Extended Blepharoplasty
Peter A. Adamson, MD, CCFP, FRCSC; Guy J. Tropper, MD, FRCSC; Becky L. McGraw,
\s=b\ Extended blepharoplasty involves ex-
tending the dissection of the skin-muscle
flap used in standard lower eyelid bleph-
aroplasty to a level below the infraorbital
rim. This technique is useful in the man-
agement of infraorbital, or malar, bags
that are seen in as many as 10% of bleph-
aroplasty candidates. A concomitant eye-
lid shortening procedure is frequently
needed to treat horizontal eyelid laxity.
Achievement of satisfactory results de-
pends on the proper suspension of the
skin-muscle flap to the lateral canthal
periosteum. Extended blepharoplasty is
an innovative way to improve infraorbital
pouching, which is otherwise beyond the
reach of the standard blepharoplasty pro-
cedure.
(Arch Otolaryngol Head Neck Surg.
1991;117:606-609)
Lowerchallenging
I
eyelid blepharoplasty
procedure
the experienced surgeon. In the stan¬
can
even
be a
for
dard lower eyelid blepharoplasty,
judgment and experience guide the
surgeon with respect to the extent of
skin and fat excision. The potential for
postoperative eyelid malposition or ec¬
tropion imposes conservatism on the
part of the surgeon. However, some
Accepted for publication September 14,1990.
From the Department of Otolaryngology\p=n-\Head
and Neck Surgery, University of Toronto (Ontar-
io).
Presented in part at the American Academy of
Facial Plastic and Reconstructive Surgery East-
ern Section, Toronto, Ontario, January 26, 1989.
Reprint requests to PO Box 47, Suite 2707, To-
ronto Dominion Bank Tower, Toronto Dominion
Centre, Toronto, Ontario, Canada M5K 1B7 (Dr
Adamson).
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MD
patients, particularly the elderly or
male patient, have large infraorbital
pouches and marked skin redundancy
with lax skin tone. Because the euphe¬
mism, "The lid cannot hold up the
cheek," holds true, the standard con¬
servative approach to lower eyelid
blepharoplasty is inadequate for man¬
agement of these patients. The ex¬
tended blepharoplasty procedure is a
modification of lower eyelid blepharo¬
plasty that enables the surgeon to cor¬
rect infraorbital pouches and excessive
skin redundancy.
Other authors have recognized this
problem and proposed treatment meth¬
ods.1 Furnas2 described festoons of the
orbicularis oculi as an occasional cause
of baggy eyelids, and categorized them
into preseptal, orbital, and jugal. To
correct such festoons, he advocated the
use of a suture suspending the myo¬
cutaneous flap of the lower eyelid to
the periosteum of the lateral canthus.
However, he limited the dissection of
the flap to the level of the infraorbital
rim. Consequently, any correction im¬
posed on the "jugal festoons" was an
indirect effect. Castañares3 proposed a
direct excision of the festoons, leaving
a facial scar, or a facial rhytidectomy
to make them less apparent.
Small,4 in 1981, first described the
extended blepharoplasty. This in¬
volved dissection of the lower eyelid
myocutaneous flap beyond the level of
the infraorbital rim and onto the an¬
terior maxilla, in order to correct large
cheek festoons. This present commu-
nication outlines our technique of ex¬
tended blepharoplasty, and stresses
the advantages it offers to select pa¬
tients without a significant increase in
morbidity.
Our use of the technique has been
directed toward elimination of blepha-
rochalasis extending beyond the in¬
fraorbital rim. While the extended
blepharoplasty procedure may be per¬
formed alone, it is usually combined
with an upper eyelid blepharoplasty.
In this case, the upper eyelid bleph¬
aroplasty is carried out first. Extended
blepharoplasty directly approaches
extensive blepharochalasis and ble-
pharoptosis, which standard lower
eyelid blepharoplasty does not ad¬
dress. Other indications for the use of
this technique include: orbital recon¬
struction with strengthening of the
lower eyelid to support a prosthesis;
lower eyelid reconstruction, particu¬
larly in cases of postoperative or post-
traumatic lower eyelid retraction; cor¬
rection of scierai show in selected cases
of thyroid ophthalmopathy; and recon¬
struction of the zygoma.4
Contraindications for extended
blepharoplasty are the same as for the
standard blepharoplasty technique.
