2000 prevention of lid retraction in lower lid blepharoplasties. an overview. jcmfs

Journal of Cranio-Maxillofacial Surgery (2000) 28, 189–200

# 2000 European Association for Cranio-Maxillofacial Surgery

doi:10.1054/jcms.2000.0143, available online at http://www.idealibrary.com on

Prevention of lid retraction after lower lid blepharoplasties: an overview

Maurice Y. Mommaerts, Giacomo De Riu

Division of Maxillo-Facial Surgery, GH St John, Bruges, Belgium and Divisione di ChirurgiaMaxillo-Facciale, Ospedale Maggiore, Parma, Italy

SUMMARY. This overview article covers the techniques that aim to prevent lid retraction after lowerblepharoplasties. After a brief review of applied anatomy (anterior, middle, posterior lamella), the causes ofblepharochalasis and of postoperative lid retraction are addressed. Clinical examinations are described that candetect a candidate at risk.

Preventive measures are described, dealing with patient positioning, approaches (transcutaneous–transconjunc-tival–combination of both), incision types, flap dissection (skin–skin-muscle–dermal flaps), muscle suspensiontechniques (muscle–muscle, muscle–periosteum), horizontal wedge excisions, lateral (tendon and tarsal) and medialcanthal procedures, CO2 laser skin resurfacing and combinations. These techniques are described and criticallyappraised. # 2000 European Association for Cranio-Maxillofacial Surgery

INTRODUCTION

The surgeon faces a constant dilemma of resectingjust sufficient skin, muscle and fat to produce thedesired elimination of lower blepharochalasis, and

Fig. 1 – Six weeks after bilateral lower blepharoplasty: cicatricial ectroppositioned vertically, away from the tear lake (A and B) because of sdownward gaze, as the lower lid retractors counterbalanced the tractiowith taping therapy.

Dedicated to Mr Peter Banks on the occasion of his retirement, East

189

not too much to produce lid retraction. This dilemmacan only be resolved with experience. Temporary lidretraction is an annoyance (Fig. 1) but definitive lidmalposition is a functional and aesthetic disaster.Judicious use of support techniques is mandatory.

ion of the left lower eyelid, and tear pooling because the punctum iscar retraction in the orbital septum. Ectropion disappeared uponn of the middle lamella (B and C). The problem resolved completely

Grinstead, August 1999.

190 Journal of Cranio-Maxillofacial Surgery

This article reviews the techniques described toprevent lower lid retraction.

APPLIED ANATOMY

The lower eyelid consists of two lamellae (Fig. 2). Theanterior lamella consists of skin and orbicularismuscle. The posterior lamella consists of the tarsalplate and attached orbital septum, the capsulopal-pebral fascia, the inferior tarsal muscle (analogous toMuller’s muscle of the upper eyelid) and theconjunctiva.

The orbital septum and tarsal plate are sometimesreferred to as ‘the middle lamella’. The orbitalseptum, the capsulopalpebral fascia and the inferiortarsal muscle fuse 5mm below the inferior tarsalborder and firmly attach to the anterior, inferior andposterior base of the tarsus. These three layers arecommonly called ‘the lower lid retractors’. Thecapsulopalpebral head of the inferior rectus muscleis a fibro-elastic structure, similar to the levatoraponeurosis, and functions only in downward gaze.

The pretarsal fibres of the orbicularis oculi muscleattach to the medial canthal ligament and formseveral insertions that pass on each side of thelacrimal sac and attach to both sides of thecanaliculus (Fig. 3). These fibres provide a pumpingmechanism for clearence of tears. The preseptal fibresmake a tendon (some call it a ligament, or apseudoraphe) laterally. Medially the upper preseptalmuscle inserts onto bone on either side of the lacrimalsac. The lower preseptal fibres insert onto thelacrimal diaphragm.

