Professional Documents
Culture Documents
Blepharoplasty: Anatomy, Planning, Techniques, and Safety: Mohammed Alghoul, MD, FACS
Blepharoplasty: Anatomy, Planning, Techniques, and Safety: Mohammed Alghoul, MD, FACS
Abstract
Blepharoplasty is one of the most commonly performed cosmetic surgical procedures. To date it remains the most powerful method of periorbital rejuve-
nation when compared to other nonsurgical modalities, especially in the aging face. Despite that, the procedure has its shortcomings that include a steep
learning curve, prolonged recovery, and potential for appearance and life-changing complications. Attaining successful outcomes relies on a solid under-
standing of facial topography, patient and technique selection, and, when appropriate, following a conservative approach. Modern blepharoplasty relies
on tissue conservation and volume enhancement rather than aggressive removal. This concept was conceived after the realization that older techniques
resulted in a hollowed appearance, which accentuated the aging process. It was further reinforced by advances in knowledge of periorbital anatomy
and aging changes. This Continuing Medical Education article will detail periorbital surgical anatomy, preoperative planning, and varied blepharoplasty
approaches and techniques, with an emphasis on safety and tailoring the procedure to the patient’s anatomy.
Editorial Decision date: January 26, 2018; online publish-ahead-of-print February 21, 2018.
used, the goal of the operation should remain the same; planning. Both upper and lower eyelids should be assessed
restoring a youthful and natural look to the eye and perior- in the context of the surrounding periorbital area. Changes
bital area. For upper blepharoplasty, the goal is to restore in the brow and cheek strongly influence the upper and
the visibility of the pretarsal space with a well-defined lower eyelids, respectively. It has become common prac-
upper lid crease while restoring an attractive upper lid tice to address both the lateral brow and cheek as part of
fold volume, in proper proportion with the pretarsal space. comprehensive periorbital rejuvenation.3,5,8,11,13,14,17-22
Lower blepharoplasty aims to create a smooth lower lid
surface with seamless transition into the cheek. As these
objectives are accomplished, the shape and dimensions of SURFACE TOPOGRAPHY
the palpebral fissure should be maintained or improved.
Ideally, the periorbital area should project anteriorly in
Like other procedures in plastic surgery, the concept of
relationship to the globe. The reverse ratio results in aes-
blepharoplasty has evolved over the years secondary to
thetically less attractive eyes as evidenced in patients with
increasing knowledge of periorbital anatomy, facial topog-
prominent eyes, negative vector, and cheek and brow
raphy, and the aging process. As a result, several surgical
deflation (Figure 1). A negative vector indicates that the
techniques have been described in an effort to maximize
globe projects further than the malar eminence23 and is
safety and improve the aesthetic results. The choice of par-
often associated with lack of anterior cheek projection and
ticular blepharoplasty technique has been heavily debated
decreased soft tissue volume of the cheek. The upper eye-
with several different schools of thought.3,6,8,11,12,14 The
lid is divided into two distinct spaces, the upper eyelid fold,
fear of postoperative complications, especially with lower
which is the space between the brow and upper lid crease,
blepharoplasty, has driven many surgeons towards more
and the pretarsal space, defined as the space between the
conservative approaches sometimes at the expense of opti-
crease and the lash line.23 The ratio between both spaces
mizing aesthetics.14 This CME article will detail periorbital
(fold:pretarsal ratio) and the difference in volume is what
surgical anatomy, preoperative planning, and varied bleph-
determines upper eyelid aesthetics. This ratio differs from
aroplasty approaches and techniques, with an emphasis
medial to lateral and between males and females. We
on safety and tailoring the procedure to the patient’s anat-
have studied the upper eyelid topographical proportions
omy to attain the desired outcome.
in attractive Caucasian female models and found that an
ideal fold:pretarsal ratio averages 1.87 medially and wid-
UPPER AND LOWER EYELID ANATOMY ens laterally to an average of 2.98, peaking at the lateral
limbus.24 These findings reflect the importance of lat-
Knowledge of periorbital anatomy, topography, propor- eral brow vertical height and fullness, and the presence
tions, and volume distribution are critical in surgical of some degree of pretarsal show in females (Figure 1).
