Surgical technique

The author reviewed the outcome of his 20 years of blepharoplasty surgery experience. He has used the technique described in this article for the past 5 years.

Candidates for blepharoplasty typically present with herniation of the orbital fat and are unhappy with puffiness and bags under their eyes. The fat prolapse is addressed through a transconjunctival approach and when there is excess skin, patients benefit from this mini‑lift technique. All patients were documented for medical and ophthalmic history such as chronic systemic disease and medications. Ophthalmic history included vision, glaucoma, trauma, allergic reactions, excess tearing, and dry eyes. In addition to a complete eye examination, evaluation of the periorbital area should consider skin laxity or excess, orbicularis laxity or hypertrophy, herniation of the orbital fat, canthal laxity, malar festoons, and rhytides. Patients with prior blepharoplasty or mid-facelift surgery were excluded.

The surgery begins by marking the incision line, 2–3 mm below the lid margin in the lateral third of the lower lid, extending to 2 mm beyond the lateral canthal angle. The line continues laterally and downward in a pre-existing laugh crease for a distance of 10–15 mm depending on the amount of skin to be excised (Figure 2).

Anaesthesia is performed by infiltration of the fornix with 2–3 ml of 2% lidocaine with 1 : 100000 adrenaline. Surgery begins with the skin incision using radiofrequency (RF), blade or CO2 laser. The orbital fat prolapse is sculpted through a transconjunctival approach9,10 a lid plate is placed to protect the globe and help the orbital fat to herniate. The fornix is exposed and an incision through the conjunctiva and retractors is made at the lower border of the tarsal plate. Using RF instrumentation, an incision is made in a classic fashion from the punctum to the lateral canthal angle, or with a more conservative mini-incision technique, in which the incisions are made at the medial, central and lateral fat pads (if a lateral fat prolapse has been assessed preoperatively). These button-hole incisions avoid a total disinsertion of the lower-lid retractor and a better assessment of fat to be removed with the use of a Chedly Lid Retractor. The lower lid is retracted on its full length, allowing a nice exposure of the whole surgical field of fat prolapse, and allowing a good visualisation of any bleeding. This dual lid retractor is insulated with a non‑reflective finish and is safe to use with a radiosurgical unit or CO2 laser11,12.

Figure 4 Marking of the excess skin to be resected

Figure 4 Marking of the excess skin to be resected

With an incision at the lower border of the tarsus, there is no need for sutures13. Once the fat prolapse has been sculpted and resected as described, attention is turned to resect the excess skin using the mini-lift technique. The skin and orbicularis are undermined, and the skin muscle flap is draped upward and laterally over the eyelid incision line with slight tension. The patient is asked to look upward to estimate the amount of vertical skin to be resected. Care must be taken not to remove more skin than necessary. Rarely will more than 4–5 mm of vertical skin need to be excised. Scissors can be used to cut the excess skin muscle flap.

One (or two) deep supporting 6-0 prolene sutures are placed through the orbicularis muscle of the temporal flap edge and into the deep subcutaneous fascia of the upper skin incision over the orbital rim. The skin is closed with interrupted 6-0 nylon sutures along the subciliary incision and the temporal portion of the wound. This technique often allows the reduction of a lymphomatous festoon, if present.

Figure 5 (A) Skin incision along the marked line. (B) Skin and orbicularis are undermined. (C) Skin-muscle flap draped upward and laterally. (D) Skin excision. (E) Nice fitting all along the skin incision without excess skin. (F) Supporting 6-0 prolene sutures. (G) Skin closed with interrupted sutures.

Figure 5 (A) Skin incision along the marked line. (B) Skin and orbicularis are undermined. (C) Skin-muscle flap draped upward and laterally. (D) Skin excision. (E) Nice fitting all along the skin incision without excess skin. (F) Supporting 6-0 prolene sutures. (G) Skin closed with interrupted sutures.

Discussion

In cosmetic surgery, and cosmetic eyelid surgery in particular, the surgeon must reach excellency in his/her results. Therefore, blepharoplasty requires meticulous, conservative and minimally-invasive techniques by an experienced eyelid surgeon. The surgeon must avoid complacency in his/her technique, must be familiar with the eyelid anatomy, thus avoiding complications and poor results, and allowing the patient a fast recovery.

The mini-lift technique to remove excess skin helps to achieve these goals. The standard and traditional subciliary incision has a number of drawbacks. Lower-lid malposition, including lower-lid retraction, lateral canthal rounding, scleral show and ectropion are complications, occurring at a rate of up to 20%. Lower-lid laxity as determined by excess anterior distraction of the lid, prolonged snap-back testing, a negative vector relationship, and prominence of the globe, are all preoperative risk factors and in the opinion of many authors, definitive indications for lateral cathal tightening14–16.

Figure 5 (G) Skin closed with interrupted sutures.

Figure 5 (G) Skin closed with interrupted sutures.

These complications may occur even if skin resection is conservative as the retraction may result from pathologic changes at a number of anatomic sites, including vertical shortening of the skin on the total length of the lower lid, postoperative scarring, and contracture of tissue. In the author’s experience, however, scarring in the plane of the orbital septum is the most common cause of post-blepharoplasty eyelid retraction. When an upward traction of the lower lid is applied, a tethering of the mid-lamella can be seen, which is evidence of scarring in the plane of the septum, without evidence of skin shortage.
Therefore, while lid retraction may be owing to mid‑lamellar scarring, ectropion and retraction may also be the result of too much skin excision and of not tightening a loose canthus. This should be diagnosed preoperatively.

Figure 6 (A) and (B) before mini-lift blepharoplasty treatment. (C) 3 weeks postoperatively and (D) 3 years postoperatively

Figure 6 (A) and (B) before mini-lift blepharoplasty treatment. (C) 3 weeks postoperatively and (D) 3 years postoperatively

The surgical manipulation of the orbicularis oculi in the traditional transcutaneous technique leads to its denervation and secondarily, to lower eyelid malposition, although these claims have not been substantied in comparative studies17–19.
The resection of the orbital fat prolapse transconjunctivally in this mini-lift technique keeps the septum unharmed, therefore avoiding complications related to septum opening in the traditional transcutaneous technique. With the mini-lift technique, there is no temporary orbicularis dystonia and no need for a formal canthoplasty. The orbicularis suspension described in this surgical technique elevates the lower eyelid to a natural and anatomically appropriate position. The resuspension of the ptotic orbicularis muscle also reinforces the underlying attenuated orbital septum, which was kept intact by addressing orbital fat prolapse via a transconjunctival approach.

The mini-lift technique helps the facial plastic surgeon to avoid the complications of the traditional transcutaneous approach and helps shorten the recovery time with minimal oedema and chemosis.Lower-lid malposition following blepharoplasty has led plastic surgeons to improve techniques into less-invasive and versatile approaches20–22.

Conclusions

Blepharoplasty remains one of the most gratifying surgeries in facial plastic surgery, but there is no tolerance for error and complications. Good patient selection, a thorough evaluation of the deformity, the choice of the proper minimally-invasive technique, and a precise and accurate execution of the surgical procedure are key to obtaining optimal results. The mini-lift lower-eyelid blepharoplasty gives very good results, is a simple and efficient technique, and is easy to execute by skilled surgeons, but also by those with less experience.