CAUSE OF BLEPHAROCHALASIS

Realisation of the progressive aesthetic change withageing is the main indication for blepharoplasty(Fig. 4). Loss of elastic fibres and changes in collagen

Fig. 2 – Anatomy of the lower eyelid. The anterior lamella consistsof skin and orbicularis muscle. The posterior lamella consists oftarsus, ‘lower lid retractors’ and conjunctiva. Sometimes septumand tarsal plate are referred to as the middle lamella.

composition with age contribute to skin laxity and lidptosis. Infra-orbital wrinkles are partly caused byexcessive sun exposure. Facial movements andmuscular habits may account for ‘crow’s feet’. Theorbicularis muscle becomes hypotonic, distendsand descends. The pretarsal hypertrophy of youthflattens. The orbital septum and Lockwood’s liga-ment (or inferior transverse suspensory ligament;Lockwood, 1886) weaken. This allows protrusion ofthe globe with secondary protrusion of the anteriorfat. The lateral canthal tendon may elongate withageing, allowing the lateral canthus to descend, whichproduces a sad appearance.

The lateral canthal tendon and the orbicularismuscle are of primary importance in the support ofthe lower eyelid. The problem of horizontal lid laxitydoes not reside in tarsal plate lengthening but in theweakening of the lateral canthal tendon (Ousterhoutand Weil, 1982; Hill, 1975), generally not of themedial canthal tendon (Shore, 1985; Ousterhout andWeil, 1982; Hill, 1975; Doxanas and Anderson, 1984).Marked tarsoligamentous sling laxity is encounteredin the 50-plus age group (Shore, 1982). If the medialtendon elongates, the medial lid may evert, rotatingthe lacrimal punctum away from the medial tear lake,resulting in pooling and epiphora.

DEFINITIONS

Retraction of the lower lid is not a synonymfor ectropion. There are several degrees of lidmalposition. Ectropion means ‘turning out’ and itaptly describes the involutional ectropion in whichthe lax lid turns out so that the palpebral conjunctiva

Fig. 3 – Pretarsal (C), preseptal (B) and orbital (A) portions of theorbicularis oculi muscle. The pretarsal fibres fuse with the medialcanthal ligament. Medially, the preseptal fibres are connected tothe lacrimal apparatus. Laterally, the preseptal fibres blend withthe lateral canthal pseudoraphe.

Fig. 4 – Effects of ageing on the lower eyelid: skin descent,pseudoherniation of fat, eyeball ptosis, narrowing of the palpebralfissure, pretarsal flattening. (From Brennan G: Aesthetic facialsurgery, 1991. New York: Raven Press, With permission.)

Fig. 5 – Preoperative (A) and 6 month’s postoperative (B) frontalview of a patient who underwent upper and lower blepharoplasty.The patient had prominent eyes that were masked by theblepharochalasis. Furnas’s (1978) muscle to periosteum suspensiontechnique had been used. The patient is satisfied and is notconcerned by the mild lateral scleral show and the rounding of thelateral canthus.

Fig. 6 – Punctum lacrimale faces vertically, just out of lacrimallake, causing mild chronic conjunctivitis. The medial portion of thelower lid is lax and lid retraction is a real concern.

Prevention of lid retraction after lower lid blepharoplasties 191

is exposed, associated with irritation and oedema,which pushes the lid even further away from theglobe. Cicatricial ectropion is produced by cicatriza-tion of the anterior lamella. It occurs in 5% ofpatients after lower lid blepharoplasties (McGraw

and Adamson, 1991). This severe form of lidretraction results in epiphora, irritation and finallykeratitis due to exposure. Inferior scleral show occursin 15 to 20% patients following lower blepharoplasty(Baylis et al., 1989). This kind of retraction is causedby shortage of the anterior lamella, due to resectionof skin or muscle, relative shortage of skin due toexcessive fat removal (Dhooghe, 1978) or traction ofthe tissues below the eyelid (Small and Scott, 1990).Scar contraction in the middle lamella in the presenceof some laxity of the lower eyelids can also causesevere lid retraction (Jordan and Anderson, 1990).Rounding of the canthal angle is a mild form of lidretraction, due to excision of tissue more lateral thanmedial of the anterior lamella.

