Cosmetic Lower Lid Blepharoplasty

This article will review the topic of cosmetic lower lid blepharoplasty including: preoperative patient evaluation and selection; blepharoplasty surgery; postoperative patient care; and complications of surgery. The emphasis of this article is surgical techniques, including standard lower lid blepharoplasty via a subciliary skin incision, lower lid blepharoplasty combined with lateral canthal lower lid tightening procedures, and the transconjunctival lower lid blepharoplasty procedure. Preoperative and postoperative surgical results are presented.     

Lower eyelid CO(2) laser rejuvenation: a randomized, prospective clinical study

PURPOSE: The effect of transconjunctival blepharoplasty alone compared with transconjunctival blepharoplasty and CO(2) laser skin resurfacing on lower lid bulging and wrinkles was examined. DESIGN: Randomized clinical trial. PARTICIPANTS: Forty-four subjects, including 13 men and 31 women. METHODS: Subjects were prospectively randomly assigned into two groups: (1) transconjunctival blepharoplasty with immediate CO(2) laser resurfacing or (2) transconjunctival blepharoplasty with CO(2) laser resurfacing 2 months later. Standardized photographs were taken before and 2 months after each procedure. A trained, masked observer graded the photographs. MAIN OUTCOME MEASURES: Bulging and wrinkles of the medial, central, and lateral portions of the lower lid were scored and compared at specified end points. RESULTS: Transconjunctival blepharoplasty alone resulted in an improvement in lower lid bulging in 92% of subjects, whereas lower lid wrinkling worsened in 46%. When transconjunctival blepharoplasty was performed with simultaneous CO(2) laser resurfacing, or with CO(2) laser resurfacing 2 months later, a statistically significant improvement in wrinkles occurred (chi square = 20.625; P < 0.0005). The timing of the procedures had no statistically significant effect on final outcome. No subject had lower lid retraction develop. CONCLUSIONS: Transconjunctival blepharoplasty and adjunctive CO(2) laser resurfacing represents an excellent alternative to transcutaneous lower blepharoplasty. The procedure addresses lower lid wrinkles, skin redundancy, and fat herniation without a scar and with little risk of lower lid retraction.     

Reconstructive lower lid blepharoplasty

The traditional lower lid blepharoplasty highlighted by fat removal and excision of excess skin via a transcutaneous approach has been replaced by a reconstructive blepharoplasty involving minimal fat removal, sculpting, or fat repositioning. Simultaneous application of chemical peels, microdermabrasion, or laser resurfacing procedures is an acceptable alternative to skin excision when there is minimal skin redundancy. This article reviews the anatomic changes in the lower eyelid that occur as a result of aging and addresses reconstructive techniques for rejuvenation of the lower eyelid.     

Lower eyelid blepharoplasty: An overview

Of the two common techniques of lower blepharoplasty, the transconjunctival approach is limited to young patients with prominent herniation of lower fat pad without skin excess and the transcutaneous approach to patients requiring skin excision. However, the current trends not only highlight the traditional sculpting of the three orbital fat pads in lower lid blepharoplasty but also additional relocation of the intraorbital fats for correcting the inferior orbital hollowing. The purpose of this review is to analyze the published literature on common types, techniques, indications, and outcomes of the multiple surgical variants of lower lid blepharoplasty often aimed at treating the redundant skin, steatoblepharon, tear trough deformity, lid laxity, and dermatochalasis, thereby to correct the negative vector and inferior orbital hollowing along with effacement of the lid cheek junction. An extensive survey of peer-reviewed literature published in English in electronic databases, as well as bibliographies from cited articles, was conducted. Databases such as MEDLINE PubMed, the Cochrane Library, and Embase were scanned using relevant medical subject heading (MeSH) terms. Clinical studies with a minimum of five study cases were included. Level III evidence, case reports, letters, editorials, and case series with fewer than five eyes were excluded. This article provides a concise overview of available literature and as such no meta-analysis was done due to the narrowed scope of the involved studies and the variety in surgical approaches and techniques of lower lid blepharoplasty.     