12 Aesthetic Surgery Journal 39(1)
In males, on the other hand, pretarsal show is not as criti- orbicularis. Orbicularis hypertrophy in some patients may
cal and upper lid fold height is more even across the width cause a noticeable bulge in that segment of the eyelid espe-
of the palpebral fissure. The upper eyelid sulcus is the cially with squinting and smiling. The preseptal segment
space between the upper lid crease and the superior orbital of the lower eyelid is where the orbital septum and orbital
rim. Uniform fullness of the sulcus is created by the orbital fat are located. Anterior protrusion of the fat compartments
fat and directly contributes to the upper lid fold’s overall in this segment results in distinct and well-localized bulges
volume. With aging, the fat content in the upper lid can (Figure 2). The eyelid cheek junction is the area defined by
increase or decrease.25 Herniation of orbital fat can create a groove or a dark soft tissue depression known as the tear
localized bulges that obliterate the sulcus. Loss of orbital trough. This trough accentuates the orbital fat protrusion
fat volume, on the other hand, deepens the sulcus and above and the upper cheek volume depletion below, result-
creates a sunken, shadow-filled area under the brow and a ing in a peak and valley visual effect and a dark shadow
round hollowed upper lid (Figure 1).25,26 As a result of this in the lower eyelid. Volume deflation in the upper cheek
volume depletion, the supraorbital rim becomes visible results in a central inverted triangular area of volume loss.28
and the supratarsal crease may appear elevated. An additional bulge may occur in the lateral cheek known
The palpebral fissure shape and dimensions should be as the malar mound. This mound results from descent of the
preserved and sometimes corrected during blepharoplasty. prezygomatic space and is bordered superiorly by the lateral
An aesthetically pleasing eye has an almond shape with orbicularis retaining ligament and inferiorly by the zygo-
superior arc that peaks medially27 and a slight upward matic cutaneous ligaments that form the midface groove.29
inclination of the lateral canthal angle (positive canthal Finally, the lateral orbital area is a very important aes-
tilt).3 The lateral canthal angle is sharp and crisp, with the thetic component that is frequently overlooked. It is formed
lateral commissure closely opposed to the globe, while the by the merger of the lateral brow and upper lateral cheek
medial canthal angle is slightly blunted and the commis- as they meet just lateral to the lateral canthus. Graduated
sure separated from the globe, by the caruncle and plica fullness from the lateral brow to the upper lateral cheek
semilunaris. Assessment of the size and shape of the lat- complements the results of blepharoplasty and closes the
eral scleral triangle preoperatively and postoperatively is a circle in periorbital rejuvenation.
useful tool to assess the palpebral fissure shape and lower
lid malposition.23 PERTINENT SURGICAL ANATOMY
The lower eyelid crease is less defined than the upper
eyelid crease, but similarly is considered a sign of youth and The eyelid is a complex structure that varies in its lay-
reflects normal lower eyelid animation. Topographically, ered composition depending on the anatomic segment.
the lower eyelid is divided into a pretarsal area, presep- The pretarsal segment extends from the lash line to the
tal area, and the eyelid cheek junction. The pretarsal seg- margin of the tarsal plate and is bilamellar. The anterior
ment has a slight natural bulge that occurs with smiling lamella is composed of skin and pretarsal orbicularis while
and animation reflecting normal function of the pretarsal the tarsus and conjunctiva make the posterior lamella. The
Alghoul13
A B
Figure 4. (A) Skin markings of upper blepharoplasty in a 73-year-old woman, showing the crease and the lateral extent of
the ellipse, which is marked parallel to the lower blepharoplasty lateral canthal incision. Ideally the distance between the two
should be 10 mm although many time this distance ends up being shorter. (B) Open-sky technique showing the upper incision,
dissection through the orbicularis oculi muscle (OO) and septum (S) exposing the preaponeurotic fat pad (PF). (C) Upper lid
orbital fat showing the preaponeurotic (central) fat pad (PF) and the paler nasal fat pad (NF). (D) The preaponeurotic fat after
it was mobilized and draped across the upper lid fold for volume augmentation.
