A graded approach in East Asian personalized lower blepharoplasty: A retrospective study spanning 12 years

Purpose: The aim of the study was to describe a graded approach for assessment and specific treatment, which can achieve satisfactory postoperative result in East Asian personalized lower blepharoplasty. Methods: We reviewed 913 patients who underwent lower blepharoplasty from 2008 to 2020. We preoperatively classified patients with different characteristics to provide personalized treatment. Results: There were 163 patients with fat herniation but no lower eyelid skin laxity, 259 patients with lower eyelid skin laxity accompanied by mild fat herniation, 313 patients with sagging lower eyelid skin accompanied by mild fat herniation and tear troughs, and a total of 178 patients with sagging skin accompanied by moderate to severe fat herniation and tear troughs. The overall success rate was 97.81%. Postoperative complications included the following: conjunctival chemosis, dry eye symptoms, and more. Conclusion: For East Asian patients with different characteristics, we achieved satisfactory postoperative results through accurate preoperative clinical grading and personalized surgical plans. The success of the operation not only depends on correct manipulation during the procedure but also on the surgeon’s accurate assessment and full grasp of the anatomy of each patient preoperatively.

Changes in Lower Eyelid Positions after Individualized Lower Blepharoplasty

PURPOSE: Various forms and degrees of morphological changes in the lower eyelid are presented in this study. A comprehensive, individualized clinical approach based on sound anatomical principles and lower lid stability is needed. We evaluated morphological outcomes of lower blepharoplasty by measuring lower eyelid position. METHODS: One hundred sixty-eight eyes underwent lower blepharoplasty between August 2009 and August 2014. The mean patient age was 62.1 +/- 13 years and mean follow-up period was 6.0 +/- 10.2 months. Lower eyelid position of 84 consecutive primary lower blepharoplasty patients (52 females and 32 males) was analyzed using digital images and measured with standardized data points using the Image J Program. RESULTS: Of the 168 individualized lower eyelid blepharoplasties analyzed, margin reflex distance 2 (MRD2) decreased from 5.4 +/- 1.1 mm to 4.9 +/- 0.8 mm (p = 0.005) and marginal nose distance (MND) increased from 59.2 +/- 18.3 mm to 61.9 +/- 17.6 mm (p < 0.001). Complications after lower blepharoplasty were not observed. CONCLUSIONS: The position of the lower eyelid improved after individualized lower blepharoplasty that addressed all the anatomical lower eyelid findings was performed.

Efficacy of Lateral Canthoplasty Combined with Transconjuctival Lower Blepharoplasty in Young Asian Patients

BACKGROUND: The lower eyelid bag associated with an old and tired appearance is not a rare aesthetic problem in young Asian people who have short palpebral fissures and an up-slanting appearance. Many patients want to make their eyes larger, brighter and more youthful at the same time. The purpose of the current study was to determine the feasibility of lateral canthoplasty combined with transconjunctival lower blepharoplasty in minimizing complications and maximizing aesthetic results. METHODS: From June 2011 to May 2014, 59 patients underwent inferior orbital fat removal and orbital septal resets through transconjunctival approaches and lateral canthoplasty. Simple inferolateral canthotomy incisions were used to provide a sufficient operative field for manipulation of the orbital septum, to lengthen the horizontal palpebral fissures and to lower the lateral canthal angle. Patients were evaluated to identify the presence of postoperative complications and to assess the need for additional operations. RESULTS: Most of the patients were satisfied with the aesthetic results during the 2-12-month postoperative follow-up period. There were no recurrences of lower eyelid bulging, postoperative asymmetry, or wound-related complications. Three cases of entropion and two cases of roundness of the lateral canthal angle occurred following the primary operation. However, there were no further complications after secondary operations to correct the tarsal-periosteal fixation position. CONCLUSIONS: Lateral canthoplasty combined with transconjunctival lower blepharoplasty using simple lateral canthotomy is a safe and effective method for maximizing aesthetic results in young Asian patients.

