroid
Figure 5. Relative midfacial (zygomatic)
Figure 6. Orbicularis muscle festoons in
orbital inflammatory disease with mild eyelid retraction and anterior displacement of orbital fat and lacrimal glands.
hypoplasia with shallow orbits and prominent globes.
the lower eyelids.
plasty surgery (Figure 5). Frequently, even conservative lower eyelid blepharoplasty surgery will result in significant lower eyelid malposition with retraction. Extreme care during skin and orbicularis muscle excision is indicated in those patients with this underlying bony abnormality. If postoperative lower eyelid retraction should occur, surgical correction requires additional superior support by vertical augmentation of the tarsal plate, as discussed in the next section. In certain individuals, hypertrophic orbicularis muscle will be present immediately inferior to the inferior orbital rims. This soft tissue abnormality is frequently referred to as "bags on bags" or eyelid "festoons" (Figure 6). During surgery the location and severity of the festoons will not be obvious because the patient is in a supine position with the effects of gravity on the redundant orbicularis muscle eliminated. The surgical correction of orbicularis muscle festoons will require an extended blepharoplasty with extensive suborbicularis muscle dissection and resupport to the periosteum at the lateral orbital rim and the body of the zygomatic bone. The supporting suture placement needs to be determined and documented preoperatively for referral during surgery.
Figure 7. Local infiltrative anesthesia
given as first step in lower eyelid blepharoplasty.
Finally, preoperative visual acuity needs to be recorded as well as preoperative photographs to document the pre-existing soft tissue abnormalities. The preoperative photographs will be used for further preoperative planning, discussion with the patient, intraoperative guidance, and postoperative comparison.
Technique: "How To Do It" Blepharoplasty surgery can be successfully performed as an outpatient procedure either in the outpatient surgical department of a hospital or in a specially prepared and equipped surgical area in a private office. Surgery is most commonly performed under local anesthesia with some form of sedation. The amount and type of sedation must be tailored by the availability of medical personnel, presence of a postoperative observation facility, and the general health of the patient. My personal preference for anesthetic solution is 2% Xylocaine with epinephrine 1: 100,000 dilution with the addition of 150 units of Wydase to 20 mL of anesthetic solution. The injection site of the local infiltrative anesthesia may be either through the lower eyelid skin or posteriorly through the palpebral conjunctiva (Figure 7).
Figure 8. Lower eyelid incision marked. Note only slight inferior angulation of the incision at the lateral canthal angle.
Figure 9. A 4-0 silk superior traction suture aids soft tissue identification and dissection of surgical planes.
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The posterior approach to local infiltrativeanesthesia can be preceded with topical Ophthaine to anesthetize the conjunctiva. The addition of 1 mEq of sodium bicarbonate to 5 mL of local anesthetic solution immediately prior to injection will significantly decrease the injection discomfort by neutralizing the acidic pH. Approximately 2 mL of anesthetic solution are given in the central aspect of each lower eyelid in a single location. The Wydase will allow gradual dispersion of the anesthetic agent throughout the anterior orbit and eyelid soft tissue. The dispersion of the local infiltrative anesthesia will occur as the patient is being prepped and the surgeon is scrubbing his or her hands. This sequence allows a full 10 to 15 minutes for total anesthetic dispersion and, more importantly, allows the epinephrine to maximally constrict the blood vessels in the surgical field. By the time the surgeon finishes his or her personal scrub, the patient has been prepped and is ready for marking of proposed incision lines. Corneal protectors can be used, but have the distinct disadvantage of potentially trapping the facial prepping solution beneath the corneal protector adjacent to the cornea. If meticulous care is taken in flushing the surface of the eye prior to placement of the corneal protector, it can be placed immediately prior to marking the patient. By referring to detailed preoperative notes and photographs the surgeon can then accurately draw the incision lines (Figure 8). Modification of the surgical plan is possible at this time but the surgeon must be aware of alteration of the orbital soft tissues in the supine patient secondary to elimination of gravitational effects. The lower eyelid blepharoplasty incision is placed approximately 2 mm below the lower eyelid lash line. It begins immediately inferior to the punctum and extends to the lateral canthal angle. From that point it extends further laterally and inferiorly at approximately 10 degrees from horizontal. The lateral incision frequently can be designed to fall within the radiating rhytids, caused by
Figure 10. A perpendicular incision is made through skin and orbicularis muscle into the pretarsal space.
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contraction of the underlying orbicularis muscle. The lateral extent of the lower eyelid blepharoplasty incision depends on the degree of suborbicularis muscle dissection that may be needed to resupport the orbicularis muscle to the lateral orbital rim. If no such support is needed, the lateral extent of the lower eyelid blepharoplasty incision will be approximately 10 mm. A 4-0silk traction suture is placed in the eyelid margin for superior eyelid traction during the soft tissue dissection (Figure9). A Westcott scissorsincision of the skin and underlying orbicularis muscle is made in the central aspect of the lower eyelid blepharoplasty incision (Figure 10). The pretarsal space is exposed, allowing the placement of one blade of the scissors within the wound. After the incision is completed in both medial and lateral directions, a skin muscle flap is dissected inferiorly, fully exposing the orbital septum (Figure 11). Care is taken not to incise the orbital septum until the infraorbital rim is encountered because anteriorly prolapsing orbital fat will obscure visualization.The lower eyelid skin muscle flap is retracted with a Desmarres retractor and hemostasis is obtained with electrocautery (Figure 12). The orbital septum is opened for the full width of the eyelid, exposing the nasal, middle, and lateral fat pads (Figure 13). Particular attention is directed to exposing the lateral fat pad because it frequently will move posteriorly with the patient in a supine position. Moderate globe and orbital pressure may be needed to prolapse the fat pads anteriorly. The nasal fat pad is easily identified by its whitish appearance, analogous to the nasal upper eyelid fat pad. As opposed to the upper eyelid fat pads, the lower eyelid fat pads have significant vessels within the fat pads. Because it is usually quite difficult to avoid incising these vessels, adequate clamping of the fat pads is needed prior to excising the anteriorly prolapsed portion of the fat pads. Attention is first directed to the lateral fat pad which is clamped with a small straight hemostat (Figure 14).