The orbicularis retaining ligament is an osseocutane- postseptal approach, and the result of this release is con-
ous septum that separates the eyelids from the cheek and necting the orbital fat with a preperiosteal or subperios-
brow and is responsible for nasojugual and palpebromalar teal plane on the anterior rim while leaving the septum
grooves (Figure 6B).28,29,31 The medial aspect of this liga- undisturbed.8,11,36 On the other hand, a transconjuncti-
ment is sandwiched between the maxillary origin of the val preseptal approach and the transcutaneous approach
preseptal and orbital orbicularis and it ends at the medial usually open the septum and encounter and release the
scleral limbus. This segment of the ligament is known as orbicularis retaining ligament while leaving the arcus
the tear trough ligament (Figure 2).28 As it travels later- undisturbed,13 except in cases where they transition into
ally it turns into a pure bilamellar septum that increases a subperiosteal plane, necessitating the release of arcus
progressively in length and fuses with the lateral orbital marginalis (Figure 7).36
thickening. This segment of the ligament is known as the The lateral canthal fixation is anatomically accom-
orbicularis retaining ligament.28 It is critical to differenti- plished through three structures that attach to the lateral
ate the orbicularis retaining ligament from the arcus mar- orbital rim at different levels. The lateral palpebral raphe
ginalis. The latter is a distinct fibrous thickening seen at is formed by the pretarsal and preseptal orbicularis and is
the orbital rim from the confluence of the orbital septum located immediately under the lateral canthal skin.37 The
with the periorbita and periosteum.30 The arcus marginalis superficial lateral canthal tendon is a continuation of the
is encountered and released through a transconjunctival orbital septum sandwiched between the muscle and the
Alghoul15
A B
E F
Figure 5. Lateral canthoplasty in steps in a 73-year-old woman. (A) Lateral canthotomy. (B) Inferior cantholysis. (C)
Estimating the degree of shortening and tightening. (D) Vertical bites through the cut end of the tarsal plate with double-armed
suture. (E) Deep periosteal bite in the lateral orbital rim close to the location of Whitnall’s tubercle, the white arrow is pointing
to Eisler’s fat pad, and (F) recreating the lateral canthal angle with a gray-line stitch.
lateral canthal tendon and inserts anteriorly on the peri- that originates from the upper and lower tarsal plates
osteum of the lateral orbital rim.35,37 The lateral canthal and inserts on Whitnall’s tubercle which is positioned 2
tendon (lateral retinaculum), is the deepest attachment to 4 mm inside the lateral orbital rim.23,37,38 It receives
16 Aesthetic Surgery Journal 39(1)
A B
Figure 6. Skin muscle flap lower blepharoplasty in a 73-year-old woman. (A) A stair-step incision starting as a subciliary
skin incision 1 to 2 mm below the lash line followed by a muscle incision preserving 4 mm strip of PTOO. (B) Dissection in
the preseptal plane or space showing the LFP and CFP separated by the arcuate expansion of Lockwood ligament, the black
arrow is pointing to the orbicularis retaining ligament and the white arrow is pointing to the lateral orbital adhesion. (C) White
arrow pointing at arcuate expansion of Lockwood ligament. (D) Mobilization of the orbital fat as pedicled flaps that can be
advance over the orbital rim. (E) Redraping of the orbital fat in the preperiosteal plane. (F) Marking the lateral wedge of skin
and muscle that are trimmed in the skin-muscle flap technique. (G) The excess skin is estimated only after excision of the
tissue laterally and orbicularis suspension. (H) Skin is conservatively trimmed, notice the elevation of the marked line that was
originally placed at the tear trough. CFP, central fat pad; LFP, lateral fat pad; PSOO, preseptal orbicularis oculi muscle; PTOO,
pretarsal orbicularis oculi muscle; OF, orbital fat; S, septum; SOOF, suborbicularis oculi fat.
contributions from the lateral horn of the levator apo- reconstructive periorbital procedures should be obtained.