Comprehensive treatment for mid-inferior facial rejuvenation / 中华医学美学美容杂志

Objective To summarize the experience of the integrated treatment on mid-face ageing for better cosmetic results.Methods A total of 56 cases were treated.With using subciliary approaches,the orbicularis oculi was resected to expose the orbital septum,the orbital fat relieved and orbital septum reseted.Hyaluronic acid was injected to some patients with obvious nasolabial fold after operation.Results 56 cases were all followed up from 6 to 26 months (11.8 months on average) postoperatively.The flabby tissue had been tightened and all got better effects.Conclusions Various combination of technologies can be applied to reach the purpose of rejuvenation by correcting the volume abnormality,resetting the tissue,elevating reasonably,and filling the facial depression.

Lower Blepharoplasty: In and Out Complementary Technique

PURPOSE: Traditional transcutaneous incision and transconjunctival incision methods are commonly used in the lower blepharoplasty. The transconjunctival method leaves no visible scars nor does it change the shape of lower eyelid contour and the surgical technique is not difficult. However removal of excess baggy skin is not possible through this method. Therefore, the transconjunctival incision method is useful only for patients who still have normal elasticity of the lower eyelids and fat that is protruding only anterocaudally. The Author will introduce a technique, which complements the limitations of these two methods mentioned above. METHODS: The author combined the transconjunctival approach and lower blepharoplasty with only the excised skin flap method. This method does not go beyond the previous methods but does apply the advantages of them. RESULTS: From March 2007 to October 2010, this new technique was performed in a total of 62 patients. Fat was removed and repositioned through transconjunctival incision. Drooped skin was excised as in the traditional blepharoplasty but only the skin flap was elevated. This prevents post-operative complications such as ectropion, sclera show, and deformation of the shape of the lower eyelids or under-resection of fat. All patients were satisfied with the post-operative appearance. CONCLUSION: The author was able to get satisfactory results while avoiding complications of traditional transcutaneous technique with this combined technique of the transconjunctival approach and the lower blepharoplasty method of skin flaps only.

Application of ultra-pulse CO2 laser in blepharoplasty / 中华医学美学美容杂志

Objective To explore the applied values of ultra-pulse CO2 laser in blepharoplasty by shortening procedure time, improving the surgical satisfactory result and alleviating the operative and postoperative hemorrhage. Methods 238 patients with bulging, redundant skin in the upper and lower eye lids, including brow lift (26 cases), double eye lid surgery (48 cases), and lower lash line incision (159 cases). Laser incision was implemented with the ultra-pulse CO2 laser system. Results Bleeding was scant in 238 cases and hence local swelling subsided quickly with excellent healing. No eetropion, he-matoma and diplopia ever occurred. 3 months to 3 years follow-up showed satisfactory for all the patients. The result was quite satisfied in clinical observation and postoperative follow-up. Conclusion Utilizing the ultra-pulse CO2 laser in blepharoplasty has confirmed the satifisfatory surgical results, decreasing the surgical time, and reducing the intraoperative and postoperative bleeding.

The Classification of Aging Lower Eyelid and Selection of the Operation Options in Asians

PURPOSE: It is generally accepted that anatomical structures of the soft tissue in Asian faces are quite different from those in Caucasian. It is presumed that these differences are due to collagen rich thick dermis and durable superficial musculo-apponeurotic system (SMAS) in Asian. We classified the aging lower eyelids and reviewed the operative procedures according to the types of aging lower eyelids in Asian. METHODS: We compared preoperative and postoperative photos of 117 patients over 30 years of age, who underwent lower blepharoplasty at the Kyunghee Medical Center from January 2001 to April 2006. We classified the patients based on the degree of skin laxity, presence of nasojugal groove and malar bag, the extent of aging process. We also reviewed the operative procedures according to each type of classification. RESULTS: We classified our patients into four types as following. Type I patients showed minimal skin-muscle excess confined to lower eyelids regardless of the facial line. For these patients, we performed only transcutaneous or transconjunctival blepharoplasty. In type II patients, nasojugal grooves were shown and skin- muscle laxity was limited to the medial side of imaginary vertical line at lateral margin of pupil. In these cases, we performed free fat graft or fat repositioning on nasojugal groove or fat removal and septal duplication confined to medial side. Type III patients displayed more advanced medial bulging and remarkable laxity over the lateral side, the same operation methods as those of type II were applied at the lateral side of the line. Type IV patients demonstrated extensive midfacial aging changes including malar bags and underwent superficial subciliary cheek lift. CONCLUSION: The lower eyelid aging of Asian is different from those of Caucasian. We think that our classification is useful in selection of appropriate operative procedure to address specific problems for Asian patients.

