🗂 總目錄 ｜ 📖 英文原文（本篇） ｜ 📝 完整翻譯 ｜ ⭐ 精華筆記

LOWER LID BLEPHAROPLASTY

LOWER LID BLEPHAROPLASTY

There are two main approaches to lower lid blepharoplasty: transcutaneous and transconjunctival. The more traditional transcutanous surgical approach requires a subciliary skin incision and trans-septal penetration to access the lower lid fat pads. The transconjunctival approach involves a transconjunctival incision, with avoidance of the septum, to access the lower lid fat pads.

Transcutaneous lower lid blepharoplasty was first described in 1967.71 In experienced hands, it can be effectively used to address lower lid skin excess, ptotic orbicularis muscle, and herniated fat pads. There are many variations to the transcutaneous approach, including a skin-only flap, skin-muscle flap, and separate skin and muscle flaps, all with or without fat excision or fat redraping. There have been no retrospective or prospective studies comparing these approaches, and generally surgeon preference and experience guide clinical practice.

The main concern with the transcutaneous approach has traditionally been the feared complication of lower eyelid ectropion and retraction, which can occur in up to 30% of cases.72 Postblepharoplasty lower lid malposition is the most common complication from surgery, as well as the most common reason for reoperation.73 The anatomic explanation for lower lid malposition after blepharoplasty has been violation of the orbital septum with subsequent scarring and cicatricial changes. However, a recent retrospective study showed no difference between rates of lower lid retraction for transconjunctival blepharoplasty performed with and without isolated violation of the

orbital septum in over 500 patients, suggesting that eyelid malposition may be more related to “multilamellar” scar formation when tissue in addition to the septum is violated.74 The location of the conjunctival incision in transconjunctival blepharoplasty may be a previously unrecognized factor in multilamellar scarring and ectropion development. The traditional location has been described as 1 to 2 mm below the inferior edge of tarsus. However, Undavia et al. recently advocated an incision 6.5 to 7.5 mm below the inferior tarsal border for the most direct access to the lower lid fat compartment and possible minimization of scarring.75

While many have argued that lateral canthal support should be a requisite part of the lower lid blepharoplasty procedure to prevent ectropion and retraction,76 others feel that lateral canthal support is only necessary when skin is being removed and/or aggressive laser resurfacing is being performed.77,78 Regardless, lid malposition seems to occur less frequently with concomitant canthal suspension.35,44,46,78–83 There are many different techniques described for obtaining lateral canthal support84: lateral canthoplasty (canthal reattachment after cantholysis), lateral canthopexy (canthal tightening without cantholysis), lateral tarsal strip, “mini-tarsal strip,” and lateral retinacular suspension. Lateral canthoplasty and canthopexy are generally reserved for those who need canthal support, but do not have lid laxity and do not need lid shortening.85 The lateral tarsal strip procedure is reserved for those with excess lid laxity and results in lid shortening and tightening, but can be associated with longer healing time, a higher rate or dehiscence, and an unnatural contour to the lower lid.86 The “mini tarsal strip” was developed to reduce postoperative morbidity associated with a full strip, but to still provide minimal lid shortening in cases of mild lid laxity and a similar tightening effect.87 The lateral retinacular suspension provides superolateral elevation of the lateral canthal tendon through an upper blepharoplasty incision, but can lead to an unnatural appearing superotemporal web.44

Attempts to reduce the rate of lower lid malposition popularized the transconjunctival approach,88–90 which was first described in 1924.91 This approach was further developed by Tessier for use in surgical exposure of the inferior orbital rim in craniofacial reconstruction and fracture repair.92 In addition to a reduction in the rate of postoperative eyelid malposition, the transconjunctival approach was felt to allow better exposure of the lower lid fat pads, the option of pedicled fat pad repositioning, and septal resuspension.93–96 Through the 1970s and 1980s, the predominant technique of cosmetic lower lid blepharoplasty evolved with the underlying principle of transconjunctival fat excision.97,98

Since this approach eliminated an external skin incision, excess skin was addressed with a skin pinch, an ablative laser, or chemical peel.99–101 The skin pinch procedure has been extensively described as an adjunct to transconjunctival lower lid

blepharoplasty in cases of excess skin. It can be combined with a lateral resuspension procedure with or without lower lid shortening.102,103 However, one retrospective study comparing transconjunctival lower lid blepharoplasty with and without skin pinch and no lateral canthal suspension, found no difference in postoperative rates of lower lid retraction, suggesting that a canthal resuspension may not always be necessary when a skin pinch is performed.77

There are no direct comparative studies of transconjunctival and transcutaneous lower lid blepharoplasty. However, there is one retrospective study comparing CO2 laser-assisted transconjunctival lower lid blepharoplasty with laser skin resurfacing and CO2-assisted transcutaneous lower lid blepharoplasty.104 While it was a small study, there were similar success rates between treatment groups. CO2 laser assistance can be used for both upper and lower lid transconjunctival and transcutaneous blepharoplasty. Compared to electrocautery, advantages include shorter operating time, less bleeding, and less tissue damage, with reduced postoperative discomfort.105 Disadvantages include the potential for poor wound healing, time spent learning (median of 3 hours of hands-on training), and equipment expense. Safety measures include stainless steel eye protection for the patient and safety glasses for the operative team.106 Some advocate for simultaneous CO2 laser lower lid blepharoplasty with muscle and septal laser tightening.107

While both transcutaneous and transconjunctival blepharoplasty with fat debulking may lead to satisfactory results, these approaches can worsen convexities at the tear trough and lid–cheek junction. As a result, there has been a recent trend toward greater preservation and augmentation of lower lid and midface volume. Part of this change in practice is related to a better anatomical understanding of the lid–cheek junction and midface.4,108–110 Instead of fat excision, many now advocate for fat preservation and repositioning as a more effective means of lower lid and midface rejuvenation. First introduced in isolation to address the tear trough deformity,111,112 fat repositioning was later described in combination with septal reset procedures and found to have relatively low complication rates with reproducibly successful cosmetic outcomes.113–115

Since then, modified approaches of fat repositioning have additionally been described, mainly involving repositioning in the subperiosteal plane instead of only in the supraperiosteal plane.116 Subperiosteal repositioning is advantageous because it is relatively bloodless, offers a lower likelihood of injury to the infraorbital nerve because of better exposure, and allows for direct suturing of the fat pedicle to overlying periosteum.89 However, more recent studies suggest that repositioning in the supraperiosteal plane is technically easier, with cosmetic outcomes that are just as good as subperiosteal repositioning.94,117

When there is minimal herniation of orbital fat, but infraorbital hollowing, injectable filler treatment to augment volume loss without surgery has been effective for return of a more youthful contour.37,38,118 However, when there is herniation of orbital fat with a clear convexity along the length of the lower lid, fat excision and/or repositioning should be performed. Another component important to a smooth lid–cheek junction is the release of the orbicularis retaining ligament, which has been described with encouraging results.119,120 Midface lift can also be coupled with lower lid blepharoplasty to further support and elevate the lower lid.121