The typical deformity after blepharoplasty consistsof inferior scleral show (worse laterally), rounding ofthe lateral canthus and shortening of the intercanthalspace (Fig. 5).

IDENTIFYING THE PATIENT AT RISK

Some patients can be eliminated on examination,namely those with prominent globes, axial myopia,shallow orbits and hypoplastic malar prominencesare as they are at risk. In persons with more than1 mm of scleral show, marked laxity frequently exists(Tenzel, 1981). If the punctum faces vertically, justout of the lacrimal lake, the medial lid is lax and thepatient is prone to eversion (Lisman et al., 1987;Fig. 6).

Several tests are described. Their terminology andexecution overlap considerably. In the horizontaltraction tests, the eyelid is pulled horizontally awayfrom the globe (Fig. 7). During the ‘Snap-back’ Test,the patient is instructed not to blink and the eyelid isreleased. If the eyelid does not snap back, somedegree of laxity is present (Tenzel, 1981; Holt and

Fig. 7 – Horizontal traction test. See text for more detailedinformation.

Fig. 8 – Vertical traction test. See text for more detailedinformation.

Fig. 9 – Lateral traction tests. See text for more detailedinformation.

Fig. 10 – The punctum moves a considerable distance laterally withlateral traction. Functional and aesthetic compromises will resultafter a lower blepharoplasty with anterior lamella tightening.


Holt, 1985). The magnitude of distraction is thecriterion in the test called Eyelid Distraction Test(Beekhuis, 1982), Pinch Test (Murakami and Orcutt,1994), or Distension Test (Stasior, 1980). More than5 (to 6mm; Jordan and Anderson, 1990) or 7mm(Beekhuis, 1982) of distraction can indicate abnormaleyelid laxity. More than 8mm is an indication forwedge resection according to Furnas (1981). ThePinch Test as defined by Furnas (1981) is used todetermine the extent of the attachments between theskin and the underlying muscle. Both are gentlypicked up at selected sites whilst the patient performsexpressive movements. The vertical traction test(Fig. 8) is called the Snap Test (Tenzel, 1981;Doxanas, 1994) or the Eyelid Retraction Test(Flowers in Aston, 1982). Gentle downward tractionis applied to the lower eyelid, everting the lid from theglobe. Once the traction is released, the eyelid shouldreturn to its natural position without a blink (Tenzel,1981) or following a single blink (Doxanas, 1994).When the lid moves back to contact the globe very

slowly or not at all until the eye is blinked, it meansthat the main factor holding the lid in contact withthe globe is the capillary seal. The lateral traction testis called the Pinching Test (Fig. 9). It consistsof pinching the lower eyelid and assessing the degreeof medialisation of the lateral canthus, which isnormally less than 2mm. We also look at thelateralization and verticalization of the punctum(Fig. 10). If this occurs, any lid tightening procedureis contraindicated and a lid support technique shouldbe chosen.

PREVENTIVE TECHNIQUES

Techniques used in the classical transcutaneousapproach

Techniques related to the skin incisionThe classical incision is situated 2–3mm below thepalpebral margin beginning 2–3mm lateral tothe punctum and extending laterally 5–10mm beyondthe canthus (Sheen, 1978). There is disagreementconcerning limiting the incision to the lateral orbitalrim. The classical blepharoplasty incision has aninferior angulation laterally (Fig. 11; Pastorek, 1983).

Fig. 11 – An inferiorly directed lateral extension (A) is prone todevelop a poor scar.

Fig. 12 – Mouth opening associated with eyeball elevationsimulates the effect of gravity in a recumbent patient.