Figure 11. Inferior dissection of a skinmuscle flap, fully exposing the orbital septum.
Figure 12. Skin-muscle flap retracted inferiorly.
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Figure 13. Orbital septum opened for the full width of the eyelid, fully exposing redundant orbital fat.
Figure 14. Hemostat has been applied to orbital fat and scissor excision of clamped fat being accomplished.
The fat is excised at the level of the hemostat and battery hot-tip cautery is applied to the cut edge of the fat pad (Figure 15).If the surgeon prefers unipolar cautery, a small area of contact between the hemostat and skin may cause a skin bum. Avoiding skin contact by pulling the hemostat anteriorly may result in excessive anterior traction on the orbital fat pads. After hemostasis is achieved, the clamped fat is slowly released and inspection performed. Additional fat removal in the lateral compartment is frequently possible as moderate orbital pressure will prolapse additional fatty tissue anteriorly (Figure 16). A similar technique is used to remove the middle and nasal fat compartments with appropriate attention directed to identification of the inferior oblique muscle, which divides the nasal from the middle fat pad. If pre-existing horizontal eyelid laxity has been determined, intraoperative horizontal tightening can be accomplished at this time. Attention is directed to the lateral canthal tendon where the full thickness portion of the lateral eyelid margin is excised, creating a lateral tongue of tarsal tissue. The lateral tongue of tarsal tissue is horizontally shortened and reattached to the internal aspect of the lateral orbital rim with a 5-0 Dexon (D1 needle) mattress suture. It is important to secure the eyelid to the Figure 16. Additional fat can be easily prolapsed anteriorly from the lateral compartment.
Figure 15. Hot tip, battery powered cautery used to cauterize cut edge of orbital fat. Note that supplemental oxygen must be discontinued during cautery,
internal aspect of the lateral orbital rim to provide good lower eyelid apposition to the globe. (See the discussion below for details of lateral cantopexy.) The skin muscle flap is then swept superiorly over the previous incision. The patient is instructed to open the mouth and look superiorly (Figure 17).This will indicate to the surgeon the amount of excess skin muscle flap which can be excised. A differential amount of skin versus orbicularis muscle can be removed as determined by the preoperative evaluation (Figure 18). Adequate orbicularis muscle must be preserved adjacent to the eyelid margin to adequateIy support the eyelid during the early postoperative period. If preoperative orbicularis muscle festoons were identified, additional soft tissue dissection is needed beneath the orbicularis muscle to include the area overlying the inferior orbital rim. The orbicularis muscle is then resupported to the lateral orbital rim with horizontal mattress sutures of 5-0 Dexon suture on a D1 needle. Incision closure can be accomplishedusing several different techniques, including a simple running 6-0 prolene suture, interrupted 6-0 silk sutures, or a running subcuticular 6-0 nylon suture (Figure 19). Whichever suturing technique is chosen, edge-to-edgemeticulous apposition
Figure 2 7 . Skin muscle flap sweep superiorly over incision to determine excess tissue.
Figure 18. Excision of excess skin and orbicularis muscle.
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Figure 19. Meticulous wound closure is mandatory.
Figure 20. Preoperative photograph prior to lower eyelid blepharoplasty only.
of the wound margins must be accomplished(Figures 20, 21).
Postoperative Management: ”Now What?” Early postoperative care following blepharoplasty surgery requires vigdant corneal protection with topical lubricating ointment until the paralyzing effects of the anesthetic agent on the orbicularis muscle subside. During this time there will be significant lagophthalmos because of inability of the orbicularismuscle to contract and close the eyelids. Ice compresses will significantly reduce the amount of postoperative edema and discomfort. The ice compresses should be changed periodically to allow the nursing personnel to assess the surgicalarea. Specifically, they should be instructed to observe the eyelid and orbital soft tissues for evidence of progressive orbital hemorrhage and secondary decreased vision. Minor incisional bleeding can occur, but usually subsides within the first hour following surgery. The patient may be discharged from the postoperative recovery area to return home followingfinal inspection of the incision and determination of adequate corneal protection during eyelid closure. Postblepharoplastypatients are instructed to continue topical iced compresses as frequently as possible during the first 24 to 48 hours after surgery. Topical lubricating ointment is needed at night in some patients with minimal residual lagophthalmos related to upper eyelid edema. This can usually be discontinued within the first week following blepharoplasty surgery. All patients are instructed in lower eyelid massage in a superior direction to prevent subcutaneous cicatricial contraction following blepharoplasty surgery. The most common complication following lower eyelid blepharoplasty is lower eyelid malposition with a combination of lower eyelid ectropion (outward turning of the eyelid margin), retraction (scleral show), or lateral canthal angle deformity (rounding). Ectropion of the lower eyelid occurs when there is vertical shortening of the anterior lamella (skin and orbicularis muscle) with
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Figure 21. Postoperative photograph following lower eyelid blepharoplasty only.