neurosis and Whitnall’s ligament superiorly, Lockwood’s The presence of dry eye symptoms and predisposing risk
ligament inferiorly, and the check ligament of the lateral factors for dry eye syndrome must be carefully evalu-
rectus muscle on its deep surface.23,37-39 ated, as upper and lower blepharoplasties cause transient
impairment in eyelid closure mechanics, and can result
PREOPERATIVE EVALUATION in worsening of symptoms postoperatively.41-43 Patients
with history of dry eyes or inability to tolerate contact
The goal of preoperative evaluation is to identify medi- lenses should undergo a Schirmer test, which relies on
cal history and anatomical features that increase the risk the degree of wetting of a filter paper strip placed at the
of postoperative complications. History of poorly con- lateral commissure. Wetting of less than 5 mm distance
trolled hypertension, bleeding disorder, and certain med- over a period of 5 minutes is considered diagnostic of
ications and herbal supplements can increase the risk of dry-eye syndrome.40,42 The presence of a normal Bell’s
bruising and bleeding.40 History of prior cosmetic and phenomenon, manifested as upward rolling of the globe
Alghoul17
E F
Figure 6. Continued
when attempting to open a closed eye should be docu- deformity.28 Pictures will often reveal asymmetries that
mented.40 Absence of Bell’s phenomenon, although is not are not clear on examination, especially with ptosis that is
a contraindication for blepharoplasty, should steer the more apparent when the patient relaxes in front of a cam-
surgeon towards a more conservative approach. History era. Three-dimensional photographs allow more accurate
of recent ocular or corneal surgery should be elucidated. measurements of periorbital volumization procedures.45
It is advisable to wait for 6 months after laser-assisted in The surgical plan should be determined after discussing
situ keratomileusis (LASIK) to allow for restoration of nor- the patient’s goals and desired outcome and it should be
mal corneal sensitivity prior to eyelid surgery, as LASIK customized depending on the presenting features.
causes blunting of the normal blink reflex temporarily.44
The patient’s specific cosmetic complaints should be veri-
Upper Eyelids
fied while looking in the mirror. Evaluation then proceeds
with careful analysis of periorbital topography and signs There are three important features that need to be evaluated
of aging. Standardized preoperative photographs are taken in the upper eyelid: (1) the presence of a well defined and
in 6 views that include a front, lateral, three quarters, and visible crease; (2) the degree of pretarsal show; and (3) the
a close-up view of the eyes. In addition, photographs of height, volume, and contour of the upper eyelid fold. The
the eyes closed in repose and of the eyes open with the marginal reflex distance-1 (MRD-1), defined as the distance
globe in upward gaze, help in evaluation of the amount of between the corneal light reflex and the upper eyelid mar-
excess skin in the upper lid and excess orbital fat in the gin, should be determined first to rule out a concomitant
lower lid, respectively. Finally, a photograph of the eyes in blepharoptosis, which should be addressed at the time of
animation (squinting) helps verify the size and function blepharoplasty. In Caucasian females, the crease has a gentle
of the pretarsal orbicularis and accentuates the tear trough arch, averages 8 to 10 mm in height from the lash line at the
18 Aesthetic Surgery Journal 39(1)
midpupil, and should be visible through its full length from can be complementary to upper blepharoplasty (Figure 8). In
medial to lateral canthi. The degree of desired pretarsal show non-Asian males, the crease (averaging 7-8 mm in height)46
varies among patients and can be determined by examining is straighter and the upper lid fold is more uniform in height
old photographs. Caution should be practiced with patients and volume with less emphasis on the visibility of the pre-
who present for upper blepharoplasty who have full visibility tarsal space. Contour irregularity of the upper eyelid fold can
of their crease and pretarsal space. A traditional upper bleph- result from excess skin, localized bulge created by herniating
aroplasty in this patient population can result in increased orbital fat, or a prolapsed lacrimal gland. Finally, the need for
pretarsal show, which can be unattractive. The youthful fat grafting to create a smooth, full, and convex upper eyelid
upper eyelid fold has a smooth surface with a progressive fold should also be determined.
