Subciliary Lower Lid Blepharoplasty

Chapter 38. Subciliary Lower Lid Blepharoplasty

Christopher T. Chia, MD; Kimberly A. Swartz, BA; Henry M. Spinelli, MD, FACS

INDICATIONS

The indications for the subciliary incision lower lid blepharoplasty (SLLB) include correction of dermatochalasis of the subciliary skin for aesthetic improvement of the periocular region, or in concert with fat resection or redistribution, canthal repositioning, or correction of other pathologic processes. This approach allows for resection of excess skin when indicated, as well as exposure of the underlying structures for other aesthetic and reconstructive techniques.

PREOPERATIVE PREPARATION

All patients undergo a complete history and physical examination with special consideration given to ophthalmologic conditions that may alter the surgical plan, such as prior surgery, dry eye, thyroid disease, blepharitis, and refractive corneal surgery. The lower lid position and vector, canthal support system, and integrity of the periocular adnexa need to be accurately determined in relation to the globe.

ANESTHESIA

Soft tissue injection of 1% lidocaine with epinephrine provides excellent analgesia and assists with hemostasis. This is often combined with conscious sedation or general anesthesia when performed alone or in conjunction with other procedures. Regional nerve blocks have been described as aiding postoperative analgesia.

POSITION AND MARKINGS

The patient is positioned with his or her head in a doughnut pillow supine in slight hyperextension with the head of the bed slightly raised. The lower eyelid incision is delineated by a line extending from the lateral canthus posteriorly in a natural skin fold 1 to 2 mm below the lash margin, anticipating leaving a cuff of pretarsal orbicularis.

DETAILS OF THE PROCEDURE

Following infiltration of the local anesthetic with vasoconstrictive agent, placement of corneal protectors and a standard prep and drape, the primary incision is made with a scalpel at the lateral extent of the surgical markings through the skin and orbicularis muscle. A Steven’s scissor is inserted into the potential space just anterior to the orbital septum in the postorbicularis/preseptal plane. The scissor is opened gently from a lateral to medial direction to develop a space extending from the preseptal to pretarsal suborbicularis regions. One limb of a fine iris scissor is inserted into the incision with the other overlying the skin of the lower lid. The marginal aspect of the incision is made just below the lash line and extended to a point lateral to the medial punctum (Fig. 38-1

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