Archive for May, 2010
Today, the vast majority of surgeons perform lower eyelid blepharoplasty or eyelid lift techniques using a transconjunctival approach with fat removal and a skin pinch to rejuvenate the lower eyelid. Additionally laser treatments or chemical peels may be used to improve skin texture and smooth wrinkles. The evolution of this treatment resulted from concerns of postoperative ectropion or lower eyelid malposition associated with more traditional techniques and lack of familiarity with the measures required to prevent these complications. The transconjunctival approach makes an incision on the inside of the eyelid and while it is a safer approach in less experienced hands, it has also resulted in an incomplete lower eyelid and midface rejuvenation.
The characteristics of the aging process of the lower eyelid and midface include decent of the midface soft tissues and fat pad, elongation of the lower eyelid, pseudoherniation of fat from around the eye resulting in puffiness, formation of the tear trough deformity, and redundancy of the skin and muscle of the lower eyelid. The transconjunctival lower eyelid blepharoplasty with fat removal and skin pinch fails to address several of these issues. Removal of fat from around the eye can lead to a hollowed appearance of the lower eyelid and an abrupt transition from the lower eyelid to the midface that appears unnatural and artificial. Additionally, a skin pinch removal from the lower eyelid fails to remove the excess muscle underneath the skin and shorten the eyelid. When considered in whole there are several problems with this technique and it fails to address several of the issues that occur with age in the lower eyelid and midface.
The skin muscle flap blepharoplasty with fat transposition is the most contemporary technique available in lower eyelid blepharoplasty, and it corrects several of the issues that the transconjunctival blepharoplasty with fat removal and skin pinch fails to address. First, and most importantly, the fat from around the eye is conserved and repositioned in the tear trough (the groove that forms between the eyelid and the nose and midface) obliterating it and resulting in a smoother more natural transition between the lower eyelid and midface. The skin muscle flap blepharoplasty also removes muscle as well as skin for a more natural correction of the redundant soft tissue of the lower eyelid. When the eyelid is properly re-suspended during the procedure the risk of permanent post procedure ectropion is virtually eliminated.
Shortening the lower eyelid is best accomplished by performing a midface lift at the same time as the lower eyelid blepharoplasty. The medical literature supports that by adding a midface lift to a lower eyelid blepharoplasty more skin and muscle can be removed resulting in a shorter more youthful lower eyelid. Most midface lift techniques do not effectively release and re-suspend the soft tissues of the midface. When considering a midface lift it is important to find a surgeon who performs a transtemporal extended subperiosteal midface lift to ensure an excellent outcome. When performing a skin muscle flap blepharoplasty with fat transposition along with a midface lift the aging characteristics of the lower eyelid and midface are more completely addressed resulting in a natural, more complete periorbital and midface rejuvenation.
It is also important to consider adding a skin resurfacing procedure to improve wrinkles and skin texture and quality of the lower eyelid and finish the rejuvenation. This can be accomplished through either chemical peels or ablative laser procedures. Contemporary laser procedures allow for excellent skin resurfacing and rejuvenation with shorter healing periods when compared to chemical peels and more traditional laser procedures. The state of the art laser skin resurfacing techniques combine an epidermal laser peel with a fractionated deep dermal laser resurfacing to treat both superficial and deep wrinkles and brown spots. The Pearl Fusion procedure combines the Pearl and Pearl Fractional procedures to offer the most advanced laser technology while providing the safest outcomes.
Finding a plastic surgeon who understands how the different surgical techniques correct the aging characteristics of the lower eyelid and makes informed recommendations based on the patient’s particular issues is important to achieve superior outcomes and avoid complications. Midface lifts can correct the drop of the cheek soft tissues, efface the nasolabial folds, and shorten the lower eyelid. While a deep plane facelift can also lift the cheek soft tissues and smooth the nasolabial folds, the midface lift offers a greater effect and more permanent change to the midface soft tissues and nasolabial folds. Performing a skin muscle flap blepharoplasty with fat transpositions along with a midface lift offers the most complete periorbital and midface rejuvenation available today.
Benjmamin C. Stong MD
Atlanta, GA