gradual increase in height and volume from medial to lat-
eral where it blends with the lateral orbital area (Figure 1).2
Lower Eyelids
This progressive increase in height and volume in females is
determined by the position of the temporal brow and retro-or- The lower eyelid position is evaluated including the pres-
bicularis oculi fat. It is for this reason that a temporal brow lift ence of scleral show or bowing of the lateral lower lid
Alghoul19
incisions should not extend nasal to the medial canthus.46 Adjunct procedures for upper blepharoplasty include
Skin infiltration with a local anesthetic is performed after lacrimal gland suspension, transpalpebral browpexy, fat
marking the crease and it can facilitate drawing on an oth- grafting, and transpalpebral corrugator resection. The
erwise redundant skin. Pinching the area of marked skin incidence of lacrimal gland prolapse has been reported
with forceps allows for making adjustments before com- to be 15% in the general population55 and higher in the
mitting to the marked pattern.51 Incisions are made pre- aging population.53 In order to expose the gland, the tem-
cisely, beginning with the crease. The upper fold incision poral orbital septum is opened and the central fat pad is
is deepened through the orbicularis oculi muscle exposing mobilized. Several techniques have been described for
the orbital septum while maintaining meticulous hemo- repositioning of the orbital portion of the lacrimal gland
stasis. Gentle pressure applied on the globe (retropulsion) including suturing the capsule of the gland to superior
allows preaponeurotic fat to bulge forward and the orbital orbital rim periosteum,56 suturing Whitnall’s ligament57 or
septum is incised. The preaponeurotic fat is trimmed or the anterior surface of the lateral horn of the levator over
redistributed along the length of the sulcus (Figure 4D). the gland to the superior orbital rim periosteum,23 or the
A B C
muscle until the lateral orbital rim periosteum is identified. septal incision or partial excision (Figures 6D and E). After
A small double prong skin hook is then used to pull on the orbicularis is redraped, a triangular skin and muscle
the incision edge laterally keeping the lower lid under ten- excision is performed laterally and inset is performed after
sion and the skin incision is placed precisely 0.5 to 1.0 mm lateral canthal tightening. Conservative subciliary skin
under the lash line. After the skin is separated from the and muscle excision is performed after lateral inset of the
orbicularis oculi, the muscle incision is extended pre- orbicularis flap (Figure 6G). Proper inset of the skin-muscle
serving 4 millimeters of pretarsal orbicularis (Figure 6A). flap is probably one of the most challenging steps of this
Dissection proceeds in a preseptal plane until the inferior technique for several reasons; there is a substantial dog ear
orbital rim is reached. In this plane, the tear trough liga- that has to be chased while maintaining a relatively short
ment and the orbicularis retaining ligaments are identified incision, sewing the orbicularis back together can create a
and are released in continuity with the lateral orbital adhe- step off that has to be leveled, and finally imprecise inset of
sion (Figure 6B). It is this complete release of the retaining the skin near the lateral canthus can result in postoperative
ligament and lateral adhesion that frees the muscle and webbing. Given the nature of the stair-step incision, careful
allows mobilization of the orbital portion of the orbicula- trimming of the preseptal orbicularis is necessary to avoid
ris6,12,59 along with its overlying subcutaneous fat compart- overlap and unintentional augmentation of the pretarsal
ment (infraorbital fat) superiorly.33 This maneuver is what orbicularis.6,12,16
defines the skin-muscle flap technique, as it redrapes and There are several advantages of the skin-muscle flap bleph-
lifts the orbicularis taking the soft tissue redundancy later- aroplasty; it provides unparalleled exposure for fat redrap-
ally where the majority of trimming occurs (Figure 6F).6,58 ing, it is a powerful technique for tightening of the anterior
After releasing the tear trough and the orbicularis retaining lamella (Figures 8-10) especially in patients with orbicularis
ligaments, the area of the SOOF is exposed and dissection oculi laxity, and it elevates the infraorbital superficial fat
proceeds in a supraperiosteal plane for 5 to 10 millimeters. compartment, which helps with blending of the eyelid-cheek
If a midface lift is intended at the same time, dissection junction (Figure 6H). On the other hand, the skin-muscle flap
can be extended further either in a supraperiosteal plane technique is considered by some an aggressive approach with
spreading through the prezygomatic and premaxillary higher incidence of postblepharoplasty lower eyelid retrac-
spaces12,29 or in a subperiosteal plane. If a midface lift is not tion.48 There is more scarring involved in the anterior and
planned, then the extent of dissection is judged by adequate middle lamella by violating the muscle and septum in addi-
release of the depression created by the retaining ligaments tion to partial denervation of the muscle which weakens the
and the size of the pocket created for fat redraping. Fat anterior support of the lower lid.48 Although EMG studies
excision or redraping (see below) is performed through a have refuted this hypothesis by showing normal innervation
22 Aesthetic Surgery Journal 39(1)
A B
A B
horizontally along the same line with conjunctiva, or sep- oculi down to the inferior orbital rim and redrapes the skin
arately as a vertical split to preserve the retracting function (Supplemental Figure 1).
