Lower lid blepharoplasty is one of the most complex facial cosmetic procedures performed, in contrast to upper lid blepharoplasty. Martin H. Devoto, MD, shares his surgical pearls.
Reviewed by Martin H. Devoto, MD
In contrast to upper lid blepharoplasty—which is considered a surgically simple procedure when given the appropriate attention to detail—that of the lower lid is one of the most complex facial cosmetic procedures performed, said Martin H. Devoto, MD.
With aging and fatigue reflected in the lower eyelid area, the key elements to achieving a youthful contour in the lower lid is providing a short vertical lower lid.
“After each decade, the length of the lower lid increases,” explained Dr. Devoto, director, Oculoplastics and Orbital Surgery Division, Consultores Oftalmologicos, Buenos Aires, Argentina.
“A short lower lid is a sign of youth.” Another element is the preservation and enhancement of the shape of the lower lid. In younger patients, the lateral canthal angle of the lower lid is higher than the medial compared with older patients. The final element that should be enhanced is the quality of the skin, he noted.
To reach these goals, Dr. Devoto and colleagues perform a three-part combination procedure—the dual-plane blepharoplasty.
- The first part is improving the tear trough with fat transposition.
- The second part is tightening the orbicularis muscle to improve laxity by placing a stitch that is passed from the superior incision above when performing an upper lid blepharoplasty or by making a separate stab incision, grasping the orbicularis muscle, and tightening it to the upper lid.
- The third component is improving wrinkles using a skin-pinching technique, which preserves the orbicular muscle function and innervation by avoiding cutting the muscle, Dr. Devoto explained.
Dr. Devoto makes a cut with a monopolar needle or CO2 laser after the lower lid is retracted. He performs the dissection in front of the septum to avoid bulging of the fat.
Dr. Devoto notes the importance of placing a corneal shield, but before that, he puts a stitch in the conjunctiva and places retractors for better exposure. He dissects inferior to the arcus marginalis, for about 10 mm and completely release the orbital retaining ligament. He advises paying attention to the exit point of the infraorbital nerve, and the dissection can be aided using a cotton swab.
When the pocket is formed, the medial and central fat pads are released in pedicules and freed using Wescott scissors. A 5-0 nylon suture is inserted about 10 mms below the premarked arcus marginalis.
The suture goes under the dissected flap and it is used to engage the medial and central fat pads to create a “curtain” of fat. The fat creates a layer that will hold and help elevate the tear trough, Dr. Devoto explained. The exit point is located slightly nasally.
A pearl at this point is to avoid overtightening the 5-0 nylon stitch, which is removed 1 week postoperatively. The lateral fat pad can be transposed in some patients, but in these cases, a dissection is necessary in the lateral area. However, this increases the degree of chemosis.
Martin H. Devoto, MD
E: [email protected]
This article was adapted from Dr. Devoto’s presentation during Oculoplastics Subspecialty Day at the 2018 meeting of the American Academy of Ophthalmology. Dr. Devoto has no financial interest in any aspect of this report.