The Fourth Option—a Novel Approach to Lower Lid Blepharoplasty

Abstract

Abstract. Three basic surgical techniques exist for lowerlid blepharoplasty: (1) the skin flap, (2) the transconjunctival approach, and (3) the skin-muscle flap. Each addresses the problems of excessive skin, muscle, and infraorbital fat either alone or in combination. None of these procedures will correct fine wrinkles. In fact, in some patients the lower-lid wrinkling appears far worse after fat removal. We describe a "fourth option" to lower-lid blepharoplasty which corrects the problem of fine wrinkling, periorbital fat herniation, and mild skin excess. For these patients, we remove the fat through a transconjunctival approach and peel the lower lid using full-strength Baker's phenol solution. To date, we have performed this procedure in 17 patients with excellent results. There have been no complications. Our longest followup is 30 months. This procedure is indicated for patients with both excess infraorbital fat and lower-lid skin with associated fine wrinkling. Only the experienced surgeon should attempt this procedure. Caution should be exercised with patients who have previously undergone blepharoplasty as severe ectropion has been reported with chemical peel around the eyelids. Lower-lid chemical peel after a modified skin-muscle flap has been described, but we believe that peeling after a transconjunctival approach is safer. We feel that with more knowledge and experience using the "fourth option" of lower-lid blepharoplasty, it will become the procedure of choice for select patients. . The skin flap procedure is indicated for those patients with good muscle tone but with excess skin and severe wrinkling. The skin-muscle flap is indicated for those patients with a balanced excess of both skin and muscle. A peel is performed in patients with fine wrinkling of the lower-lid skin as their only problem.We describe a fourth technique of lower-lid blepharoplasty that corrects in one step the problems not addressed by the other three procedures, i.e., the combination of fine lower-lid wrinkles, periorbital fat herniation, and mild skin excess. The first patient to undergo this procedure had aging changes of the face consisting of fine rhytids and pigment changes. She did not want extensive surgery so she elected a full-face chemical peel. She wished correction of moderate periorbital fat herniation at the same time (Fig. 1). Because of the concerns of elevating a skin-muscle flap after a chemical peel, a transconjunctival approach for fat removal was performed followed by the full-face peel [5]. This article presents our preliminary results, current indications, and possible attendant morbidities with the use of this novel technique for lower-lid blepharoplasty. Materials and MethodsFour different surgeons have performed this procedure on a total of 17 Caucasian patients ages 32-59 (mean = 48). Followup ranged from 2 to 30 months.

23 Lower Eyelid Blepharoplasty

“…In the senior author's practice, the most commonly performed lower lid procedure consists of transconjunctival fat excision, pinch excision of skin, and 35% trichloroacetic acid (TCA) peeling (described later). 15,[18][19][20] The skin excision is needed to recontour the lower eyelid once the fat has been removed. There frequently is less excess than one initially estimates before the fat excision is performed.…”

Role of Fat in the Lower Eyelid

“…19 Improvement has been significant enough to lead some authors to recommend resurfacing in conjunction with transconjunctival fat resection as a first-line treatment option for lower lid bags. 20 Although skin contraction following resurfacing is apparent, tightening the skin alone does not address the presence of excess muscle or fat in the lower lid. Moreover, vertical contraction can lead to lower lid malposition or frank ectropion in patients who have significant lower lid laxity.…”

“…The transconjunctival method results in no externally visible scarring and also allows for safer coincident cutaneous resurfacing-the "third option" as described by McKinney and Zukowski. 20…”