These may be classified into general
and ophthalmological. General con¬
traindications include unrealistic pa¬
tient expectations, bleeding diatheses,
diabetes, smoking, or other medical
conditions making elective surgery in¬
advisable. Ophthalmologic contraindi¬
cations include monocular vision and
unstable thyroid ophthalmopathy.
Any suspicion of thyroid dysfunction
calls for a thorough endocrinologie
evaluation. The presence of xe-
rophthalmia or proptosis should sug¬
gest additional caution. Scierai show-
should prompt the surgeon to search
for a history of previous trauma or
surgery to the eyelid. The structure
responsible for eyelid retraction
should be established, and this should
be addressed during surgery.
Fig 1.—Extended blepharoplasty incision (sol¬
id line). It is longer and slightly higher than the
MATERIALS AND METHODS
standard blepharoplasty incision (dashed line).
Preoperative Assessment
Preoperative assessment is similar to
that for standard blepharoplasty.5 In addi¬ Fig 2.—Extent of undermining for extended
tion, the surgeon should delineate the ex¬ blepharoplasty, into the lateral canthal area,
tent of infraorbital pouching below the below the infraorbital rim, and over the zygoma.
The short dashed line indicates the infraorbital
level of infraorbital rim. This pouching may
rim.
take the form of a single fold of edematous
skin assuming a dependent position below
the rim, or may appear as a second set of
pouching, separate from the fatty palpebrai
pouches, and extending inferolaterally over
the zygoma. The quality of the skin, skin
rhytids, and the amount of fat prolapsing
from the various compartments is esti¬
mated. "Squinching" of the eyes delineates
the orbicularis oculi and its degree of
prominence.2 Scierai show, lagophthalmos, Fig 3.—Estimation of the redundant portion of
and eyelid tone must be noted and dealt the lateral skin-muscle flap and its excision.
with during surgery. A Schirmer's test is
performed on all patients. Each patient is
also referred for assessment by an ophthal¬ At the lateral aspect of the incision,
mologist, and preoperative photographic sharp scissors are used to spread the fibers
documentation is obtained. of the orbicularis oculi muscle. With the
assistant exerting firm downward traction
Operative Technique on the skin of the cheek, a plane is easily
The procedure may be performed under dissected between the orbicularis oculi and
local anesthesia with intravenous sedation, the subjacent orbital septum. Blunt dissec¬
or under general anesthesia if combined tion of this avascular plane creates a com¬
with other procedures. We routinely ad¬ posite musculocutaneous flap anteriorly. Fig 4.—Orbicularis suspension suture an¬
chored to the lateral canthal periosteum. The
minister methylprednisolone (120 mg) and Undermining is continued inferiorly into dashed line indicates the infraorbital rim.
cefazoline (1 g) intravenously at the begin¬ the infraorbital region anterior to the zy¬
ning of the procedure. Lidocaine (Xylocaine goma, 1.0 to 2.0 cm below the orbital rim as
1% ) with epinephrine (1:100 000) is used for needed, as well as laterally into the lateral aging the vessels found medially in the
infiltrative anesthesia. A delay of 6 to 7 canthal region (Fig 2). This facilitates later vicinity of the fat pad. The inferior oblique
minutes is expected to allow adequate vas¬ redrapage of the flap and tension-free is seen between the medial and central fat
oconstriction to develop. wound closure. The blunt dissection mini¬ pad, and must be respected. Scissor excision
After the upper eyelid blepharoplasty mizes trauma to the blood supply of the flap of fat is limited to that projecting above the
procedure, the lower eyelid is approached. and decreases the risk of damaging the in¬ level of the orbital rim and is preceded by
Incision of the skin is started at a point just fraorbital nerve. After the undermining is injection of the base of the fat globule with
lateral to the inferior punctum 2 to 2.5 mm complete, the musculocutaneous flap is ele¬ local anesthetic, followed by bipolar elec-
below the lash line. It is then carried later¬ vated by incising the orbicularis oculi su¬ trocautery. Absolute hemostasis is secured
ally up to the level of the lateral canthus, periorly along the subciliary incision. with bipolar electrocautery.
which is higher than that generally reached While retractors hold the flap inferiorly, Laxity of the eyelid is frequently present,
in the standard blepharoplasty procedure. additional exposure of the fat pads is gained particularly in this category of patient.