horizontal eyelid laxity, causing the eyelid margin to be displaced anteriorly away from the surface of the globe. Vertical shortening of the deeper eyelid structures or illadvised suture closure of the orbital septum may cause lower eyelid retraction. In this situation the eyelid maintains good apposition to the globe; however, the eyelid is displaced inferiorly with sclera visible inferior to the cornea in primary gaze, ie, “scleral show” (Figure 22). The retracted lower eyelid may be physically tethered by cicatricial bands extending from the inferior tarsal border to the inferior orbital rim. Attempting to elevate the lower eyelid by manual traction will reveal tethering bands beneath the skin that preclude superior displacement of the eyelid. Lateral canthal soft tissue deformity occurs following excessivevertical excision of the lower eyelid skin muscle flap. The lateral canthal angle will be displaced inferiorly from its normal position slightly superior to the medial canthal angle, causing the horizontal axis of the palpebral fissure to be slanted inferiorly in an antimongoloid appearance. In addition, rounding of the lateral canthal angle will be present (Figure 23, A and B). Blepharoplasty patients who have lower eyelid malposition problems frequently will have symptoms related to corneal exposure secondary to incomplete eyelid closure. They may complain of foreign body sensation, ocular irritation, or epiphora. The increased tearing (epiphora) may be secondary to two distinct mechanisms: 1) increased reflexive tearing secondary to corneal irritation or 2) punctal malposition with poor tear outflow secondary to punctal and eyelid ectropion. If the corneal exposure symptoms are mild, adequate control can be accomplished with topical lubricating eye drops and ointment. Prolonged topical antibiotic eye drops and/or ointment are not indicated because of possible toxic insult to the compromised corneal epithelium, leading to additional epithelial breakdown. Night time eyelid taping in a closed position may be needed in more severe cases of lagophthalmos (inability to close the eyes). Fortunately, lower eyelid malposition frequently improves with time, massage and occasional topical steroid ointment. If im-
J Dermatol Surg Oncol 1992;lB:1100- 1109
1106 NEUHAUS
Figure 22. Right lower eyelid ectropion. Left lower eyelid retraction.
B
A
Figure 23. 4) Normal palpebral fissure and lower eyelid appearance. B) Excessive skin and/or muscle removed during lower eyelid blepharoplasty.
provement ceases and unacceptable eyelid malposition persists, surgical correction is indicated. In patients with persistent lower eyelid malposition, a lower eyelid skin graft can be avoided by surgery directed to the lateral canthal tendon soft tissues. The surgical technique requires horizontal tightening of the inferior limb of the lateral canthal tendon with resupport of the lower eyelid soft tissues to the periosteum of the lateral orbital rim.
Figure 24. Lateral canthoplasty begins by 4) dividing the lateral canthus into superior and inferior limbs. B) lnferior lateral canthal limb is lysed from its lateral orbital rim attachment (bottom). Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists (8)3, Sun Francisco, American Academy of Ophthalmology, 1990
The surgeon completes a lateral canthotomy, dividing the lateral canthal tendon into a superior and inferior limb (Figure 24). Both limbs are still attached to the periosteum along the inner aspect of the lateral orbital rim. The lateral canthotomy extends beyond the lateral orbital rim approximately 10 mm. Using tactile sensation of the intact inferior limb of the lateral canthal tendon, the surgeon divides the tendon at its attachment, releasing the lower eyelid. In those postblepharoplastypatients with lower eyelid retraction (scleral show) with cicatricial tethering between the tarsal plate and the inferior orbital rim, lysis of the cicatricial tissue should be performed. Subcutaneous division of the tethering tissue can be achieved by tactile sensation of the cicatricial tissue while superior traction is placed on the lower eyelid (Figure 25). As the tethering tissue is divided, eyelid mobilization and repositioning is possible. A lateral strip of tarsus is fashioned by removal of the lateral 5 mm of the eyelid margin and reflection of a skin muscle flap from the anterior surface of the tarsal plate.
Figure 25. Vertically shortened orbital septum and cicatricial tissue are divided. Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists(83, Sun Francisco, American Academy of Ophthalmology, 1990. Cicatrix from tarsus to inferior orbital rim
B
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Figure 26. Lateral tongue of tarsal tissue is formed by reflecting a skin-muscle pap from anterior aspect of tarsal plate. Lateral eyelid margin including eyelash follicles have been removed. Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists (8)3, Sun Francisco, American Academy of Ophthalmology, 1990.
Inferior eyelid retractors and conjunctiva are then divided at the inferior tarsal border, completing the formation of a lateral tongue of tarsal tissue (Figure 26). A vertical incision through the periosteum at the lateral orbital rim at the proposed tendon insertion site is made. The proposed site is usually placed approximately 2 to 4 mm superior to the previous attachment site to provide for the unavoidable postoperative inferior migration of the reconstructed eyelid and lateral canthal tendon soft tissues. A horizontal mattress suture of 5-0 Dexon (D1 needle) is placed from the posterior to the anteriorsurface of the tarsal plate (Figure 27). The horizontal mattress suture is then completed by passing both arms of the suture from the internal aspect of the lateral orbital rim out through the periosteal incision (Figure 28). This assures good eyelid-to-globe apposition with the lateral canthal tendon positioned at the internal aspect of the lateral orbital rim. A firm periosteal purchase of each pass
_..-
Figure 28. Both arms of the horizontal mattress suture are placed from internal aspect of lateral orbital rim and out through a pre-placed periosteal incision. Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists (8)3, Sun Francisco, American Academy of Ophthalmology, 2990.
Figure 29. 4) Lateral tongue of tarsal tissue has been sutured to internal aspect of orbital rim. Two horizontal mattress sutures are placed in skin muscle pap. B) Flap is sutured to lateral orbital rim for additional lower eyelid support. Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists (83, Sun Francisco, American Academy of Ophthalmology, 2990.
Figure 27. Horizontal 5-0 Dexon suture 0 - 2 needle) is placed from posterior to anterior aspect of the lateral tongue of tarsal tissue. Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists (8)3, Sun Francisco, American Adademy of Ophthalmology, 2990.
B
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of the needle is mandatory to secure the eyelid in its new position. Additional horizontal mattress sutures of 5-0 Dexon suture can be placed from the orbicularis muscle to the lateral orbital rim periosteum to provide further support for the eyelid (Figure 29). In those patients with severe ectropion or eyelid malposition, a free, full-thickness skin graft can be placed in the anterior lamella of the eyelid. An incision is made approximately 2 mm below the eyelash line of the lower eyelid. A skin flap is dissected inferiorly and allowed to recede, releasing the inferior traction of the lower eyelid margin. As the lower eyelid margin moves superiorly, the recipient site of the skin graft will be created. A retroauricular skin graft is obtained, thinned of subcutaneous tissue, and sutured in place. Cotton soaked in mineral oil or a roll of aseptic gauze can be used to stent the skin graft in place (Figure 30).