Fig. 13 – Lateral Z-blepharoplasty according to Lewis (1966).


This leads to scarring across natural skin folds andproduces lateral stretching on the closure rather thanthe preferable supero-temporally directed pull(Shagets and Shore, 1986). This may well contributeto lateral scleral show and rounding of the canthalangle.

Techniques related to flap dissectionIf larger amounts of skin removal are anticipated, askin flap is advocated by some, to preserve theorbicularis muscle and to reduce the risk of scleralshow (Aston, 1988). More bleeding, longer operatingtime and possible ischemia are the major disadvan-tages (Rees, 1980). The skin flap technique wasoriginally recommended by Castanares (1951), andalso to a limited extent by Casson and Siebert (1988)to avoid an overcorrected appearence. The latterauthors resect the pretarsal muscle portion only ifthere is hypertrophy, thus preserving a supportivesling. It is also the standard technique of Guy andLiverett (1981), who penetrate muscle and septum togain access to the fat pads.

A skin-muscle flap has the advantages of anavascular plane, simplicity, rapidity, reduced immedi-ate morbidity and lack of scar tissue plane betweenskin and muscle. The original cephalad-to-caudaddissection was passed by J. Eastman Sheehan of NewYork to Sir Archibald McIndoe and reported byBeare (1967; see also: Rees and Dupuis, 1970; Rees

and Wood-Smith, 1973). Spira (1978) and Aston(1982, 1988) favour the lateral-to-medial variation.Small (1981) makes the horizontal incision 1mmbelow and McCullough and English (1988) 4mmbelow the lashes to keep a supportive sling ofpretarsal muscle. A skin-muscle flap can still producescleral show, when tightened enough to completelycorrect all wrinkles.

The authors prefer the lateral to medial dissection.The lateral extension is deepened to the periosteumwith a 15 surgical blade (Swann-Morton, Sheffield,UK) and iris scissors are used to separate the musclefrom the septum. The horizontal incision isperformed with the scissors angulated to preserve asmuch pretarsal muscle as possible.

Techniques to ensure proper skin (and muscle)excision with skin-muscle flapsMouth opening associated with eyeball elevationsimulates the effect of gravity in a recumbent patient(Fig. 12). The lid margin should be positioned at thelevel of the limbus before planning the skin resection(Dhooghe, 1978). Pressure under the malar promi-nence in order to relieve the tissue pull under theeyelid (Lewis in Dhooghe, 1978) can lead to theexcision of too much skin and muscle.

Full thickness skin flaps (anterior lamella tightening)Lewis (1966) advocated a lateral Z-blepharoplasty toprevent lateral ectropion (Fig. 13). Gonzales-Ulloaand Stevens (1967) joined the upper and lower lidskin excision to create a lateral triangle in which theexternal canthal angle could be moved (Fig. 14).If overdone, this may create a lateral skin web. Thesetechniques have been abandoned.

Dermal flaps (anterior lamella tightening)Dermal flaps dissected off the skin (muscle) flap wereadvocated by Beare (1967), Rees (1969), Edgerton andWolfort (1969). Early dimpling (Flowers, 1993) andsubcutaneous cysts in 21% of the patients (Adamsonet al., 1979) were noted.

Fig. 14 – V-Y plasty according to Gonzales-Ulloa and Stevens(1967).

Fig. 15 – After skin and muscle excision, the lateral edge of theorbicularis muscle is suspended to periosteum at the lateral orbitalborder via a tunnel through the muscle at the cephalic side of theincision (Furnas, 1978; Flowers, 1987; Mladick, 1993).

Fig. 16 – Skin fold after subpalpebral face lifting (extended lowerblepharoplasty). The blepharoplasty was combined with reductionof the nasolabial folds, correction of the malar fat ptosis andcorrection of the malar pouches. (A) Preoperatively; (B) 6 monthspostoperatively.


