Introduction

A vast number of procedures exist to rejuvenate the lower eyelid and the midface. These include minimally invasive techniques, such as injectables and fillers, in addition to a wide array of surgical options. The technique ultimately chosen will depend on the needs of the individual and the preference of the surgeon.

The use of injectables and fillers can provide satisfactory lower eyelid and midface rejuvenation in selected patients. Botulinum toxin can address periocular rhytids when injected laterally. Soft tissue deficiency of the eyelid–cheek junction, often termed tear-trough deformity, can be carefully corrected with fillers. The use of injectables avoids the cost and recovery time of surgery and is a minimally invasive technique for lower eyelid and midface rejuvenation.

In patients with more significant midfacial aging, surgical procedures on the lower eyelid and mid-face are indicated. A transblepharoplasty, preauricular, or transtemporal approach can be used to access and rejuvenate the midface. The midface can be approached through the lower eyelid in several ways. The transblepharoplasty approach allows for lower eyelid fat removal and fat repositioning. Transblepharoplasty midfacial lifting can be done through a transcutaneous or a transconjunctival incision. Lower eyelid fat repositioning with skin removal and canthal repositioning are also possible through a transblepharoplasty approach. The preauricular and transtemporal approaches allow for a wide vector of tissue suspension and good scar camouflage.

The procedure chosen for lower eyelid and midface rejuvenation should consider the surgeon′s comfort level, patient desires and expectations, and the required downtime. In choosing between the available options, the surgeon should assess anatomical and aesthetic needs, and patients should assess cost and their willingness to undergo the procedure(s). This chapter outlines the background of lower eyelid and midface treatment, pertinent anatomy, patient selection, technical aspects of the selected procedure, postoperative care, expected results, and complications.

Background: Basic Science of Procedure

The facial plastic surgery literature describes a variety of strategies for treating the lower eyelid and midface complex.1 Early literature of midface rejuvenative procedures describes skin-lift-only techniques, usually utilizing a lateral preauricular approach. Surgical techniques to address aging of the lower eyelid and midface have evolved to incorporate dissection and repositioning of the deeper tissues, including a combination of subperiosteal, sub–superficial musculoaponeurotic system (sub-SMAS), and deep plane techniques.1 In synthesizing the vast options available, the early view of skin excision and tightening has shifted to a modern aim to support, fill, and suspend.2

The most important philosophical change in treating the lower eyelid and midface has resulted from the strategy of restoring three-dimensional volume where it has been lost or shifted.3 Volume restoration can be accomplished surgically with autologous fat or with injectable fillers. The trend of combining surgical lifting with volume restoration has maximized midface rejuvenation while emphasizing natural-appearing results.

Pertinent Anatomy

The anatomy of the midface has not changed over time. However, the surgeon′s understanding of what anatomical components contribute to midfacial volume has evolved. The lower eyelid and midface are now viewed as a single complex ( Fig. 25.1 ). To be successful, the surgeon must understand the anatomical relationships and tissue layers of the midface and lower eyelid, including the aesthetics of the area that change with aging. The six prominent features in midfacial aging include (1) descent of the lower eyelid–cheek junction, leading to a hollowed appearance and attenuation of the infraorbital rim, (2) ptosis of the malar fat pad with loss or change of midfacial projection, (3) exposure and deepening of the tear trough, (4) prominence of the nasolabial fold, (5) midfacial skeletal bone loss, and (6) increase of bony orbit volume.4,5 Treatment of these changes is based on the underlying anatomical structures involved.

The region of the lower eyelid–cheek complex begins at the lower eyelid margin superiorly and extends to the melolabial fold inferomedially. The medial boundary extends to the cheek–nose junction and is ill-defined. The most lateral aspect of the cheek ends conceptually along the anterior line of the masseter muscle and the frontal projection of the zygoma.

The tissue layers of the lower eyelid and midface guide procedural interventions in the area. In the lower eyelid, the most superficial layer is the skin, followed by the orbicularis oculi muscle ( Fig. 25.2 ).6 Together, the skin and orbicularis oculi muscle compose the anterior lamella of the lower eyelid. The fibrous orbital septum composes the middle lamella and contains the medial, central, and lateral fat pads of the lower eyelid ( Fig. 25.3 ).6 The posterior lamella of the lower eyelid consists of the tarsus, the lower eyelid retractors, and the conjunctiva.

The demarcation of the lower eyelid from the mid-face can be ill-defined and is created by the cutaneous attachments of the orbitomalar ligament, which is an extension of the infraorbital rim periosteum ( Fig. 25.4 ).6 The orbitomalar ligament forms a horizontal division between the fat pads of the orbit and the suborbicularis oculi fat pad (SOOF) of the upper midface, both of which are deep to the orbicularis oculi muscle. The inferior border of the orbicularis oculi muscle is continuous with the SMAS of the facial musculature. The midface SMAS envelopes the levator labii superioris alaeque nasi, levator anguli oris, and zygomaticus major and minor muscles. Overlying the SMAS in the inferior midface is the triangular malar fat pad. There is also a separate, fixed preperiosteal fat pad beneath the lip elevator musculature.7

The relationships between skin, fat compartments, suspensory ligaments, muscle, and bone can lead to aesthetic aging changes in the lower eyelid and midface. Correctly diagnosing the underlying anatomical etiology of changes in the lower eyelid–midface complex is critical. Problems that can be addressed include aging or redundancy of the lower eyelid skin ( Fig. 25.5 ), horizontal lower eyelid laxity, inferior orbital fat prolapse or pseudoprolapse, the tear-trough deformity6 ( Fig. 25.6a,b ), midface descent, and the presence of a skeletal negative vector ( Fig. 25.7 ). Table 25.1 provides a brief overview of these common problems, their etiology, and treatments.