A
Figure 30. 4) Inferior tethering by vertical shortening of anterior lamella skin is released by infralash skin incision with subcutaneous dissection. B) Superior traction suture from lower eyelid margin to brow has been placed, and full-thickness skin graft sutured in the defect. Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists @)3, Sun Francisco, American Academy of Ophthalmology, 1990.
B Figure 31. 4) Recessing lower eyelid retractors after a lateral canthotomy has been accomplished. B) Vertical augmentation of the posterior eyelid lamella with an ear cartilage graft.
I
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,
B
In those patients with shallow orbits, proptosis, or relative midfacial bone hypoplasia, horizontal eyelid tightening may result in the lower eyelid slipping beneath the globe as it is horizontally tightened. If further horizontal tension is placed on the eyelid, it simply slips further beneath the globe, intensifying the inferior malposition problem. Vertical stabilization and augmentation of the retracted lower eyelid in this subset of patients requires placement of an ear cartilage or hard palate graft along the posterior aspect of the lower eyelid. This procedure is combined with horizontal tightening of the lateral canthal tendon with recession of the lower eyelid retractors to provide a recipient bed for posterior eyelid augmentation grafting (Figure 31, A and B). Residual lower eyelid soft tissue following blepharoplasty surgery usually consists of excessive residual eyelid skin, orbicularis muscle with festoons overlying the infe-
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nor orbital rims, or an overlooked fat pad, especially the temporal fat pad. Secondary blepharoplasty is possible; however, the surgeon should be aware that excessive eyelid skin or orbicularis muscle resection will cause lower eyelid malposition problems. Because a skin incision will result in further vertical shortening of the eyelid skin even if no skin is removed, a conjunctival approach is indicated for secondary eyelid fat removal in the lower eyelid. Because of surgically altered eyelid anatomy, the surgeon needs to pay particular attention to anatomic
NEUHAUS LOWER EYELID BLEPHAROPLASTY
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relationships during secondary orbital fat removal to avoid damage to the inferior oblique muscle.
Conclusion: “I‘ve Made It.” Successful lower eyelid blepharoplasty surgery can be a source of both the patient and physician satisfaction. As long as patient expectations are consistent with realistic surgical goals, lower eyelid blepharoplasty is an important aspect of overall facial aesthetic surgery.
Lower Eyelid Blepharoplasty RUSSELL W. NEUHAUS, MD BACKGROUND.Lower eyelid blepharoplasty is a frequently performed procedure to reverse partially gravitational aging effects on eyelid tissues. Careful planning, proper execution, and appropriate management of potential postoperative complications will generally result in a happy and satisfied patient. However, in any surgical procedure that is primarily aesthetic in nature, the surgeon needs to be constantly aware of factors that may compromise the functional integrity of the eyelid. A patient with altered visual function or ocular discomfort is no longer primarily concerned about the final aesthetic appearance of even the most perfectly executed, technically correct blepharoplasty procedure.
T
he surgical goals in lower eyelid blepharoplasty are directed to improved aesthetic appearance of redundant and displaced lower eyelid soft tissues. Frequently, the preoperativeevaluation of a patient with aesthetic eyelid concerns will reveal latent functional lower eyelid problems as well. Most commonly these include horizontal eyelid laxity with lateral canthal tendon laxity and/or dehiscence from its attachment to the lateral orbital rim. Other latent functional difficulties may include early keratitis sicca (dry eye), mild orbicularismuscle weakness, or pre-existingmedical problems such as thyroid eye disease or other orbital inflammatory conditions. However, with careful attention to detailed preoperative evaluation and planning of the technical aspect of the surgical procedure, the probability of a successful operation with improved aesthetic appearance is enhanced. A single surgicaltechnique is not appropriate for every patient. In fact, every patient requires some modification of the standard surgical procedure to achieve the best possible result. Some of the technical aspects that need to be determined preoperatively include the eyelid skin incision location, amount of excess skin versus excess underlying orbicularis muscle, presence of orbicularis muscle festoons, identification of prominent lower eyelid fat pads, and evaluation of horizontal eyelid laxity. Intraop-
In private practice. Address correspondence and reprint requests to: Russell W.Neuhaus, MD, 3705 Medical Pkwy, Suite 370, Austin, TX 78705.
1100
OBJECTIVE.To describe the preoperative evaluation, surgi-
cal technique, and postoperative complications of lower eyelid blepharoplasty. Specific attention will be given to lower eyelid retraction and ectropion following blepharoplasty. CONCLUSION. Successful lower eyelid blepharoplasty surgery can be a source of both patient and physician satisfaction. As long as patient expectations are consistent with realistic surgical goals, lower eyelid blepharoplasty is an important aspect of overall facial aesthetic surge ry. J Dermatol Surg Oncol 1992;lB:llOO-1109.
erative surgical attention to meticulous hemostasis and manipulation of delicate eyelid soft tissues will further enhance a pleasing aesthetic result Following surgery, appropriate management of complications if they occur will improve the final result and reassure the anxious patient. Lower eyelid malposition problems -including ectropion, retraction, or lateral canthal deformity- are the most common problems following lower eyelid blepharoplasty. Appropriate supportive medical management including the use of topical lubricating eye drops and ointment is frequently all that is needed. In those patients with persistent lower eyelid malposition problems or acute malposition problems with corneal decompensation, surgical correction can be quite successful in protecting the cornea from further exposure and achieving an acceptable cosmetic result. If residual soft tissue is present after blepharoplasty it can be addressed with secondarylower eyelid blepharoplasty after complete healing has occurred.
Preoperative Evaluation: ”Decision Before Incision” Determining who is an acceptable candidate for lower eyelid surgery requires the evaluation of the patient’s desires in light of what can realistically be accomplished surgically. Frequently the lower eyelid blepharoplasty procedure is performed simultaneously with other aesthetic surgery in the upper eyelid or facial area. It is important that each functional facial unit is considered separately and in concert with other proposed facial surgery.