Muscle to muscle suspension (anterior lamellatightening)Fossati (1967) sutures the divergent fibres of the lowerto the upper orbicularis laterally. Papel (1994)elevates a skin flap for 1 cm inferiorly, then continueswith a skin-muscle flap. A lateral wedge resection isperformed in the orbicularis muscle that is closedwith 5/0 polydiaxone sutures.

Muscle to periosteum suspension (anterior lamellasupport)The musculo-periosteal suspension was originallydeveloped by Wheeler (1939) to correct entropionand for the same purpose modified by Leber andCramer (1977). Hinderer (1977, 1979, 1987) andFurnas (1981) undermine the lateral part of themuscle and displace it upwards. The triangle surpass-ing the lateral canthus is excised and the free bordersutured to the raphe and periosteum at the levelof the lateral canthus. Mladik’s (1979) techniqueis similar, but drapes the skin medially. Reidy (1960),Spira (1978), Adamson et al. (1979) and Flowers(1981) also remove the skin from the lateral

triangular flap and after undermining fix it to orbitalperiosteum through an upper blepharoplastyincision. Furnas (1978), Flowers (1987) and Mladick(1993) eliminate the skin undermining and thelongitudinal splitting and excision of the muscle(Fig. 15). They resect only skin and suspend theorbicularis muscle through a muscular tunnel tothe orbital rim. We use the latter technique in everycase where a transcutaneous approach is necessaryto redrape the skin. It is an expedient procedure.Time consuming anterior or posterior lamellatightening is avoided. The palpebral fissure doesn’tchange in position or width.

Muscle (in continuity with SMAS and facial tissues)to periosteum suspension (extended anteriorlamella support)Dissection of the myocutaneous flap must beextensive so that when it is lifted, the cheek flap iselevated and the nasolabial fold flattens slightly(Furnas, 1978; Adamson et al., 1979; Shorr and Fallor,1985; Mladick, 1993; Small, 1981). The muscle flap isgenerally suspended to the lateral orbital rim(Adamson et al., 1991). It can be combined with amodified Bick procedure (Small, 1981) or Kuhnt-Szymanowski pentagonal wedge excision (Wilkinsand Hunter, 1981; Adamson et al., 1991) in case ofextreme laxity. Faivre (1980, 1987) calls it ‘subpal-pebral lifting’ and sutures the muscle also to the lowerorbital rim. The technique is also used to treatfestoons (Small, 1981) or to reposition the malar fatpads (Owsley, 1993).

Disadvantages are the lateral scar, especially inyoung patients and the lateral canthal roll of tissue inpatients with redundant lateral adnexal skin (correc-tion is possible by rhytidectomy; Fig. 16).

Horizontal eyelid tightening by posteriorlamella tightening

Horizontal wedge excision. The Kuhnt-Szymanowskiprocedure (Kuhnt, 1908) (Fig. 17) was recommended

Fig. 17 – Kuhnt-Szymanowski Procedure (Kuhnt, 1908) (See text.).

Fig. 18 – A modified Bick Procedure.

Fig. 19 – Lateral Canthal Tendon Plication Procedure (Websteret al., 1979, Flowers, 1993).

Fig. 20 – Tendon detachment and fixation to the bone through atunnel in the upper blepharoplasty incision (Flowers, 1993).


by Fomon (1960), Castanares (1963), Rees and Wood-Smith (1973), McKinney (1977) and Rees (1980). Theblock resection of the tarsus may exaggerate laxity ofthe canthal tendons and produce a horizontallynarrowed palpebral fissure (Doxanas and Anderson,1984), or round eye (Jordan and Anderson, 1990).

A modified Bick procedure (Fig. 18) was advocatedby Leone (1970) and Raflo (in Aston, 1982). Itinvolves tarsal excision at the lateral canthus withsuturing of the tarsal plate to the remnants of thelateral canthal tendon. It relies upon the strengthof the weakened lateral tendon. McCord and Shore(1983) therefore anchor to the periorbit, whilstDortzbach (1983) does both and adds muscle tomuscle suspension.