Transconjunctival lower eyelid blepharoplasty. Technique and complications

The transconjunctival lower eyelid blepharoplasty is extremely effective at reducing lower lid fullness due to prominent orbital fat. The authors performed 122 consecutive transconjunctival blepharoplasties over a 24-month period. Four patients had skin excision via the pinch technique in conjunction with the transconjunctival fat excision. The main complication was under excision of fat which occurred in nine patients (7.4%). Moderate postoperative wound hemorrhage without hematoma formation occurred in one patient (0.8%). There were no cases of lid retraction, ectropion, entropion, inferior oblique palsy, or over excision of fat. The main advantage of this technique is that it avoids the most common complication of transcutaneous lower eyelid blepharoplasty, namely lower eyelid retraction.     

下睑成形改良术治疗不同类型睑袋的疗效

目的：探讨改进后的下睑成形术治疗不同类型睑袋的疗效。
　　方法：选取2010-05/2015-05间我院实施下睑成形术的患者67例67眼,按照睑袋情况进行分型,并采取不同改进术式：A组：单纯脂肪膨出型12眼采用经结膜切口入路法;B组：皮肤或(和)轮匝肌松弛型19眼,采用经皮肤入路法,需在手术过程中切除下睑皮肤、眼轮匝肌;C组：皮肤肌层松弛合并眶脂膨出型13眼,采用经皮肤入路法,术中切除眶隔脂肪、皮肤及眼轮匝肌;D组：混合型23眼,采用经皮肤入路法,需在手术中切除眶隔脂肪、皮肤及眼轮匝肌。
　　结果：术后5 d拆线,术后随访3~6 lo。四组患者手术效果优良率分别为100%、95%、100%及96%,差异无统计学意义(P>0.05)。患者下睑外观平坦,眶脂膨出消退,有1眼出现轻度睑外翻,2眼眶下缘凹陷以及4眼切口对合欠佳,术后2 lo均自行恢复。未出现斜视复视、下睑退缩等严重并发症。四组患者术后并发症发生率分别为8%、11%、8%及13%,差异无统计学意义( P>0.05)。
　　结论：改进后的下睑成形术治疗不同类型睑袋术后效果满意。     

睑袋成形术后眼轮匝肌功能状态的临床研究

目的探讨睑袋成形术后眼轮匝肌的功能状态及其影响因素。方法用肌皮瓣法矫正下睑袋32例（64眼）,分别在术前和术后5d、14d、1个月、3个月和6个月,以结膜囊染料消失法进行泪囊排泄功能测试。结果术后5d、14d和1个月结膜囊染料消失时间较术前明显延长（P〈0．001）,3个月和6个月检测结果与术前相比差异无统计学意义（P〉0．05）。结论肌皮瓣法睑袋成形术,术后早期眼轮匝肌泵作用明显减弱;但术中精细操作,减少对组织的损伤,有利于术后眼轮匝肌泵功能的恢复。     

A case of primary lid tuberculosis after upper lid blepharoplasty

Primary lid tuberculosis after lid surgery is a very rare condition and is likely caused by the introduction of bacilli through epithelial injury. Secondary infection, due to direct hematogenous spread or contiguous spread from adjacent structures are more common presentations of lid tuberculosis. The authors experienced a case of primary lid tuberculosis occurring in a 19 year old female after blepharoplasty for making a eyelid crease. Her upper lid skin showed a reddish and non-tender mass lesion measured 3x1 cm, which was diagnosed as the tuberculosis through typical histopathological findings (caseous necrosis), acid-fast bacilli stain and PCR, and treated with anti-tuberculosis medications.     