0 1992 by Elsevier Science Publishing Co., Inc. 0148-0812/92/$5.00
NEUHAUS LOWER EYELID BLEPHAROPLASTY
J Dermatol Surg Oncol 1992;18:1100- 1109
The surgeon needs to be aware that aesthetic and functional changes that occur following upper eyelid blepharoplasty will impact the result of lower eyelid blepharoplasty. Specifically,transient upper eyelid lagophthalmos (inability to close the eyelids) secondary to postoperative upper eyelid edema will exacerbate the corneal exposure secondary to any lower eyelid retraction following lower eyelid blepharoplasty. Pre-existing lower eyelid horizontal laxity may not be functionally evident until increased inferior traction occurs after lower eyelid blepharoplasty. Preoperative lower eyelid laxity can be determined by the eyelid retraction test. After the patient is instructed not to blink, moderate inferior manual traction is applied to the lower eyelid and then released (Figure 1).If normal horizontal tightness is present with good orbicularismuscle tone, the lower eyelid will assume a normal anatomic position with good apposition to the globe immediately. With mild lower eyelid horizontal laxity the lower eyelid will require several seconds to assume its normal anatomic position. With moderate horizontal eyelid laxity the lower eyelid will only assumeits normal anatomicalposition following eyelid blinking. With severe horizontal eyelid laxity the lower eyelid malposition will persist with blinking and will be a functional problem before lower eyelid blepharoplasty is performed. If lower eyelid horizontal laxity is diagnosed preoperatively,intraoperative correction is indicated during blepharoplasty, as discussed below. Because mild keratitis sicca (dryeye) may by asymptomatic, a properly performed Schirmer's test should be accomplished prior to blepharoplasty surgery. The Schirmer's test strip is placed in the inferior cul-de-sac of the eye to determine reflexive tear production (without the use of topical anesthetic agents) and basal tear production (after the use of topical anesthetic agents) (Figure 2). Less than 5 mm of wetting suggests an inadequate tear production. A borderline dry eye may not become symptomatic until stressed by increased corneal exposure following blepharoplasty surgery. Patients with borderline
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dry eyes may still be acceptable blepharoplasty candidates, but a more conservative operation is indicated and the need of either short- or possible long-term topical tear supplementation needs to be discussed with the patient preoperatively. In patients with a history of a previous Bell's palsy or facial nerve dysfunction, it is important to determine whether any residual orbicularis muscle weakness is present. With the patient maximally closing the eyelids, the examiner tries to elevate the upper eyelid (Figure 3). Any asymmetry in the ability to open the upper eyelid manually against the maximally contracted orbicularis muscle signifies sigruficant orbicularis muscle weakness. Although the patient may be compensated prior to blepharoplasty surgery, corneal exposure may become a problem after blepharoplasty secondary to orbicularis muscle dysfunction and lagophthalmos. A history of previous thyroid disease should raise one's suspicion of underlying dysthyroid orbital inflammatory disease (Graves' disease) with secondary soft tissue redundancy and anteriorly prolapsed orbital fat and lacrimal gland into the eyelids (Figure 4). Although patients with Graves' orbital inflammatory disease can successfully undergo blepharoplasty surgery, additional attention needs to be directed to possible globe proptosis, upper or lower eyelid retraction, anteriorly prolapsed lacrimal glands into the eyelid, and engorged blood vessels that may be present. Finally, the general medical health of the patient needs to be evaluated with specific attention to any aspirincontaining compounds or nonsteroidal anti-inflammatory drugs that the patient may be taking. These medications need to be discontinued 10 days prior to surgery so that platelet function can return to normal. Underlying bony skeletal problems will affect overlying soft tissue surgery. Specifically, shallow orbits with relative globe proptosis in association with midfaaal bony hypoplasia of the zygomatic bone predisposes the lower eyelid to a retracted position following blepharoFigure 3. Attempting manual upper
Figure 2. Schirmer's test strip in inferior Figure 1. Lower eyelid retraction test.
cul-de-sac.
eyelid elevation during maximal orbicularis muscle constriction.
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Figure 4. Patient with dysthyroid
Figure 5. Relative midfacial (zygomatic)
Figure 6. Orbicularis muscle festoons in
orbital inflammatory disease with mild eyelid retraction and anterior displacement of orbital fat and lacrimal glands.
hypoplasia with shallow orbits and prominent globes.
the lower eyelids.
plasty surgery (Figure 5). Frequently, even conservative lower eyelid blepharoplasty surgery will result in significant lower eyelid malposition with retraction. Extreme care during skin and orbicularis muscle excision is indicated in those patients with this underlying bony abnormality. If postoperative lower eyelid retraction should occur, surgical correction requires additional superior support by vertical augmentation of the tarsal plate, as discussed in the next section. In certain individuals, hypertrophic orbicularis muscle will be present immediately inferior to the inferior orbital rims. This soft tissue abnormality is frequently referred to as "bags on bags" or eyelid "festoons" (Figure 6). During surgery the location and severity of the festoons will not be obvious because the patient is in a supine position with the effects of gravity on the redundant orbicularis muscle eliminated. The surgical correction of orbicularis muscle festoons will require an extended blepharoplasty with extensive suborbicularis muscle dissection and resupport to the periosteum at the lateral orbital rim and the body of the zygomatic bone. The supporting suture placement needs to be determined and documented preoperatively for referral during surgery.
Figure 7. Local infiltrative anesthesia
given as first step in lower eyelid blepharoplasty.
Finally, preoperative visual acuity needs to be recorded as well as preoperative photographs to document the pre-existing soft tissue abnormalities. The preoperative photographs will be used for further preoperative planning, discussion with the patient, intraoperative guidance, and postoperative comparison.
Technique: "How To Do It" Blepharoplasty surgery can be successfully performed as an outpatient procedure either in the outpatient surgical department of a hospital or in a specially prepared and equipped surgical area in a private office. Surgery is most commonly performed under local anesthesia with some form of sedation. The amount and type of sedation must be tailored by the availability of medical personnel, presence of a postoperative observation facility, and the general health of the patient. My personal preference for anesthetic solution is 2% Xylocaine with epinephrine 1: 100,000 dilution with the addition of 150 units of Wydase to 20 mL of anesthetic solution. The injection site of the local infiltrative anesthesia may be either through the lower eyelid skin or posteriorly through the palpebral conjunctiva (Figure 7).