Lateral canthal procedures. These involve lateraltendon resections, suspensions and plications, andtarsal plate resections and suspensions (with orwithout dissection of a lateral strip). Suspension bysuturing is always performed at the midpupillarylevel, 2–3mm higher than originally and at the lateralperiosteum about 2–3mm posterior to the orbital rimat Whitnall’s tubercle.1

Lateral Canthal Tendon Resection (Tenzel, 1981)aimed at repositioning without reattachment of thelateral tarsus to the periorbit and orbital rim. Thetendon was not severed in the Lateral CanthalTendon Plication Procedure (Webster et al., 1979,Flowers, 1993; Fig. 19). Later, Flowers (1993)detached the tendon and fixed it to the bone througha tunnel in the upper blepharoplasty incision(Fig. 20). He described a second-layer supportof muscle suspension to bone or periosteum. We alsowish to mention the Lateral Canthal Sling Procedure

1Whitnall’s ligament or superior transverse ligament is a band ofcondensed fascial sheath of the levator muscle approximately14–20mm above the superior border of the tarsus. Whitnall’stubercle is the lateral orbital tubercle, approximately 5mm behindthe rim (Whitnall, 1932).

(Tenzel et al., 1977) and the Lateral Canthal TendonTuck Procedure (Schaefer, 1979).

Lateral Canthal Tendon Resection with Conjunc-tiva Preservation (Patipa, 1993) needs a description(Fig. 21). After skin-muscle flap dissection, apentagonal wedge of pretarsal muscle fibres and

Fig. 21 – Lateral Canthal Tendon Resection with ConjunctivaPreservation (Patipa, 1993).

Fig. 22 – The Lateral Tarsal Strip Procedure.

Fig. 23 – The Medial Canthopexy Procedure (Murakami andOrcutt, 1994).


lateral canthal tendon are resected. The eyelid marginand conjunctiva are not incised (4–5mm width). Thelateral edge of the tarsus and the medial stump of thelateral canthal tendon are sutured with 3 suturesVicryl 6/0. If there is a buckling of conjunctiva, a2-mm lateral canthotomy is performed behind thepreplaced suture.

The lateral tendon is a fragile structure, oftenrarefied by ageing, and unreliable for orthopaedicsuspension (Jordan & Anderson, 1990 and Friedmanet al., 1981). Another disadvantage is the post-operative appearance of ‘bunched’ sutures at thelateral canthi. If lid tightening is indicated, this ispreferably done in combination with a tarsal suspen-sion technique.

Suspension of the tarsus was originally describedby Eden in 1911, then by Sheehan in 1927. The mostpopular procedure is the Lateral Tarsal StripProcedure (Anderson and Gordy, 1979), modified bymany others and given different names, such asLateral Canthal Tarsal Strip Procedure (Putterman,1979), Tarsal Suspension (Lisman et al., 1987), TarsalTongue procedure (Smith and Lisman, 1981),Enhanced Tarsal Strip (Jordan and Anderson, 1989)or Tarsal Tuck Procedure (Jordan and Anderson,1990). The procedure basically involves a lateral

canthotomy, lysis of the inferior crus of the tendon,dissecting a tarsal strip and suspending it at the innerside of the lateral orbital rim (Kopelman and Keen,1994; Fig. 22). Variations include excision of thelateral part of the tarsal tongue (Jordan andAnderson, 1990), no dissection of the tarsal plate(Jordan and Anderson, 1990), no dissection ofconjunctiva off the tarsal plate to preventpostoperative oedema (Lisman et al., 1987), abrasionof the conjunctiva to obtain firm union andavoidance of inclusion cysts (Jordan and Anderson,1989), no removal of the anterior lamella and fullthickness (skin, muscle, tarsus) suturing using 4/OPDS to the inner periorbit (Jordan and Anderson,1989), step-like rim-tarsal excision (Hinderer, 1987),periosteal flap formation or stab incision to reach thebone (Hamako and Baylis, 1980; Lisman et al., 1987),combination with muscle to muscle suspension (Lis-man et al., 1987), combination with muscle toperiosteum suspension (Hinderer et al., 1987), com-bination with lysis of retractors (McCord and Shore,1983).

