25 Lower Blepharoplasty and Midface Rejuvenation


25 Lower Blepharoplasty and Midface Rejuvenation

Christina K. Magill and Jonathan M. Sykes

Key Concepts

  • The procedure chosen to rejuvenate the lower eyelid and midface depends on the comfort level of the surgeon and the individual needs of the patient.

  • The lower eyelid and midface should be viewed as a single complex.

  • Procedures to rejuvenate the lower eyelid–midface complex can be minimally invasive or surgical.

  • Correctly diagnosing pathology in the lower eyelid and midface is critical; the surgeon must determine if there is a skin problem, horizontal lower eyelid laxity, excess periorbital fat in relation to the cheek, tear-trough deformity, malar fat pad descent, or a bony problem, such as a negative vector.

  • Three-dimensional volume restoration is the aesthetic goal in treating the lower eyelid and midface complex.


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.

A frontal photograph of a patient with volume deficiency of the midface. He has undergone upper and lower eyelid blepharoplasties in addition to canthal tightening. Tightening or lifting the lower eyelid without addressing the midface can lead to a suboptimal result in patients who need midfacial volume.

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.

The periocular musculature is shown. The orbicularis oculi has three named parts in surgical nomenclature that are not true anatomical separations: the orbital orbicularis, the preseptal orbicularis, and the pretarsal orbicularis.
The postseptal compartments of the upper and lower eyelids are shown. The lower eyelid has three fat pads that lie beneath the orbital septum. The nasal fat pad and the central fat pad are separated by the inferior oblique muscle.
A sagittal section through the lower eyelid and upper midface demonstrates the boundary created by the orbitomalar ligament between the lower eyelid fat pads and the suborbicularis oculi fat pad.
The patient shown has excessive lower eyelid skin that creates prominent lower eyelid “bags.” Removal of fat alone would not address the primary pathology of excess lower eyelid skin.
The medial orbicularis oculi muscle and the superior levator labii superioris oblique nasi muscle define the tear trough (a). The tear trough is an area of the medial lower eyelid and midface junction that can become prominent with aging (b).

Common problems causing aesthetic changes in the lower eyelid–midface complex

Lower eyelid–midface problem



Skin rhytids

Chronological aging and sun exposure can lead to periorbital fine lines and wrinkles

Skin resurfacing with CO2 laser or trichloracetic acid peel, botulinum toxin to lateral periocular rhytids

Horizontal laxity

Involutional changes in the tarsus and/or shortening of the anterior lamella

Lateral tarsal strip or canthopexy; midface lift to recruit and support anterior lamellar tissue of the lower eyelid

Inferior orbital fat prolapse

Relaxation of the fibrous orbital septum

Inferior eyelid blepharoplasty (transconjunctival or transcutaneous)

Pseudo–fat prolapse

Edema of the lower eyelid gives the appearance of fat prolapse; pressure to fat pads in the upward gaze does not resolve fullness (as it would in true fat prolapse)

Address underlying cause of edema; possible restoration of midface volume with fillers, fat augmentation, or midface lift to balance infe rior eyelid–midface complex

Tear-trough deformity

The groove between the levator labii superioris and levator alaeque nasi muscles can deepen with the herniation of postseptal fat over the orbitomalar ligament, and the descent of prezygomatic fat

Careful injection with hyaluronic acid–based fillers, or fat augmentation

Midface descent

Descent of the buccal fat pad

If hollowed appearance, filler or fat augmentation; possible midface lift

Negative vector

The inferior orbital rim falls posterior to the anterior convexity of the cornea ( Fig. 25.7 )

Cautious and conservative lower eyelid blepharoplasty, fat repositioning, restoration of midface volume to balance negative vector

A frontal and lateral view of a patient with ectropion, epiphora, and a prominent negative vector are shown. In the lateral view, the inferior orbital rim (solid line) falls posterior to the anterior convexity of the cornea (dashed line), thus creating a negative vector.

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Jun 21, 2020 | Posted by in Craniofacial surgery | Comments Off on 25 Lower Blepharoplasty and Midface Rejuvenation

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