Figure 8. Lower eyelid incision marked. Note only slight inferior angulation of the incision at the lateral canthal angle.
Figure 9. A 4-0 silk superior traction suture aids soft tissue identification and dissection of surgical planes.
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The posterior approach to local infiltrativeanesthesia can be preceded with topical Ophthaine to anesthetize the conjunctiva. The addition of 1 mEq of sodium bicarbonate to 5 mL of local anesthetic solution immediately prior to injection will significantly decrease the injection discomfort by neutralizing the acidic pH. Approximately 2 mL of anesthetic solution are given in the central aspect of each lower eyelid in a single location. The Wydase will allow gradual dispersion of the anesthetic agent throughout the anterior orbit and eyelid soft tissue. The dispersion of the local infiltrative anesthesia will occur as the patient is being prepped and the surgeon is scrubbing his or her hands. This sequence allows a full 10 to 15 minutes for total anesthetic dispersion and, more importantly, allows the epinephrine to maximally constrict the blood vessels in the surgical field. By the time the surgeon finishes his or her personal scrub, the patient has been prepped and is ready for marking of proposed incision lines. Corneal protectors can be used, but have the distinct disadvantage of potentially trapping the facial prepping solution beneath the corneal protector adjacent to the cornea. If meticulous care is taken in flushing the surface of the eye prior to placement of the corneal protector, it can be placed immediately prior to marking the patient. By referring to detailed preoperative notes and photographs the surgeon can then accurately draw the incision lines (Figure 8). Modification of the surgical plan is possible at this time but the surgeon must be aware of alteration of the orbital soft tissues in the supine patient secondary to elimination of gravitational effects. The lower eyelid blepharoplasty incision is placed approximately 2 mm below the lower eyelid lash line. It begins immediately inferior to the punctum and extends to the lateral canthal angle. From that point it extends further laterally and inferiorly at approximately 10 degrees from horizontal. The lateral incision frequently can be designed to fall within the radiating rhytids, caused by
Figure 10. A perpendicular incision is made through skin and orbicularis muscle into the pretarsal space.
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LOWER EYELID BLEPHAROPLASTY
contraction of the underlying orbicularis muscle. The lateral extent of the lower eyelid blepharoplasty incision depends on the degree of suborbicularis muscle dissection that may be needed to resupport the orbicularis muscle to the lateral orbital rim. If no such support is needed, the lateral extent of the lower eyelid blepharoplasty incision will be approximately 10 mm. A 4-0silk traction suture is placed in the eyelid margin for superior eyelid traction during the soft tissue dissection (Figure9). A Westcott scissorsincision of the skin and underlying orbicularis muscle is made in the central aspect of the lower eyelid blepharoplasty incision (Figure 10). The pretarsal space is exposed, allowing the placement of one blade of the scissors within the wound. After the incision is completed in both medial and lateral directions, a skin muscle flap is dissected inferiorly, fully exposing the orbital septum (Figure 11). Care is taken not to incise the orbital septum until the infraorbital rim is encountered because anteriorly prolapsing orbital fat will obscure visualization.The lower eyelid skin muscle flap is retracted with a Desmarres retractor and hemostasis is obtained with electrocautery (Figure 12). The orbital septum is opened for the full width of the eyelid, exposing the nasal, middle, and lateral fat pads (Figure 13). Particular attention is directed to exposing the lateral fat pad because it frequently will move posteriorly with the patient in a supine position. Moderate globe and orbital pressure may be needed to prolapse the fat pads anteriorly. The nasal fat pad is easily identified by its whitish appearance, analogous to the nasal upper eyelid fat pad. As opposed to the upper eyelid fat pads, the lower eyelid fat pads have significant vessels within the fat pads. Because it is usually quite difficult to avoid incising these vessels, adequate clamping of the fat pads is needed prior to excising the anteriorly prolapsed portion of the fat pads. Attention is first directed to the lateral fat pad which is clamped with a small straight hemostat (Figure 14).
Figure 11. Inferior dissection of a skinmuscle flap, fully exposing the orbital septum.
Figure 12. Skin-muscle flap retracted inferiorly.
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Figure 13. Orbital septum opened for the full width of the eyelid, fully exposing redundant orbital fat.
Figure 14. Hemostat has been applied to orbital fat and scissor excision of clamped fat being accomplished.
The fat is excised at the level of the hemostat and battery hot-tip cautery is applied to the cut edge of the fat pad (Figure 15).If the surgeon prefers unipolar cautery, a small area of contact between the hemostat and skin may cause a skin bum. Avoiding skin contact by pulling the hemostat anteriorly may result in excessive anterior traction on the orbital fat pads. After hemostasis is achieved, the clamped fat is slowly released and inspection performed. Additional fat removal in the lateral compartment is frequently possible as moderate orbital pressure will prolapse additional fatty tissue anteriorly (Figure 16). A similar technique is used to remove the middle and nasal fat compartments with appropriate attention directed to identification of the inferior oblique muscle, which divides the nasal from the middle fat pad. If pre-existing horizontal eyelid laxity has been determined, intraoperative horizontal tightening can be accomplished at this time. Attention is directed to the lateral canthal tendon where the full thickness portion of the lateral eyelid margin is excised, creating a lateral tongue of tarsal tissue. The lateral tongue of tarsal tissue is horizontally shortened and reattached to the internal aspect of the lateral orbital rim with a 5-0 Dexon (D1 needle) mattress suture. It is important to secure the eyelid to the Figure 16. Additional fat can be easily prolapsed anteriorly from the lateral compartment.