The Lateral Tarsal Strip Procedure can exaggerateeyelid retraction in patients with preoperative promi-nent globes. Resection of the tarsal plate by a Kuhnt–Szymansowki procedure may create lid notching, or arecurrence of lid retraction due to further stretchingof the lateral canthal tendon (Jordan and Anderson,1990). The Lateral Tarsal Strip Procedure on theother hand frequently widens the palpebral fissure byeliminating lateral canthal tendon weakness(Doxanas, 1994). Problems with the Tarsal TuckProcedure may include indentations at the canthusand bunching of tissue lateral to it if too large a biteof tarsal plate is taken (McKinney, 1990). Since it is adermis-to-periosteum suture, it may fail in the longrun (McKinney, 1990). We therefore reserve thisprocedure for revision surgery.

Medial canthal procedures. The Medial CanthopexyProcedure involves an incision 1 cm long, 3–4mmbelow and parallel to the ciliary margin andplacement of a vertical mattress suture in themedial canthal tendon (Murakami and Orcutt, 1994;Fig. 23).

Fig. 24 – Taping of the lateral incisions to provide external anteriorlamella support (Suture Strip, Genetic Laboratories, Minnesota,and USA).

Fig. 25 – Preseptal (A) and postseptal (B) route to the orbital fat inthe transconjunctival approach.

Table 1 – Fitzpatrick sun-reactive skin types I to VI (Fitzpatrick,1997)

Skin color Skin type Sunburn Tan

White I Yes NoII Yes MinimalIII Yes YesIV No Yes

Brown V No YesBlack VI No No


Middle and posterior lamella considerationsBy exposing the fat pads by three small horizontalincisions in the medial, central and lateral portions ofthe septum, the integrity of the middle lamella issafeguarded (Dortzbach, 1983).

Horizontal sectioning of the posterior lamella ofthe eyelid can be added to other procedures to reducethe downward pull of lid retractors (Putterman, 1979;Hamako and Baylis, 1980; Harvey and Anderson,1981; Jordan and Anderson, 1989).

Ancillary proceduresIn case of any tendency to ectropion, a Frost2 suturethrough the three lamellae is taped to the foreheadfor 2 to 3 days (Dortzbach, 1983). Injections oftriamcinolone acetonide can help (Friedman et al.,1981). Our experience with taping and massage hasbeen favourable (Fig. 24).

Techniques used in the transconjunctival approach

The transconjunctival approach was first describedby Bourguet (1928) and popularised by Tessier (1973).The indications are young patients with pseudoher-niation; patients 30–50 years of age with no trueexcess of skin; revision or secondary blepharoplasty(to correct mild rounding and scleral show): patientsrequesting no external scar; dark-skinned candidateswith possibility of postoperative hypopigmentation.Contraindications are a tight lower eyelid (Zarem andResnick, 1991) and a hypertrophic orbicularis muscle(Fedok and Perkins, 1996). There are sometimesdifficulties in removing fat from the temporal pocket.

There are two approaches, the pre- and thepostseptal (Fig. 25). The preseptal approach requiresidentification of the inferior border of the tarsus andmaking an incision approximately 1 to 2mm below(Rousso and Fedok, 1993; Perkins et al., 1994)through conjunctiva and inferior retractor muscula-ture. Then the muscle is separated from the septum.

2Frost suture is a lower eylid suspension suture, that has beenrecommended to prevent the occurence of ectropion and excessscleral show (Frost, 1934).