of the muscle. There have been no reported complications,
however, from dividing the CPF horizontally. Staying in
the postseptal plane until the inferior orbital rim is reached
Fat Transposition and Fat Grafting
leads to the posterior aspect of the arcus marginalis, so this First described by Loeb62 in 1981, using the orbital fat as
plane continues naturally into a subperiosteal plane unless pedicled grafts to augment the eyelid-cheek junction has
an incision is made at the inferior border of the septum become a popular and reliable technique. The orbital
above the arcus marginalis to continue in a supraperiosteal fat can be accessed through a preseptal or a postseptal
plane. A subperiosteal dissection is performed with a per- approach and is redraped in a subperiosteal or suprape-
iosteal elevator taking care not to injure the infraorbital riosteal plane.6,8,9,11,13,14,16,17,36,63 In a preseptal approach,
neurovascular bundle, which is clearly visualized.8,11,36 the orbital septum is opened or partially excised and the
The tear trough and orbicularis retaining ligaments are not fat is mobilized by lysis of the fibrous connective tissue
directly severed as their periosteal origin is elevated, there- that restricts it (Figure 6D). The use of a needle-tip electro-
fore there is more emphasis on “arcus marginalis release” cautery on a low current facilitates this dissection, which
in this type of procedure than on orbicularis retaining lig- is continued until the fat pedicles are completely freed and
ament release. The end effect should be similar as the tear redraped over the inferior orbital rim without creating any
trough area of depression is elevated and separated from tension on the lower lid (Figure 6E). The septal reset tech-
bone. A preseptal dissection is preferred by others13 as it nique, described by Hamra,64 involves incising the inferior
provides better access to release the palpebral part of the border of the septum and advancing the septum along with
orbicularis oculi, tear trough ligament, orbital part of the the orbital fat over the orbital rim where it is secured.16,64,65
orbicularis oculi, and the orbicularis retaining ligament. The most common orbital fat redistribution is the use of
After the fat is redraped, lateral canthal tightening can be the nasal and central fat compartments to augment the area
performed when indicated and the conjunctival incision of the tear trough with its accompanying central triangu-
is closed or left to heal by secondary intention. The skin lar depression at the eyelid cheek junction, while excising
is addressed through a separate incision when indicated. the lateral fat compartment.3,6,8,9,11,13 Fat transposition has
Different techniques were described for skin excision been reported with and without anchoring to periosteum or
including a “pinch”7 and a skin only flap.8,17 In a “pinch” to skin.6,8,11-13,36 The use of excised orbital fat as free grafts
blepharoplasty, the skin is pinched with forceps creating a has been also reported with good outcomes.13,15
vertical skin pillar that is excised and closed while avoid- Fat grafting has become an important adjunct proce-
ing any everting tension on the lid margin. A skin only flap dure that is being performed more frequently with both
on the other hand separates the skin from the orbicularis upper and lower blepharoplasties. This is attributed to
24 Aesthetic Surgery Journal 39(1)
A B
several recent topographical and anatomical studies that term canthopexy indicates lateral tightening of the lower
advanced our understanding of periorbital aging and its lid without a canthotomy or cantholysis, while canthop-
relationship to soft tissue deflation, and facial fat com- lasty is lid tightening in the presence of canthotomy and/
partments of the face.22,33,34,66 The purpose of fat graft- or cantholysis (Figure 5). Lateral canthoplasty allows for
ing is to blend the eyelid-cheek junction and to improve lid shortening in cases of severe lower lid laxity, in addition
both the anterior and lateral brow and cheek projection, to reshaping and repositioning of the lateral canthal angle,
enhancing periorbital aesthetics. In the upper lid, fat while canthopexy is merely a splinting procedure that
grafting improves the volume of the upper eyelid sulcus, maintains the posture of the lid and relaxes with time.60
the upper lid fold, and the brow.18,26 This has a favorable Canthopexy is more frequently applied in the setting of aes-