From there, the incision is extended hori¬ by drawing the lower eyelid superiorly with Horizontal laxity is assessed with the pinch
zontally in a lateral direction over 12 to 15 a temporary tarsal suture. Excision of a test, in which the eyelid is distracted from
mm, preferably along a preexisting rhytid. small strip of orbital septum provides ac¬ the globe and released. The degree of dis¬
This incision is approximately 3- to 4-mm cess to the protuberant fat. The fat is gen¬ traction and the ability of the eyelid to snap
longer than is generally used for standard tly teased from the surrounding tissue us¬ back into place are determined. Mild de¬
blepharoplasty (Fig 1). ing blunt dissection. One should avoid dam- grees of laxity may be adequately managed

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 Fig 5.—A 44-year-old man with infraorbital pouching. Top left, Preoperative anteroposterior view. Top right,
Preoperative right lateral view. Bottom left, One-year postoperative anteroposterior view. The procedure in¬
volved elevation of the flap 2 cm beyond the infraorbital rim, 6-mm horizontal eyelid shortening, and 8-mm
lateral skin excision. Bottom right, Postoperative right lateral view.

with the orbicularis suspension procedure
described below. More severe degrees of
laxity are treated with a lateral cantho-
plasty." Extreme cases of laxity may re¬
quire a horizontal eyelid resection, such as
the modified Bick procedure laterally, or
the Kuhnt-Szymanowski pentagonal wedge
excision at the lateral limbus. The eyelid
margin is reapproximated with 6-0 silk
everting sutures on the skin starting from
the gray line, while 5-0 polyglactin (Vicryl)
sutures are used to reestablish continuity of
the tarsal plate and pretarsal strip of the
orbicularis oculi.
Redrapage of the lower eyelid musculo¬
cutaneous flap is accomplished in a supero-
lateral direction. The patient is instructed
to adopt a neutral gaze. Gentle distraction
on the cheek is used to simulate the effect of
gravity when the patient resumes an up¬
right position. Care must be taken to avoid
inferior displacement of the lower eyelid
margin during this maneuver. Scierai show
is unacceptable at this point, and an 0.5-mm
overlap of the lower eyelid on the limbus is
preferred. Once estimation of the redun¬
dancy of the flap is confirmed, the excess
skin and muscle is trimmed laterally (Fig
3). Undermining of the skin around the lat¬
eral canthal part of the incision and flap
will allow better redrapage of the skin and
avoid standing tissue cones (dog-ears) on
skin closure.
Proper suspension of the flap is the most
important step of the procedure. A perma¬
nent horizontal mattress suture (4-0 Mer-
silene) is placed in the orbicularis oculi and
the deeper dermis of the edge of the muscu¬
locutaneous flap, and then sutured to the
periosteum of the inner aspect of the lateral
canthal area (Fig 4). Two such suspension
sutures are placed to elevate the flap supe-
rolaterally in order to remove all tension
from the infraciliary skin suture line. The
rest of the orbicularis muscle is approxi¬
mated laterally with inverted 4-0 poly¬
glactin (Vicryl) sutures. Interrupted, evert¬
ing 6-0 silk sutures maintain the under¬
mined skin edges together. The redundant
medial part of the flap is then trimmed and
the wound is closed with simple 6-0 silk su¬
tures.
Postoperative care consists of head ele¬
vation and continuous application of ice-
cold wet compresses for at least 24 hours.
Generous use of ophthalmic drops during
the day and ointment during the night ad¬
equately protects the cornea and conjunc¬
tiva. Patients are instructed to apply topi¬
cal antibiotic ointment to the wounds two to
three times a day, until the sutures are re¬
moved on the fourth postoperative day. The
horizontal eyelid resection sutures (Bick or
Kuhnt-Szymanowski) are left in place for a
total of 7 days.
RESULTS
The senior author (P.A.A.) has used
the extended blepharoplasty tech¬
nique for 3 years. The experience and
long-term results obtained from seven
cases have been encouraging and sug¬
gest further application of the tech¬
nique. Approximately 10% of the pa-

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 tients presenting for blepharoplasty
may be candidates for this technique.
All of the patients in our series who
qualified for the extended approach
were men. Their ages ranged from 44
to 61 years, with an average age of 54
years.
