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    Extended lower blepharoplasty best addresses lid-cheek junction

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    A lower eyelid and midface cosmetic extended blepharoplasty is an innovative surgical technique that can best address the lid-cheek junction, one of the central goals in rejuvenation of the lower eyelid, says Jeffrey Schiller, M.D., clinical assistant professor of ophthalmology at the University of Medicine and Dentistry of New Jersey, Newark.

    The lower eyelid region has become a very popular target for both nonsurgical and surgical rejuvenation procedures, ranging from minimally invasive filler and fat grafting techniques to blepharoplasty. The orbitomalar sulcus is the hollow between the lower eyelid and upper cheek, and the medial part of this depression has been termed the tear trough. The tear trough is caused by the tethering of the skin by its attachment to the orbicularis oculi origin on the maxilla, Dr. Schiller says, and it is this area where rejuvenation techniques are aimed at correcting the tear trough.

    WHY EXTENDED? According to Dr. Schiller, the three components of the orbitomalar sulcus region that will generally need to be addressed include orbital fat prolapse above the sulcus; the orbicularis retaining ligament (ORL) and orbicularis oculi tethering of the skin to the maxilla and zygoma just inferior to the orbital rim; and the descent of the cheek or loss of volume inferior to the sulcus.

    "The true anatomy around the eye and what is seen in textbooks vary to a certain degree. The images in most textbooks depict the orbicularis muscle as a doughnut that originates on the medial canthal tendon, but in reality, the muscle also originates on the maxilla directly beneath the tear trough hollow," says Dr. Schiller, who also has offices in New York.

    A standard blepharoplasty procedure will typically entail removing excess skin and fat from above the tear trough area. However, according to Dr. Schiller, standard blepharoplasty does not adequately correct the orbitomalar sulcus deformity.

    "Standard blepharoplasty will address the bag or bulge above the orbitomalar sulcus, but it will not correct the circular hollow beneath that bulge. Here, an extended lower blepharoplasty that addresses the whole lid-cheek junction is a much more effective technique to correct this cosmetic thorn," Dr. Schiller says.

    HOW IT'S DONE Dr. Schiller developed an extended lower blepharoplasty technique that involves aggressively releasing the tethering of the ORL at the lateral and middle third of the orbitomalar sulcus, and medially, the lower orbicularis oculi muscle origin. He says that releasing the tethering of these tissues to the lower eyelid and cheek allows lifting of the cheek and smoothening of the lid-cheek junction and tear trough.

    Following IV sedation, the fat pockets are infiltrated with local anesthesia (lidocaine 2 percent with epinephrine 1:100,000) through the transconjunctival approach, while the suborbicularis plane is injected transcutaneously across the entire lid to 2 cm below the inferior orbital rim, at the lateral canthal region, and over the lateral orbital rim periosteum.

    The lower lid is then everted and using a CO2 laser, an incision is made transversely in the inferior fornix (in most cases) through the conjunctiva and through the lower eyelid retractors. The orbital fat is then exposed and resected conservatively in the medial, central and lateral fat pockets as needed. The arcuate expansion of the inferior oblique separating the central from the lateral fat pockets is preserved, and the conjunctival incision is closed with one or two interrupted 6-0 plain gut sutures.



    Using the carbon dioxide laser, Dr. Schiller makes a subciliary incision through the skin and orbicularis oculi muscle 2 mm inferior to the lash line from the junction of the central and medial thirds of the lower lid to the lateral orbital rim, usually 1 cm to 2 cm lateral to the lateral commissure. Using the laser, Dr. Schiller says he will perform a suborbicularis dissection inferiorly, ending at the inferior orbital rim. The skin-muscle flap is then retracted and digital palpation and direct visualization beneath the flap localizes the ORL.

    Dr. Schiller then proceeds to divide the multiple lamellae of the ORL in the suborbicularis/preseptal plane to 2 cm inferior to the orbital rim, including the attachment at the lateral orbital thickening. In order to achieve a full mobilization of the eyelid and cheek and to efface the tear trough when present, Dr. Schiller says he divides the fibers of the orbicularis oculi origin into the face of the maxilla close to the bone medially, until palpation verifies that all tethering of the eyelid to the orbital rim is released.

    The flap is then gently pulled superiorly and the amount of redundancy is determined. Using the laser, Dr. Schiller will conservatively resect the skin-muscle flap in two triangles created by a vertical incision at the lateral aspect of the flap lateral to the lateral commissure. He then supports the skin-muscle flap by suturing the orbicularis fascia to the lateral orbital rim periosteum with a superior and slightly lateral vector using a 4-0 polyglactin horizontal mattress suture. The skin is then closed with a running 6-0 polypropylene suture.

    "The extended lower blepharoplasty technique using the CO2 laser is relatively easy to perform and can be mastered with appropriate training. It allows me to smooth the contour of the lid-cheek junction and significantly elevate the descended and/or deflated malar fat pad, returning the region to its once youthful appearance," Dr. Schiller says.

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