effect on the position of the brow and the upper eye- thetic blepharoplasty and canthoplasty is reserved to cases
lid fold to pretarsal space ratio. The main target areas in where lower lid horizontal shortening is indicated. Several
the upper lid are sulcus both medially and laterally and canthopexy techniques have been described, each differ in
the lateral brow fat compartment (retroorbicularis oculi the lower lid tissue being captured with suture including
fat, ROOF). In lower blepharoplasty, fat grafting the deep tarsus,6 inferior or lateral retinaculum,38,39 or superficial lat-
medial fat compartment improves the anterior cheek pro- eral canthal tendon (Video 2).35 They all, however, anchor
jection and the inverted V defromity, while fat grafting to the periosteal lining of the lateral orbital rim.6,8,11,35,38,39
the lateral and medial SOOF helps improve the lateral Although the term “canthopexy” has also been used to
cheek projection and blend the eyelid cheek junction, describe anchoring the orbicularis to periosteum,8 this
respectively.22,33,34 The main challenge with concomi- maneuver is more in line with orbicularis suspension. To
tant fat grafting and blepharoplasty is trying to perform date there is no consensus on the routine use of lateral
grafting in a plane that has not been violated, in order canthal tightening with lower blepharoplasty, perhaps due
to comply with Coleman’s fat grafting principles.67 This to the fact that blepharoplasty techniques vary in approach,
becomes more challenging when the tear trough and the dissection, and amount of tissue removal. This is further
orbicularis retaining ligaments are released, opening up confounded by publications showing low rate of lower lid
both the medial and lateral SOOF compartments. One malposition with selective68,69 or no canthopexy70 even
possible advantage of subperiosteal dissection is the pres- with skin-muscle flap blepharoplasty. It should be noted
ervation of the preperiosteal plane, where fat grafting can however, that a lateral canthal tightening procedure is
be performed concomitantly. The use of both micro and required in the following situations: (1) a skin-muscle flap
fractionated (fracto) fat grafting have been reported for blepharoplasty; (2) patients with negative vector; and (3)
blending the eyelid junction.18,22 patients with moderate to severe lower lid laxity.
focus on reporting complications and need for revision. exposure, and lymphatic disruption.42,43,74 A recent ana-
Only a few studies utilized some form of objective evalu- tomical study of the periorbital lymphatic drainage by
ation or aesthetic score calculation.14,68,69,71 The FACE-Q Shoukath et al described the presence of a deep lymphatic
eye module has been developed as a patient reported out- drainage system that drains the conjunctiva and passes
come measure but hasn’t been widely adopted yet due to deep to the preseptal orbicularis piercing the orbicularis
its recent introduction.72 Postoperative complications after retaining ligament laterally at its junction with lateral
blepharoplasty include hematoma, asymmetry, lagoph- orbital thickening.75 These findings are suggestive that any
thalmos, lower lid malposition, scleral show, dry eyes, procedures involving deep lateral dissection can theoret-
frank lower lid ectropion, lateral canthal webbing, and ically increase the incidence of chemosis. The incidence
chemosis. The most devastating complication after bleph- of reported postoperative chemosis ranges between 0% to
aroplasty is blindness that can occur as a result of globe 12.1%, with one series reporting an incidence of 34.5%.43
injury, retrobulbar hematoma, and/or fat grafting.46,73 The data from previously published case series suggest
Reported complications and reoperation in the literature higher incidence of chemosis with the skin muscle flap
minimizing exposure.40-43 Support of the lower lid with support: a comprehensive 10-year review. Plast Reconstr
taping during the healing phase and early treatment of Surg. 2008;121(1):241-250.
chemosis are critical especially if symptoms persist longer 7. Rosenfield LK. The pinch blepharoplasty revisited. Plast
than two weeks. Surgical correction of lagophthalmos due Reconstr Surg. 2005;115(5):1405-1412; discussion 1413.
to skin or muscle over resection, and lower lid malposition 8. Massry GG. Comprehensive lower eyelid rejuvenation.