The advantage is that the septum becomes fibrousand tighter to act against pseudoherniation. Thedisadvantage is that the cicatrisation may result ininferior retraction (Zarem and Resnick, 1991). In thepostseptal approach, the incision is made at least4mm below the caudal margin of the inferior tarsus(Baylis et al., 1989; Zarem and Resnick, 1991;Waldman, 1994; Fedok and Perkins, 1996). Withsmall buttonhole incisions to allow access into thenasal and central pockets and then into the lateraland temporal fat pockets; no suturing is requiredaccording to Doxanas (1994).

Zarem and Resnick (1991) reported no instances ofprolonged lower lid retraction problems, presumablybecause the anterior and middle lamellae are leftintact. Skin excess was often more apparent than real,with the skin being necessary to recontour the lowereyelid after fat excision. Skin excision was rarelyrequired. They noted a temporary elevation in thelower-eyelid position due to transection of the lowerlid retractors.

To treat the skin wrinkles, a chemical peel(Waldman, 1994), CO2 laser skin resurfacing or thepinch technique (Parkes et al., 1973; Parkes andBassilios, 1978; Waldman, 1994) can be added. In thepinch technique tweezers are used to identify skin


excess which is removed by scissors. CO2 laser skinresurfacing of the pretarsal and preseptal skincombined with fat removal by the transconjunctivalapproach can only be applied in patients classified asFitzpatrick I to III (Table 1; Fitzpatrick, 1997). Ittakes the patients longer to resume work than withskin excision techniques because of the associatedskin care.

Combinations of transconjunctival and transcutaneousapproaches

Weber et al. (1992) advocates a canthotomy andinferior cantholysis and a limited skin-muscle flap(to the temporal limbus) to eliminate wrinkles(Fig. 26). The nasal fat pad is removed by limitednasal conjunctival incision; then the middle andtemporal fat pads are removed by septal exposurefrom the lateral skin-muscle flap. A tarsal tongue isdissected with removal of the cilia, the mucocuta-neous junction, conjunctiva and skin, and sutured to

Fig. 26 – Canthotomy and inferior cantholysis, and a limited skin-muscle flap (to the temporal limbus) to eliminate wrinkles Weberet al. (1992).

Fig. 27 – Transconjunctival button hole approach to the fat andmuscle suspension by plication. Skin removal in the lateral one halfto two-thirds of the eyelid Doxanas (1994).

the orbital rim periosteum. Skin and muscle areredraped and any excess is removed.

Doxanas (1994) uses a combined technique forpatients with minimal skin excess. He uses transcon-junctival buttonholes to gain access to the fat and hedoes muscle suspension by plication but no cantho-lysis. Skin is removed in the lateral half to two thirdsof the eyelid (Fig. 27).

CONCLUSION

The transconjunctival retroseptal approach topseudoherniation in the young patient, with no skinexcess and no pretarsal hypertrophy, is the techniqueof choice to prevent postoperative lid retraction. Thetranscutaneous approach with a skin-muscle flap,muscle plication and suspension is indicated in allcases that have no pre-existing ectropion or scleralshow. Postoperative taping and massage prevent andtreat temporary lid retraction. Periorbital CO2 laserskin resurfacing in a second session eliminates the‘crow’s feet’ and removes any persistent lid wrinkles.When fine wrinkles are present, the retroseptaltransconjunctival fat removal and CO2 laser resurfa-cing has potential but needs further research.

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Maurice Y. Mommaerts LDS, MD, DMD, FEBOMSConsultant Maxillo-Facial SurgeonGH St JohnRuddershove 10B-8000 BrugesBelgium

Tel: +32(0) 50 45 22 60Fax: +32(0) 50 45 22 79E-mail: [email protected]

Paper received 11 November 1999Accepted 30 May 2000

2000 prevention of lid retraction in lower lid blepharoplasties. an overview. jcmfs

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