In all patients, severe lower eyelid
pouching extended below the infraor¬
bital rim. The extended technique was
applied without causing a significant
increase in operative time. This lower
eyelid myocutaneous flap was elevated
as much as 2 cm below the infraorbital
rim in three patients and 1 cm or more
in the others. On the average, 7 mm of
redundant skin was excised from the
lateral aspect of the flap. This is more
than the average of 2.5 mm that we re¬
move laterally in the standard bleph¬
aroplasty procedure.6 More aggressive
myocutaneous flap elevation was per¬
formed in the later cases, as more con¬
fidence in the orbicularis suspension
suture was obtained. Horizontal eyelid
shortening was performed in every in¬
stance, removing an average of 4.9 mm.
Follow-up ranged from 6 to 15
months. Chemosis seemed more prev¬
alent than in standard cases, but re¬
solved in all patients within 2 to 6 days.
Some degree of minor dimpling may
occur if the suspension stitch is placed
too superficially in the dermis. This
1. Gonzalez-Ulloa M, Stevens E. The treatment
of palpebral bags. Plast Reconstr Surg. 1961;
27:381-396.
2. Furnas DW. Festoons of orbicularis muscle
as a cause of baggy eyelids. Plast Reconstr Surg.
1978;61:540-546.
3. Castanares S. A comparison of blepharo-
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can be corrected by skin undermining
during the surgery and with massage
postoperatively. One patient present¬
ing with scierai show preoperatively
had persistent show postoperatively.
The patient was asymptomatic and
pleased with the result. All patients
were very satisfied with the improve¬
ment achieved. No patient suffered fa¬
cial hypesthesia in the infraorbital
nerve distribution. None of the pa¬
tients in this group suffered from dry
eye symptoms preoperatively or post¬
operatively. Figure 5 illustrates a rep¬
resentative case.
COMMENT
Extended blepharoplasty utilizes
wider undermining of the standard
blepharoplasty musculocutaneous flap
in the region of the upper cheek and
zygoma. Redrapage of this larger flap
allows elimination of, or at least im¬
provement in, the infraorbital pouches
that cannot be addressed with stan¬
dard blepharoplasty techniques. This
redrapage often provides some lift and
smoothing of skin in the mid-cheek re¬
gion, but should not be promoted as a
substitute for facial rhytidectomy. The
patient should not be led to anticipate
significant improvement in the melo-
labial fold, even though minor im¬
provements may be noted.
References
plasty techniques. In: Masters F, Lewis JR, eds.
Symposium on Aesthetic Surgery of the Face,
Eyelids, and Breast. St Louis, Mo: CV Mosby Co;
1972.
4. Small RG. Extended lower lid blepharoplas-
ty. Arch Ophthalmol. 1981;99:1402-1405.
5. Holt JE, Holt GR. Blepharoplasty indica-
Although relatively easy to describe
and perform, extended blepharoplasty
calls for cautious and judicious appli¬
cation. The larger myocutaneous flap
and skin excision, especially in older
patients, constitutes a significant risk
for postoperative scierai show and dry
eye syndrome. Hence, great emphasis
needs to be placed on the use of nonre-
sorbable suspension sutures to secure
the flaps to the lateral canthal perios¬
teum.
Extended blepharoplasty is an inno¬
vative way to address edematous
"bags" of skin or festoons of orbicu¬
laris oculi muscle extending below the
infraorbital rim. It represents a valu¬
able modification of the standard
blepharoplasty procedure, and pro¬
vides a significant improvement of in¬
fraorbital pouching not otherwise
available. Our experience has provided
us with good results and justifies its
continued use.
Suggested readings include the following:
1. Small RG. Extended lower lid blepharoplas¬
ty. Arch Ophthalmol. 1981;99:1402-1405. (The clas¬
sic description of extended blepharoplasty.)
2. Holt JE, Holt GR. Blepharoplasty indica¬
tions and preoperative assessment. Arch Oto¬
laryngol. 1985;111:394-397. (A review of the anat¬
omy, pathology, and indications for blepharoplas¬
ty, as well as a discussion of the complete
preoperative evaluation for blepharoplasty.)
tions and preoperative assessment. Arch Oto-
laryngol. 1985;111:394-397.
6. McGraw BL, Adamson PA. Post-blepharo-
plasty ectropion: prevention and management.
Presented at the Spring Meeting of the American
Academy of Facial Plastic and Reconstructive
Surgery, Palm Beach, Fla, May 4, 1990.