Indications and Technique for Lower Blepharoplasty via Subciliary Incision

Francisco G. Bravo

ANATOMY

The lower eyelid consists of an anterior, middle, and posterior lamella¹ (FIG 1A).
The skin and the orbicularis oculi muscle form the anterior lamella.
The orbital septum, orbital fat, and suborbicularis adipose tissue form the middle lamella.
The tarsal plate, lower eyelid retractors (capsulopalpebral head and fascia), and the conjunctiva form the posterior lamella.
The orbicularis oculi muscle is subdivided into the pretarsal, preseptal, and orbital components.
There are three postseptal fat compartments in the lower eyelid (FIG 1B).
Nasal and central fat pads are separated by the inferior oblique muscle.
Central and lateral fat pads are separated by the arcuate expansion of the Lockwood ligament (FIG 1C).
The orbicularis retaining ligament or orbitomalar ligament attaches the palpebral orbicularis oculi muscle to the underlying maxilla (FIG 2A).
The tear trough or nasojugal groove and the lid-cheek junction or palpebromalar groove extend below the orbital rim and are explained by anatomical features in the subcutaneous plane² (FIG 2B).

PATIENT HISTORY AND PHYSICAL FINDINGS

The preoperative evaluation for patients seeking lower eyelid surgery includes a detailed assessment of the patient’s medical history and a thorough physical examination.³
Medical history
- Special attention should be paid to risk factors that may predispose to postoperative complications.
- Thyroid pathology, diabetes, hypertension, heart disease, coagulopathy, and any previous periorbital surgery or trauma should be documented.
- Vision disorders such as impaired visual acuity or the need to use corrective glasses or contact lenses should be noted before surgery.
- The use of medications such as aspirin and other nonsteroidal anti-inflammatory drugs, anticoagulants, and certain vitamins and herbal supplements such as vitamin E and ginkgo should be recorded and suspended 2 weeks prior to surgery.
- Smoking history should also be documented and interrupted preferably for 4 weeks prior and 2 weeks after surgery.
- A history suggestive of dry eye syndrome should be clarified, and if present, the decision to proceed should be discussed carefully with the patient.
Physical examination
Evaluation should be performed with three goals in mind:
- Document preoperative eye function
- Identify anatomic features that may predispose patients to developing postoperative complications.
- Identify the specific anatomical features that are causing the patient’s concern in order to customize the procedure.
Functional evaluation should include an examination and documentation of visual acuity, extraocular muscular movements, Bell phenomenon, pupillary response, and adequate tear production through a Schirmer or tear break-apart time test.³
Anatomic features that may predispose to postoperative complications such as lower eyelid retraction, ectropion, or malposition include the following:
- A negative vector caused by a prominent eye or a retruded maxilla, which may be measured by a Hertel exophthalmometer.
- Tarsoligamentous or horizontal lid margin laxity with a measurable lag in the snap-back test and a greater than 6 mm distraction test.
- A negative canthal tilt in which the lateral canthus lies at a lower position in relationship to the medial canthus.
- Scleral show in which the lid margin rests below the corneoscleral limbus.

Specific anatomic features that need to be identified as possible causes of the morphological concerns the patient might wish to address include⁴^,⁵

FIG 1 • A. The lower eyelid consists of an anterior, middle, and posterior lamella. B. There are three postseptal fat compartments in the lower eyelid. C. Central and lateral fat pads are separated by the arcuate expansion of the Lockwood ligament.

FIG 2 • A. The orbicularis retaining ligament or orbitomalar ligament attaches the palpebral orbicularis oculi muscle to the underlying maxilla. B,C. The tear trough or nasojugal groove and the lid-cheek junction or palpebromalar groove extend below the orbital rim and are explained by anatomical features in the subcutaneous plane.

Orbital fat herniation or prolapse due to fat pad hypertrophy or caused by excessive laxity of the orbital septum and orbicularis oculi muscle
Tear trough deformity and a deep lid-cheek junction
Dark circles due to skin pigmentation or prominent intramuscular vasculature in patients with thin, translucent skin and subcutaneous fat atrophy
Dermatochalasis or skin excess and rhytides
Orbicularis prominence or hypertrophy
Malar bags and festoons

IMAGING

The use of high-quality preoperative photography is a key element to plan and carry out eyelid surgery, as well as to document and serve as reference for clinical examination.
Standardization in patient positioning, lighting, lens focal length, and background is crucial to avoid misinterpretation and distortion of the patient’s anatomic features.⁶
The photographic series should include frontal, oblique, and profile views, as well as frontal views while smiling, rising the eyebrows, frowning, gazing upward, and closing the eyes, and also with slight posterior and anterior head tilts while looking into the lens.
High-quality video capture should also be considered to appropriately document ocular and eyelid function preoperatively.
Digital imaging software may be an important adjunct to precisely evaluate eyelid morphology and to detect asymmetries, which are common in the lower eyelid.⁷

NONOPERATIVE MANAGEMENT

With the popularity and appeal of noninvasive procedures among cosmetic surgery patients, a thorough and earnest discussion should be maintained regarding the advantages and disadvantages of such techniques vs surgical options attending to the patient’s particular anatomic features and concerns.
Botulinum toxin may be employed to reduce skin wrinkles and expression lines along the lateral portion of the lower eyelid, as well as to soften orbicularis hypertrophy or protrusion.
Skin resurfacing techniques with either lasers or chemical peels such as trichloroacetic acid or phenol-croton oil may be performed to improve skin quality and dermatochalasis.
The use of fillers such as hyaluronic acid, collagen, or the patient’s own fat may be infiltrated around the lower eyelid to correct an evident tear trough or deep lid-cheek junction or to augment the inferior orbital rim and malar area to provide better support and contour in a negative vector patient.
The use of nonsurgical procedures should not be discarded even if surgery is indicated as they may be valuable adjuncts to improve and enhance the results after lower blepharoplasty.

SURGICAL MANAGEMENT

The decision to proceed with surgery depends on the specific anatomic concerns of the patient as well as on the degree and duration of the result sought.⁸
Indications for surgery include herniated and prolapsed bags, an evident tear trough deformity or deep lid-cheek junction and orbicularis muscle laxity or excess skin.
Patients with good skin quality might be better candidates for a transconjunctival approach.
Risks to the patient include hematoma, infection, and lower eyelid retraction or malposition.
The main steps include access to the eyelid bags through a subciliary incision, release of the arcus marginalis and orbitomalar ligament, removal of lower eyelid fat, lateral canthopexy, and resuspension or tightening of the orbicularis muscle.
The skin should be excised conservatively in most cases, and canthal support techniques should be employed routinely to decrease the incidence of lower lid retraction or scleral show.