Lower Blepharoplasty by Repositioning of Orbital Fat

Palpebral bag of the lower eyelid & tear trough groove is regarded as a sign of aging. This is mainly caused by weakening of the orbital septum, atrophy of the orbicularis oculi muscle and slackness of the skin. This palpebral bag is usually combined with a depression along the inferior orbital rim which is called a tear trough groove. In the past, the surgical excision of the fat pad has been the mainstay of the management of lower palpebral bag in cosmetic blepharoplasty. But, excision of the protruded orbital fat as a treatment for palpebral bag may contribute in long term to the senile enophthalmos due to a volume reduction of the intraorbital adipose tissue. Recently, fat pad sliding method with septal incision has been performed for preservation of orbital fat. This technique, however, causes problems such as lid ecchymosis, chemosis, lid contour irregularity, ectropion, and retrobulbar hematoma formation. The authors propose to restore the functional integrity of orbital septum. Attenuated orbital septum with orbital fat was stretched and transposed to cover the bony framework. The orbital septum with orbital fat meticulously sutured to the periosteum of inferior orbital rim with 5-0 nylon. This technique of septal draping over the inferior orbital rim was performed in 54 consecutive individuals(108 lower eyelids) for 27 months period. The overall results obtained, with the exception of mild degree of puffiness encountered soon after the surgery, were satisfactory and morbidity was minimal.

Superficial Subciliary Cheek Lift for Rejuvenating Infraorbital Region and Orbitomalar Groove

PURPOSE: Aging changes of midface include drooping of lower lid, wrinkles of malar area, orbitomalar groove and deepening of nasolabial fold from drooping of malar fat pad. Improvement of lower lid can be achieved through lower blepharoplasty, but improvement of cheek can not be gained. Superficial subciliary cheek lift(by Moelleken, 1996) is a method that lifts malar fat pad through extended subciliary incision. We obtained simultaneous improvement of lower lid, malar wrinkles and orbitomalar groove with modification of this technique. METHODS: From December 2003 to January 2006, we performed this method on 21 patients among volunteers for lower blepharoplasty who wanted to correct orbitomalar groove and malar wrinkles. Under local anesthesia, lateral extension of subciliary incision is done 1cm from the lateral orbital rim. Skin-muscle flap is elevated, and dealing of orbital fat and septum is the same as with ordinary lower blepharoplasty. After downward subcutaneous dissection through extended incision, exposing the upper 1/3 level of malar fat pad, superolateral fixation is done to superior deep temporal fascia. Excision of the upper part of fat pad is performed, if needed. After excision of overlapped skin-muscle flap, skin closure is done. RESULTS: We obtained satisfactory results with this simple method for improvement of orbitomalar groove and malar wrinkles among patients for lower blepharoplasty. During a follow-up period of 5 months on the average, no revision was performed. CONCLUSION: Under local anesthesia, lower blepharoplasty and improvement of orbitomalar groove and malar wrinkles can be achieved at the same time. It is good for patients who do not want conventional midface- lifting. But surgeons should select patients and perform cautiously for it may leave a scar of the extended incision that require over 2 months for maturation and it is insufficient for improvement of nasolabial fold compared to conventional mid face-lifts.

The Effect of Transconjunctival Lower Blepharoplasty Combined with Pinch Skin Excision Technique

PURPOSE: The aim of this study was to analyze the effects of transconjunctival lower blepharoplasty combined with the pinch skin excision technique. METHODS: This study followed 15 patients over a six-month period who had undergone transconjunctival lower blepharoplasty combined with the pinch skin excision technique. The follow-up period exceeded 6 months. After subconjunctival injection of local anesthetic, incisions of the conjunctiva and lower lid retractors were made. The exposed fat pads were excised by clamping, excising, and cauterizing the base of the pad. The conjunctiva was closed with a continuous 6-0 Vicryl suture. If there was mild skin excess, a pinch skin excision technique was used. RESULTS: There were no complications (i.e., lower eyelid retraction, ectropion, etc.). All 15 patients were satisfied with the final result. CONCLUSIONS: The transconjunctival lower blepharoplasty combined with the pinch skin excision technique in middle-aged patients with prominent lower eyelid fat and skin excess had lower complication rates and higher patient satisfaction than the transcutaneous approach.