Total lower lid reconstruction:clinical outcomes of utilizing three-layer flap and graft in one session

METHODS: Seventeen patients with total or near total lower eyelid defect were included. The defects were reconstructed in three layers. Posterior lamella was reconstructed by using tarsoconjunctival free graft from the ipsilateral upper lid and periosteal flap from lateral orbital rim. Mobilization of residual orbicularis muscle provided a rich blood supply; and the anterior lamella was reconstructed by skin flap prepared from upper lid blepharoplasty as a one-pedicular or bipedicular bucket handle flap.RESULTS: The cause of lower eyelid defect was basal cell carcinoma in 15 patients and trauma in two of them. No intraoperative and postoperative complication occurred. Patients were followed from 10 to 15mo postoperatively. Cosmetic results were favorable in all patients and we had acceptable functional results. Thickness of the reconstructed tissue was a concern in early postoperative period.CONCLUSION:Three-layer lower lid reconstruction in one session is an effective technique for total lower lid reconstruction with minimal complications and acceptable functional and aesthetic outcomes and can be considered as a safe alternative for the preexisting techniques.     

The Angres Permalid-Liner method to enhance the result of cosmetic blepharoplasty

The purpose of cosmetic blepharoplasty is the reduction of redundant soft tissue of the upper and lower eyelids, improvement due to wrinkling and relaxation of the lid skin, and eradication of the fullness and bulges in the lids. The Angres Permalid-Liner is a new microsurgical procedure that implants various earthtone color pigments to the base of the eyelashes. When done together with aesthetic blepharoplasty, it can dramatize the eyes by giving sharper definition to the eye shape, makes lashes look thicker, makes the eye look larger and amplifies the whites of the eyes. At the same time, it can also be used to eliminate dark circles around the eyes, blend in skin grafts, and mask unsightly blemishes.     

Cosmetic blepharoplasty

Performing flawless cosmetic blepharoplasty surgery requires attention to many details. A proper medical work-up with establishment of patient rapport and preoperative photographic documentation should begin the evaluation. The surgical correction of concomittant brow position abnormalities should be considered. Resection of the brow fat pad is useful in recontouring bulky brows and redefining the superior sulci. Upper lid tissue resection needs to be individualized with skin resection, skin muscle resection, and lipocontouring of the suborbicularis muscle as well as with Burows triangles and "W" plasties. Lower lids may be handled by skin flap resection alone, myocutaneous flaps resection, or a combination of both. Lateral tarsal suspension avoids lower skin retraction.     

Reconstructive upper lid blepharoplasty

Cosmetic upper eyelid blepharoplasty is not a procedure comprising skin and fat resection only. Efficient and effective functional repair of the upper lid requires brow stabilization or elevation, levator aponeurotic repair, lacrimal gland suspension, and cutaneous laser resurfacing when necessary.     

Central retinal artery occlusion following cosmetic blepharoplasty.

A case is presented of a 70-year-old white male who underwent a bilateral cosmetic lower lid blepharoplasty with fat removal. He subsequently developed a right orbital haemorrhage which resulted in the occlusion of the central retinal artery. The patient had no light perception with his right eye for approximately 1 hour, but vision was eventually restored to 20/20 after emergency therapeutic measures. There are many possible causes of visual loss following blepharoplasty, with orbital haemorrhage being the most common. Visual loss secondary to blepharoplasty can be prevented in the preoperative, intraoperative, and postoperative phases of surgery. Blindness as a complication of cosmetic blepharoplasty can be reversible if recognised early and treated appropriately. These facts must be kept in mind by all surgeons who perform blepharoplasties.     

Correction of the Everted Punctum by Medial Canthoplasty

S ummary
A useful technique for correction of eversion of the punctum is medial blepharoplasty where an intermarginal adhesion is produced between the lid margin nasal to the puncta. This procedure combined with advancement of a canthal skin flap restores the punctum to its correct position.     

Surgical correction of senile entropion of the lower lid with fascia lata sling.

A method of surgical correction of senile entropion of the lower lid with heterogenous fascia lata sling is described with no tissue loss and minimum of surgical trauma.     