Figure 15. Hot tip, battery powered cautery used to cauterize cut edge of orbital fat. Note that supplemental oxygen must be discontinued during cautery,
internal aspect of the lateral orbital rim to provide good lower eyelid apposition to the globe. (See the discussion below for details of lateral cantopexy.) The skin muscle flap is then swept superiorly over the previous incision. The patient is instructed to open the mouth and look superiorly (Figure 17).This will indicate to the surgeon the amount of excess skin muscle flap which can be excised. A differential amount of skin versus orbicularis muscle can be removed as determined by the preoperative evaluation (Figure 18). Adequate orbicularis muscle must be preserved adjacent to the eyelid margin to adequateIy support the eyelid during the early postoperative period. If preoperative orbicularis muscle festoons were identified, additional soft tissue dissection is needed beneath the orbicularis muscle to include the area overlying the inferior orbital rim. The orbicularis muscle is then resupported to the lateral orbital rim with horizontal mattress sutures of 5-0 Dexon suture on a D1 needle. Incision closure can be accomplishedusing several different techniques, including a simple running 6-0 prolene suture, interrupted 6-0 silk sutures, or a running subcuticular 6-0 nylon suture (Figure 19). Whichever suturing technique is chosen, edge-to-edgemeticulous apposition
Figure 2 7 . Skin muscle flap sweep superiorly over incision to determine excess tissue.
Figure 18. Excision of excess skin and orbicularis muscle.
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Figure 19. Meticulous wound closure is mandatory.
Figure 20. Preoperative photograph prior to lower eyelid blepharoplasty only.
of the wound margins must be accomplished(Figures 20, 21).
Postoperative Management: ”Now What?” Early postoperative care following blepharoplasty surgery requires vigdant corneal protection with topical lubricating ointment until the paralyzing effects of the anesthetic agent on the orbicularis muscle subside. During this time there will be significant lagophthalmos because of inability of the orbicularismuscle to contract and close the eyelids. Ice compresses will significantly reduce the amount of postoperative edema and discomfort. The ice compresses should be changed periodically to allow the nursing personnel to assess the surgicalarea. Specifically, they should be instructed to observe the eyelid and orbital soft tissues for evidence of progressive orbital hemorrhage and secondary decreased vision. Minor incisional bleeding can occur, but usually subsides within the first hour following surgery. The patient may be discharged from the postoperative recovery area to return home followingfinal inspection of the incision and determination of adequate corneal protection during eyelid closure. Postblepharoplastypatients are instructed to continue topical iced compresses as frequently as possible during the first 24 to 48 hours after surgery. Topical lubricating ointment is needed at night in some patients with minimal residual lagophthalmos related to upper eyelid edema. This can usually be discontinued within the first week following blepharoplasty surgery. All patients are instructed in lower eyelid massage in a superior direction to prevent subcutaneous cicatricial contraction following blepharoplasty surgery. The most common complication following lower eyelid blepharoplasty is lower eyelid malposition with a combination of lower eyelid ectropion (outward turning of the eyelid margin), retraction (scleral show), or lateral canthal angle deformity (rounding). Ectropion of the lower eyelid occurs when there is vertical shortening of the anterior lamella (skin and orbicularis muscle) with
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Figure 21. Postoperative photograph following lower eyelid blepharoplasty only.
horizontal eyelid laxity, causing the eyelid margin to be displaced anteriorly away from the surface of the globe. Vertical shortening of the deeper eyelid structures or illadvised suture closure of the orbital septum may cause lower eyelid retraction. In this situation the eyelid maintains good apposition to the globe; however, the eyelid is displaced inferiorly with sclera visible inferior to the cornea in primary gaze, ie, “scleral show” (Figure 22). The retracted lower eyelid may be physically tethered by cicatricial bands extending from the inferior tarsal border to the inferior orbital rim. Attempting to elevate the lower eyelid by manual traction will reveal tethering bands beneath the skin that preclude superior displacement of the eyelid. Lateral canthal soft tissue deformity occurs following excessivevertical excision of the lower eyelid skin muscle flap. The lateral canthal angle will be displaced inferiorly from its normal position slightly superior to the medial canthal angle, causing the horizontal axis of the palpebral fissure to be slanted inferiorly in an antimongoloid appearance. In addition, rounding of the lateral canthal angle will be present (Figure 23, A and B). Blepharoplasty patients who have lower eyelid malposition problems frequently will have symptoms related to corneal exposure secondary to incomplete eyelid closure. They may complain of foreign body sensation, ocular irritation, or epiphora. The increased tearing (epiphora) may be secondary to two distinct mechanisms: 1) increased reflexive tearing secondary to corneal irritation or 2) punctal malposition with poor tear outflow secondary to punctal and eyelid ectropion. If the corneal exposure symptoms are mild, adequate control can be accomplished with topical lubricating eye drops and ointment. Prolonged topical antibiotic eye drops and/or ointment are not indicated because of possible toxic insult to the compromised corneal epithelium, leading to additional epithelial breakdown. Night time eyelid taping in a closed position may be needed in more severe cases of lagophthalmos (inability to close the eyes). Fortunately, lower eyelid malposition frequently improves with time, massage and occasional topical steroid ointment. If im-
J Dermatol Surg Oncol 1992;lB:1100- 1109
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Figure 22. Right lower eyelid ectropion. Left lower eyelid retraction.
B
A
Figure 23. 4) Normal palpebral fissure and lower eyelid appearance. B) Excessive skin and/or muscle removed during lower eyelid blepharoplasty.
provement ceases and unacceptable eyelid malposition persists, surgical correction is indicated. In patients with persistent lower eyelid malposition, a lower eyelid skin graft can be avoided by surgery directed to the lateral canthal tendon soft tissues. The surgical technique requires horizontal tightening of the inferior limb of the lateral canthal tendon with resupport of the lower eyelid soft tissues to the periosteum of the lateral orbital rim.