Dual Plane Method with Orbital Fat Repositioning in Lower Blepharoplasty

Blepharoplasty is a commonly performed aesthetic surgery, but there is still no commonly used standard method for the correction of orbital fat bulging in lower blepharoplasty. We performed dual plane method by elevating skin flap and muscle flap separately, and then repositioned orbital fat with preserving orbital septum for correction of orbital fat bulging in lower blepharoplasty. Between July, 1998 and June, 2005, one hundred and fifty six patients underwent lower blepharoplasty by author's method. The results were satisfactory in all of the patients. Complications were six cases of hematoma and ten cases of visible scar in lateral canthal area. There was no skin flap necrosis, hyperpigmentation, skin irregularity or ectropion. In lower blepharoplasty for the sufficient excision of skin and operation of orbicularis oculi, we performed precise correction of skin and muscle independently by dual plane approach, by separate elevation of skin flap and muscle flap, and were able to reposition orbital fat easily and safely with preservation of orbital septum.

Correction of the Tear Trough Using Orbital Fat Graft from the Lower Lid

Lower palpebral bags and tear trough grooves are the common signs of aging. Weakness of the orbital septum, atrophy of the orbicularis oculi muscle, slackness and laxity of the lower lid skin are the main causes of these aging changes. Tear trough groove with skeletonization of the lower orbital rim can not be corrected easily by the conventional lower blepharoplasty, but the augmentation of the volume, can be an effective method. Lower lids provide a well vascularized recipient site, which is vital for proper grafting of fat to occur. We treated tear trough groove with free fat graft of surgically removed orbital fat. Surgical excision of the fat pad and septal reinforcement with free fat graft below the levator labii superioris alaeque nasi muscle were performed to correct tear trough groove. This technique was performed in 29 consecutive individuals from October, 2001 to January, 2005. Palpebral bags and tear trough groove were corrected concomitantly and obtained a youthful attractive midface with no secondary hollowness of lower lid and irregularity. The overall results obtained were satisfactory without any complications. Recurrence of tear trough deformity due to grafted fat absorption was not noted during the 7 months of the follow-up period. The authors conclude that the procedure is safe and effective in selected patients.

The Effect of Upper and Lower Lid Blepharoplasty for Patients with Corneal Problems due to Medial Upper and Lower Eyelash

PURPOSE: Epicanthal folds and epiblepharon which often develop in oriental children are congenital anomalies of eyelids. These may need surgical correction because corneal irritation may develop by medial upper and lower eyelash besides cosmetic problems. V-Y plasty and Mustarde's method are standards for correction of epicanthal folds, but not usually performed because of cosmetic scar formation. METHODS: This study included 26 patients, 52 eyes (19 females, 38 eyes; 7 males, 14 eyes) with corneal irritation due to medial upper and lower eyelash. We performed upper and lower lid blepharoplasty simultaneously and analyzed their results and complications through medical records. RESULTS: Epiblepharon associated with epicanthus tarsalis was found in 22 patients, 22 eyes, epicanthus palpebralis in 4 patients, 8 eyes. At the time of surgery mean age was 7 years old (3.7~10.3 years old). During the follow-up more than 6 months, double fold asymmetry was found in 1 patient, double fold loosening in 1 patient, 2 eyes, lower eyelid undercorrection in 2 patients, 3 eyes. CONCLUSIONS: These findings suggest that simultaneous upper and lower lid blepharoplasty for patients with corneal problems due to medial upper and lower eyelash is more unsatisfactory in the cosmetic result than standard method, but has advantage of less scarring, and thought to be a good method to relieve corneal irritation.

Fat Preservation Lower Blepharoplasty: Septal Draping Over Inferior Orbital Rim

Although the surgical excision of the fat pad has been the mainstay of the management of lower palpebral bulge in cosmetic blepharoplasty, procedures that depend on fat removal may render the patient deficient of fat, with the appearance of a hollow orbit. The concept of fat conservation during lower blepharoplasty has been developed by several authors in recent years. Attenuated orbital septum was released along the arcus marginalis and transposed to cover the bony framework. The orbital septum meticulously sutured to the pre-periosteal soft tissue with 5-0 polyglactin. This technique of septal draping over the inferior orbital rim was performed in 30 consecutive individuals (60 lower eyelids) for an year period. The overall results obtained were satisfactory and morbidity was minimal.