Facial Plast Surg. 2010;26(3):209-221.
should be undertaken when it becomes clear that those
9. Goldberg RA. Transconjunctival orbital fat repositioning:
changes are irreversible. The use of punctal plugs and an transposition of orbital fat pedicles into a subperiosteal
ophthalmology referral can be considered in patients with pocket. Plast Reconstr Surg. 2000;105(2):743-748; discus-
prolonged or refractory symptoms. sion 749.
10. Pacella SJ, Nahai FR, Nahai F. Transconjunctival bleph-
aroplasty for upper and lower eyelids. Plast Reconstr Surg.
CONCLUSION 2010;125(1):384-392.
11. Sullivan PK, Drolet BC. Extended lower lid blepharoplasty
26. Ramil ME. Fat grafting in the hollow upper eyelids and considerations to avoid dry eye syndrome. Plast Reconstr
volumetric upper blepharoplasty. Plast Reconstr Surg. Surg. 2007;119(7):2232-2239.
2017;140(5):889-897. 45. Stern CS, Schreiber JE, Surek CC, et al. Three-dimensional
27. Lambros V. Observations on periorbital and midface topographic surface changes in response to com-
aging. Plast Reconstr Surg. 2007;120(5):1367-1376; discus- partmental volumization of the medial cheek: defin-
sion 1377. ing a malar augmentation zone. Plast Reconstr Surg.
28. Wong CH, Hsieh MK, Mendelson B. The tear trough lig- 2016;137(5):1401-1408.
ament: anatomical basis for the tear trough deformity. 46. Rohrich RJ, Coberly DM, Fagien S, Stuzin JM. Current
Plast Reconstr Surg. 2012;129(6):1392-1402. concepts in aesthetic upper blepharoplasty. Plast Reconstr
29. Wong CH, Mendelson B. Facial soft-tissue spaces and Surg. 2004;113(3):32e-42e.
retaining ligaments of the midcheek: defining the premax- 47. Tepper OM, Steinbrech D, Howell MH, Jelks EB, Jelks
illary space. Plast Reconstr Surg. 2013;132(1):49-56. GW. A retrospective review of patients undergoing lateral
30. Kakizaki H, Malhotra R, Madge SN, Selva D. canthoplasty techniques to manage existing or potential
Lower eyelid anatomy: an update. Ann Plast Surg. lower eyelid malposition: identification of seven key pre-
62. Loeb R. Fat pad sliding and fat grafting for leveling lid 69. Schiller JD. Lysis of the orbicularis retaining ligament
depressions. Clin Plast Surg. 1981;8(4):757-776. and orbicularis oculi insertion: a powerful modality for
63. Yoo DB, Peng GL, Massry GG. Transconjunctival lower lower eyelid and cheek rejuvenation. Plast Reconstr Surg.
blepharoplasty with fat repositioning: a retrospective com- 2012;129(4):692e-700e.
parison of transposing fat to the subperiosteal vs supra- 70. Maffi TR, Chang S, Friedland JA. Traditional lower bleph-
periosteal planes. JAMA Facial Plast Surg. 2013;15(3): aroplasty: is additional support necessary? A 30-year
176-181. review. Plast Reconstr Surg. 2011;128(1):265-273.
64. Hamra ST. The zygorbicular dissection in composite rhy- 71. Rosenberg DB, Lattman J, Shah AR. Prevention of lower
tidectomy: an ideal midface plane. Plast Reconstr Surg. eyelid malposition after blepharoplasty: anatomic and
1998;102(5):1646-1657. technical considerations of the inside-out blepharoplasty.
65. Hamra ST. Repositioning the orbicularis oculi mus- Arch Facial Plast Surg. 2007;9(6):434-438.
cle in the composite rhytidectomy. Plast Reconstr Surg. 72. Klassen AF, Cano SJ, Grotting JC, et al. FACE-Q eye module
1992;90(1):14-22. for measuring patient-reported outcomes following cosmetic
66. Ramanadham SR, Rohrich RJ. Newer understanding of eye treatments. JAMA Facial Plast Surg. 2017;19(1):7-14.