Figure 24. Lateral canthoplasty begins by 4) dividing the lateral canthus into superior and inferior limbs. B) lnferior lateral canthal limb is lysed from its lateral orbital rim attachment (bottom). Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists (8)3, Sun Francisco, American Academy of Ophthalmology, 1990
The surgeon completes a lateral canthotomy, dividing the lateral canthal tendon into a superior and inferior limb (Figure 24). Both limbs are still attached to the periosteum along the inner aspect of the lateral orbital rim. The lateral canthotomy extends beyond the lateral orbital rim approximately 10 mm. Using tactile sensation of the intact inferior limb of the lateral canthal tendon, the surgeon divides the tendon at its attachment, releasing the lower eyelid. In those postblepharoplastypatients with lower eyelid retraction (scleral show) with cicatricial tethering between the tarsal plate and the inferior orbital rim, lysis of the cicatricial tissue should be performed. Subcutaneous division of the tethering tissue can be achieved by tactile sensation of the cicatricial tissue while superior traction is placed on the lower eyelid (Figure 25). As the tethering tissue is divided, eyelid mobilization and repositioning is possible. A lateral strip of tarsus is fashioned by removal of the lateral 5 mm of the eyelid margin and reflection of a skin muscle flap from the anterior surface of the tarsal plate.
Figure 25. Vertically shortened orbital septum and cicatricial tissue are divided. Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists(83, Sun Francisco, American Academy of Ophthalmology, 1990. Cicatrix from tarsus to inferior orbital rim
B
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Figure 26. Lateral tongue of tarsal tissue is formed by reflecting a skin-muscle pap from anterior aspect of tarsal plate. Lateral eyelid margin including eyelash follicles have been removed. Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists (8)3, Sun Francisco, American Academy of Ophthalmology, 1990.
Inferior eyelid retractors and conjunctiva are then divided at the inferior tarsal border, completing the formation of a lateral tongue of tarsal tissue (Figure 26). A vertical incision through the periosteum at the lateral orbital rim at the proposed tendon insertion site is made. The proposed site is usually placed approximately 2 to 4 mm superior to the previous attachment site to provide for the unavoidable postoperative inferior migration of the reconstructed eyelid and lateral canthal tendon soft tissues. A horizontal mattress suture of 5-0 Dexon (D1 needle) is placed from the posterior to the anteriorsurface of the tarsal plate (Figure 27). The horizontal mattress suture is then completed by passing both arms of the suture from the internal aspect of the lateral orbital rim out through the periosteal incision (Figure 28). This assures good eyelid-to-globe apposition with the lateral canthal tendon positioned at the internal aspect of the lateral orbital rim. A firm periosteal purchase of each pass
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Figure 28. Both arms of the horizontal mattress suture are placed from internal aspect of lateral orbital rim and out through a pre-placed periosteal incision. Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists (8)3, Sun Francisco, American Academy of Ophthalmology, 2990.
Figure 29. 4) Lateral tongue of tarsal tissue has been sutured to internal aspect of orbital rim. Two horizontal mattress sutures are placed in skin muscle pap. B) Flap is sutured to lateral orbital rim for additional lower eyelid support. Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists (83, Sun Francisco, American Academy of Ophthalmology, 2990.
Figure 27. Horizontal 5-0 Dexon suture 0 - 2 needle) is placed from posterior to anterior aspect of the lateral tongue of tarsal tissue. Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists (8)3, Sun Francisco, American Adademy of Ophthalmology, 2990.
B
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of the needle is mandatory to secure the eyelid in its new position. Additional horizontal mattress sutures of 5-0 Dexon suture can be placed from the orbicularis muscle to the lateral orbital rim periosteum to provide further support for the eyelid (Figure 29). In those patients with severe ectropion or eyelid malposition, a free, full-thickness skin graft can be placed in the anterior lamella of the eyelid. An incision is made approximately 2 mm below the eyelash line of the lower eyelid. A skin flap is dissected inferiorly and allowed to recede, releasing the inferior traction of the lower eyelid margin. As the lower eyelid margin moves superiorly, the recipient site of the skin graft will be created. A retroauricular skin graft is obtained, thinned of subcutaneous tissue, and sutured in place. Cotton soaked in mineral oil or a roll of aseptic gauze can be used to stent the skin graft in place (Figure 30).
A
Figure 30. 4) Inferior tethering by vertical shortening of anterior lamella skin is released by infralash skin incision with subcutaneous dissection. B) Superior traction suture from lower eyelid margin to brow has been placed, and full-thickness skin graft sutured in the defect. Reprinted with permission from Neuhaus RW: Focal Points: Clinical Modules for Ophthalmologists @)3, Sun Francisco, American Academy of Ophthalmology, 1990.
B Figure 31. 4) Recessing lower eyelid retractors after a lateral canthotomy has been accomplished. B) Vertical augmentation of the posterior eyelid lamella with an ear cartilage graft.
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In those patients with shallow orbits, proptosis, or relative midfacial bone hypoplasia, horizontal eyelid tightening may result in the lower eyelid slipping beneath the globe as it is horizontally tightened. If further horizontal tension is placed on the eyelid, it simply slips further beneath the globe, intensifying the inferior malposition problem. Vertical stabilization and augmentation of the retracted lower eyelid in this subset of patients requires placement of an ear cartilage or hard palate graft along the posterior aspect of the lower eyelid. This procedure is combined with horizontal tightening of the lateral canthal tendon with recession of the lower eyelid retractors to provide a recipient bed for posterior eyelid augmentation grafting (Figure 31, A and B). Residual lower eyelid soft tissue following blepharoplasty surgery usually consists of excessive residual eyelid skin, orbicularis muscle with festoons overlying the infe-
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nor orbital rims, or an overlooked fat pad, especially the temporal fat pad. Secondary blepharoplasty is possible; however, the surgeon should be aware that excessive eyelid skin or orbicularis muscle resection will cause lower eyelid malposition problems. Because a skin incision will result in further vertical shortening of the eyelid skin even if no skin is removed, a conjunctival approach is indicated for secondary eyelid fat removal in the lower eyelid. Because of surgically altered eyelid anatomy, the surgeon needs to pay particular attention to anatomic
NEUHAUS LOWER EYELID BLEPHAROPLASTY
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relationships during secondary orbital fat removal to avoid damage to the inferior oblique muscle.
Conclusion: “I‘ve Made It.” Successful lower eyelid blepharoplasty surgery can be a source of both the patient and physician satisfaction. As long as patient expectations are consistent with realistic surgical goals, lower eyelid blepharoplasty is an important aspect of overall facial aesthetic surgery.
