Blepharoplasty Subciliary Approach

Lower blepharoplasty is performed for various reasons, with the most common presentations being a feeling of "looking old" or "looking tired." Other complaints may include "baggy eyelids," "swollen eyelids, worse in the morning," and "my photographs make me look tired." Some surgeons have noticed an increase in facial cosmetic consultations, which they attribute to the omnipresence of social media. Although there are many different techniques available when performing lower blepharoplasty, modern surgeons have come to appreciate that preoperative assessment allows a combination of procedures to give the best cosmetic and functional results. It is now expected that the surgeon will be familiar with a variety of techniques and can combine them to tailor such techniques to each patient, rather than always performing the same procedure on every patient. Blepharoplasty can be defined as "changing the shape of the eyelid" and can be performed for functional and aesthetic indications. Subciliary blepharoplasty is the approach to the deeper lower eyelid structures via a transcutaneous incision placed in the subciliary crease. It can be combined with a lateral canthotomy and cantholysis for lid-tightening if required. Some surgeons will use this approach when repairing the orbital floor or zygomatic-maxillary complex (ZMC) fractures. Transcutaneous blepharoplasty is usually indicated in cases with skin and muscle laxity, with or without fat prolapse. Traditionally, the skin is incised 1 mm below the lash line in the subciliary area. Once the skin is incised, 2 possible variations are named depending upon the plane of dissection. A 'skin flap' can be raised, elevating the thin eyelid skin off the orbicularis oculi muscle. In 1951, Castanares described the 'skin-flap' technique as best suited for eyelids with excess lax skin and atonic orbicularis muscle. The second technique is termed the 'skin-muscle' flap, where the orbicularis oculi muscle is incised as it attaches to the tarsal plate, and the plane of dissection is deep to the orbicularis and superficial to the orbital septum. McIndoe-Beare popularized this technique and proposed its use in younger patients with robust orbicularis muscle tone. Regardless of the specific plane of dissection used, lower lid malpositions, particularly ectropion, may be encountered in the subciliary approach owing to contractile scarring that everts the lash line and grey line away from the globe. The most common causes of this complication include unaddressed eyelid laxity, overzealous skin excision, denervation of the orbicularis, breach of the orbital septum, or unfavorable scarring. A meticulous preoperative examination can identify eyelid laxity, which must then be addressed at the time of blepharoplasty. In an effort to avoid the potential for ectropion, Bourget introduced the transconjunctival approach, which Zarem and Resnik popularized as beneficial in avoiding ectropion. This approach is discussed in an additional article on StatPearls.com. The selection of a transcutaneous approach or a transconjunctival approach for lower lid rejuvenation is an area of active controversy with vocal advocates on all sides. It behooves the surgeon to be familiar with both approaches, allowing treatment to be tailored to the patient. Maffi et al. reviewed 2007 patients over a period of 30 years who underwent traditional transcutaneous blepharoplasty without additional support by a senior experienced surgeon and reported only 0.4% symptomatic lid malposition post-surgery, which supports the safety and effectiveness of this procedure. This is a similar, low complication rate to that seen in transconjunctival approaches. Contemporary lower lid blepharoplasty has also benefited from advances in the understanding of the anatomical changes of the aging face, the importance of orbicularis retaining ligament (ORL), the orbitomalar sulcus deformity, and tear trough deformity. Current literature focuses on smoothing the lid-cheek junction for a more youthful look using techniques like the release of retaining ligaments, fat transposition, and mid-face augmentations. Also, lid-anchoring procedures have been emphasized to treat any lid laxity. Although these techniques for lid-cheek junction smoothing can be accomplished through the transconjunctival approach, the transcutaneous approach allows for an excellent field of exposure for fat transposition, ORL release, midface-lift procedures, as well as lateral canthal tightening procedures with the additional advantage of skin redraping.  Many surgeons routinely integrate or combine these approaches to get the best outcomes and minimize complications in lower lid blepharoplasty. For a patient without excess skin and muscle, transconjunctival blepharoplasty, along with fat transposition and skin laser treatment, can be performed. Patients with excess skin-muscle require combining a skin-muscle flap through a subciliary incision with ORL release, fat transposition, lateral canthal support, and minimal removal of fat through the conjunctiva. Similarly, multimodality 5-step blepharoplasty, described by Rohrich et al. includes (1) malar fat augmentation, (2) minimal fat resection transconjunctivally preserving orbicularis, (3) ORL release, (4) lateral canthal tightening procedure, (5) minimal skin removal via subciliary incision.