Research

AESTHETIC SURGERY JOURNAL - MAY/JUNE 1999

Reprinted from AESTHETIC SURGERY, St. Louis
Vol. 19, No 3, p. 253-255, June, 1999 (Printed in the U.S.A)
(Copyright (C) 1999, by American Society for Aesthetic Plastic Surgery, Inc.)

Hamid Massiha, MD, New Orleans, LA, is a board-certified plastic surgeon and an ASAPS member.

Open Approach to Lower Lid Correction Offers Many Advantages

The shape and harmony of the eyelids contribute substantially to the beauty of the eyes. Any operation on the eyelids requires attention to detail in planning and the utmost surgical precision. It is important to individualize the operation to suit the deformity. For this purpose, I have classified lower lid deformities with suggested treatments (see Table for summary).

Transconjunctival blepharoplasty is the most appropriate technique for a patient with stage I deformity, in which there are excess fat bags under the eyes with no muscle laxity and superficial skin wrinkles only. Additional use of C02 laser skin resurfacing may be all that is required. About 5% of my patients are in this category.

Stage II is identified as muscle and skin laxity presenting as a crescent-shaped crease under the eyelid fat pads. Here cheek and lower lid structures are separated. For this deformity an open approach with preseptal orbicularis muscle tightening to the lateral orbital rim is indicated. Briefly, in this method pretarsal orbicularis muscle is left intact, and only the skin is dissected. At the lower level of the border of the tarsus, the skin flap is converted to a skin muscle flap. Only preseptal muscle with the overlying skin is tightened to the lateral orbital rim.(1)

The stage III deformity is a more advanced form of stage II, with significant lower lid laxity. To treat this deformity, I use a noninvasive canthopexy. In noninvasive canthopexy a tunnel is created under the soft tissue of the lateral canthal area, and the preseptal orbicularis muscle is tucked up in a high position without extra incisions in the lid corners.(2)

I perform noninvasive canthopexy in about 80% of my lower lid surgeries and traditional canthopexy in about 5%.

Stage IV is the most severe form of lower lid laxity, consisting of skin and muscle looseness with differing degrees of lower lid margin incompetence. For treatment I perform a noninvasive canthopexy or, if needed, a conventional canthopexy with or without lid shortening. I perform canthopexy in about 80% of my lower lid surgeries and traditional canthopexy in about 5%.

I find that as soon as skin/muscle laxity is present, an open approach offers many advantages. In addition to easy access to remove or manipulate excess orbital fat directly and accurately, other benefits include the ability to tighten loose preseptal orbicularis muscle (as explained earlier)(1); remove excess, wrinkled lower lid skin; raise cheek and nasolabial fold fat pads; correct festoons and zygomatic pads; raise the lateral canthal angle, if needed (sad eyes); and correct the crescent deformity of the lower lid. This deformity is a separation of the cheek/eyelid unit resulting from aging. The most rewarding outcome of using this technique to correct a crescent deformity, for both the patient and surgeon, is the preservation of the natural shape of the eyelid (Figure A.).

It is also important to note that ectropion, or a less severe condition that I have termed "presenile ectropion," can be corrected with a combination of canthopexy and open blepharoplasty. Presenile ectropion is a condition in which the eyelid level is high enough, but it is loose anteroposteriorly-in other words, it doesn't stick snugly to the globe. Cold air and wind can get behind a loose lid, causing burning and tearing.

In general, during the last several years, I have been removing less and less fat. However, my treatment for very severe fat pads is to conservatively remove them, coagulating the surface so that it shrinks and no fat protrudes along the level of the inferior orbital rim. In mild to moderate cases, no fat is removed. When the skin/skin- muscle flap method is used, (1) I find that shrinkage from coagulation is sufficient. This is possible because tightened preseptal muscle holds back small amounts of fat.

A, Preoperative view of patience with crescent deformity and protruding fat pads.	B, postoperative view with correction of deformity by use of the open technique.

I have not found it very helpful to pull fat out of the orbit and suture around it to sculpt the lower lid. Tightening the preseptal muscle contours the cheek-lower lid unit and adequately corrects the hollow took and crescent deformity.(1)

With regard to recovery, both the transconjunctival and open approaches cause bruising to a similar degree. In the open approach, in severe cases where there is a need to extend the canthopexy, chemosis can be a problem. I presently treat this during surgery with hydrocortisone eye ointment and follow up with hydrocortisone eye drops (gentamicin sulfate with dexamethasone [generic] ointment and drops [Tobradex(R), Alcon, Inc., Humacao, Puerto Rico]).

I have found the following guidelines (l,2) to be helpful in obtaining a natural-looking eyelid:

Leave the pretarsal part of the orbicularis muscle intact; it will avoid many problems.

Do not try to fully lift the cheek and nasolabial fold through an eyelid incision. Some degree of cheek and nasolabial area lift occurs naturally during preseptal muscle tightening. Trying to obtain more lift in this area invites complications.