采用180°旋转皮瓣修复眼睑肿物切除术后眼睑皮肤缺损的临床研究

目的　探讨采用180°旋转皮瓣修复眼睑肿物切除术后眼睑皮肤缺损的安全性和有效性。方法　回顾性分析29例38眼采用180°旋转皮瓣修复眼睑肿物切除术后造成的眼睑皮肤缺损患者。术中按照标记线切除肿物后,在肿物一侧或两侧标记松弛的上睑或下睑皮肤量,按照重睑或眼袋延长线切开皮肤,在靠近皮肤缺损区的上方或下方留5 mm左右宽的蒂,分离皮瓣,并带有少量的眼轮匝肌,然后将皮瓣旋转180°,修剪皮瓣后间断缝合,再连续缝合供皮区皮肤切口。术后加压包扎48 h。对术后外观和皮瓣的存活情况进行连续性观察。结果　所有180°旋转皮瓣均在眼睑缺损区良好存活,不需要打包加压,而且皮瓣收缩量低,术后手术瘢痕相对隐蔽。2眼皮瓣在术后早期出现皮瓣尖端发黑;多数皮瓣蒂部早期存在轻度猫耳现象,术后3个月猫耳逐渐平复,除1眼术后6个月因上睑皮肤松弛和猫耳现象而行上睑成形术外,其余患者均无需二次手术。结论　180°旋转皮瓣手术操作相对简单,可避免发生眼睑外翻、变形等并发症,是眼睑前层缺损修复的备选方法。     

Long-term results of autogenous palmaris longus frontalis sling in children with congenital ptosis

PURPOSE: To investigate the long-term outcome of using autogenous palmaris longus tendon (PLT) sling for correcting congenital ptosis in children. METHODS: This is an observational case series involving 15 eyelids of 14 consecutive children with congenital ptosis who underwent frontalis suspension surgery using PLT in a university teaching hospital. RESULTS: One child had bilateral ptosis and the other children had unilateral ptosis. The age of patients at the time of surgery ranged from 2 to 7 years, with an average of 4.7 years. At a mean follow-up of 92 months (range, 80-104 months), all eyelids were successfully corrected with good lid height. No recurrence or other postoperative complications were encountered except one patient who developed a small skin fold over the PLT harvest site.CONCLUSION: Long-term lid position is remarkably stable after surgical correction using PLT. PLT sling appears to be a safe and effective treatment for children with congenital ptosis requiring frontalis sling operation. It could be a good alternative to autogenous fascia lata, and further studies, to compare these two sling materials seem warranted.     

Levator sling for Marcus Gunn ptosis.

A modified simple technique of sling operation is presented in 15 cases using the levator aponeurosis as the material for the sling as originally devised by Lemagne and Bemcher. The levator is cut behind the superior transverse ligament and the posterior part of the levator is cauterised and allowed to retract into the orbit. The horns are cut from behind forwards, and the levator, which is kept attached on the tarsal plate, is used to lift up the lid. This method eliminates the jaw winking phenomenon as well as lifting the lid.     

Lower eyelid position after transconjunctival lower blepharoplasty with versus without a skin pinch

PURPOSE: To evaluate the effect of transconjunctival lower blepharoplasty with or without a skin pinch on lower eyelid position. METHODS: Retrospective analysis of patients undergoing bilateral lower blepharoplasty using a transconjunctival approach with or without a skin pinch. Patients undergoing other surgical procedures that could affect lower eyelid position were excluded. Twenty-five patients (50 eyes) underwent transconjunctival blepharoplasty without skin pinch and 20 patients (40 eyes) underwent transconjunctival blepharoplasty with a skin-pinch technique. Preoperative and postoperative photographs were measured for the horizontal corneal diameter and distance from light reflex to lower eyelid margin (MRD2). The ratio of MRD2 to corneal diameter was multiplied by 11 to standardize to a corneal diameter of 11 mm. Student t test was used for statistical analysis. RESULTS: There were 8 male and 37 female patients. Average follow-up was 4 months. Mean preoperative standardized MRD2 was 4.68 mm and 4.65 mm for transconjunctival blepharoplasty without and with skin pinch, respectively. Mean postoperative standardized MRD2 was 4.73 mm and 4.70 mm for transconjunctival blepharoplasty without and with skin pinch, respectively. The mean change in lower eyelid position was 0.05 mm after each technique. The change in lower eyelid position was not statistically significant for either group (p > 0.5). There was no significant difference in lower eyelid position change between the 2 groups (p > 0.99). CONCLUSIONS: Transconjunctival lower blepharoplasty with or without a skin pinch yields a stable postoperative lower eyelid position.