AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Multimedia
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Multimedia
• References

Rejuvenation of the orbital area is one of the most sought-after procedures in aesthetic surgery. According to the American Society of Plastic Surgeons, eyelid surgery is the fourth most common cosmetic surgical procedure, with at least 233,000 procedures performed in 2006. Numerous approaches to rejuvenation of the lower eyelids have been described in the literature. A successful surgeon must have intricate knowledge of the periorbital anatomy, sound training in the various approaches to the periorbita, and a healthy respect for the potential complications.

Transcutaneous lower blepharoplasty is defined as a process of improving the appearance of the lower eyelids by using a subciliary skin incision. The technique of lower lid blepharoplasty has evolved dramatically over the past 50 years. With careful observation, it becomes evident that a single procedure cannot correct all undesirable features caused by aging and individual anatomic variations. Progress in this area has occurred after critical review of results by practitioners who have accumulated large series of patients and by careful anatomic studies in the cadaver laboratory and the operating room.

History of the Procedure

As described in the Indian document Susruta-tantra, the origins of eyelid surgery are believed to date back to 400 BCE.¹ The term blepharoplasty was coined by Von Graefe in 1818 to describe eyelid surgery. Based on contributions from Miller,² Bourguet,³ and Noel,⁴ Castañares defined the pathology of orbital "bags" from pseudoherniation of orbital fat.⁵ He described what may be considered the modern blepharoplasty, in which skin was elevated from the orbicularis muscle and postseptal fat was resected.

Bourguet is credited with the first description of separate retroseptal fat compartments and the transconjunctival approach to its removal.³ Transconjunctival blepharoplasty is suited for patients with bulging fat in the lower lids, with little or no skin excess.

Sir Archibald McIndoe was the first to perform elevation of the skin-muscle flap with resection of retroseptal fat in the 1950s. The technique gained popularity because of its use of dissection, which afforded an increased margin of safety. This technique is ideal for patients with excesses of both fat and skin of the lower lid.

Furnas, perhaps as a precursor to current approaches in midfacial elevation, recognized that bags in the aging lower lid may be more than lax skin and fat.⁶ He focused on the contribution of laxity of the orbicularis oculi muscle in the aging lid in certain individuals and demonstrated that addressing the lax orbicularis muscle improved results in these individuals.⁶ Loeb described the concept of fat preservation and translocation rather than resection to soften the transition between the lower eyelid and cheek in the nasojugal fold.⁷ Hamra championed the cause of fat preservation and expanded the concept with complete release of the arcus marginalis with fat translocation to soften the prominent orbital rim and nasojugal fold in the aging orbit.⁸

In the early 1990s, skin resurfacing with chemical peels and carbon dioxide laser resurfacing combined with transconjunctival lower lid fat resection radically changed the approach to lower lid rejuvenation.⁹ In general, the transconjunctival approach to fat removal has been associated with reports of faster recovery and a lower occurrence rate of lower lid malposition, though this was not substantiated in a comparative study.^{10, 11} Proponents of this technique cite denervation of the orbicularis oculi muscle after transcutaneous blepharoplasty as an etiology of lower lid malposition. Recent studies using electromyography and videography dispute this assumption.¹²

In recent years, emphasis has been given to adding lateral canthal support as an important adjunct to lower lid blepharoplasty. Lower lid malposition and ectropion are among the most feared complications following lower lid blepharoplasty. Lateral canthoplasty and lateral tarsal strip procedures were initially used to correct established lid malposition; however, more recently, it has become an accepted and useful prophylactic measure against lid malposition in cosmetic blepharoplasty.^{13, 14, 15}

The 1990s was also a time of intense interest in alternative approaches to midfacial rejuvenation. Just as the brow contributes to the aging changes in the upper lid, cheek descent in the midface commonly accompanies aging changes in the lower lid. Improvement in the aesthetic results has been achieved through a number of alternative methods of addressing the midface along with the lower eyelid. The transcutaneous lower eyelid incision became a popular approach for lifting the soft tissues of the cheek through a subperiosteal or preperiosteal approach.¹⁶ Cheek lifting through a subciliary incision is not in the scope of this chapter.

Alternatively, cheek augmentation either with fat or alloplastic material has been recommended to address the sequelae of midfacial aging.^{17, 18} As a result of more extensive rejuvenation procedures in the midface and of deep skin resurfacing techniques, lower lid support now is recognized as a critical component of lower lid rejuvenation.

Clinical

Preoperative assessment

Jelks and Jelks have nicely detailed the preoperative evaluation and considerations to minimize postoperative complications and dissatisfaction.¹⁹ First, the surgeon must listen carefully to the patient's description of the problem for which he or she desires correction. Elicit any history of eye surgery or ophthalmologic problems. Query patients about unusual tearing or eye dryness, frequent blinking, redness or burning of the eyes, or contact lens intolerance. Medical disease processes that potentially can result in periorbital problems include hyperthyroidism or hypothyroidism; renal, cardiac, or hepatic dysfunction; and collagen-vascular disorders. Chronic allergies, prior eye surgery, past psychiatric history, tobacco and alcohol use, and steroid usage should also be noted.

The disastrous consequences of perioperative bleeding must be avoided if possible. The use of anticoagulation medications must be discontinued, and the coagulation profile should be normal prior to elective cosmetic surgery in the periorbital area. The patient should discontinue aspirin and antiplatelet agents 3 weeks prior to surgery and for 1 week afterward.

Physical

The goals of the physical examination are to determine the relative contribution of the anatomic components of the lower lid and periorbital area to the patient's complaint and to screen for preexisting ophthalmologic conditions that may affect the surgical approach. Carefully note the surface anatomy of the periorbital region (see Image 4). Preoperative photography is essential for documenting existing eyelid and periorbital anatomy. The recommended preoperative views include full-face close-up views of the periorbital area with eyes in neutral and upward gaze and lateral views. Photographs should be of such quality that valid comparisons can be made between the preoperative and postoperative conditions.

Jelks and Jelks described the relationship between the anterior projection of the globe, lower lid, and malar eminence as representing the key element in the preoperative evaluation (see Image 6).¹⁹ A negative relationship exists when the globe lies anterior to the lower lid and malar eminence. A negative relationship has a high risk of postoperative lid malposition and is an indication to include a technique for lower lid support in the treatment plan.

Perform the lid snap-back test for excess lower lid laxity. If the lid can be distended more than 10 mm from the globe or if the lid does not briskly return to its natural resting state, include a lower lid support procedure in the treatment plan. Document and demonstrate to the patient existing scleral show and lagophthalmos. Record visual acuity for best-corrected vision to screen for unrecognized deficits. Test each eye separately.

McKinney and Byun reported that the Schirmer test and tear film breakup analysis have not been as predictive for postoperative dry eye problems as the preoperative history and physical examination, and they are not performed routinely.²⁰

If the patient has a history of ophthalmologic problems or concerns are identified in the preoperative history and physical examination, preoperative consultation with an ophthalmologist is recommended.

Again, standardized preoperative photographs should be a routine part of the surgeon's preoperative assessment. Fine lines, crow's feet, dyschromias, and telangiectasias should be pointed out to the patient preoperatively. Discussion about adjunctive procedures to address these problems should occur before surgery.

INDICATIONS

Section 3 of 9  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Multimedia
• References

Candidates for lower lid blepharoplasty should undergo a thorough preoperative history and physical examination. Psychological stability with regard to clearly defined goals and expectations preoperatively is the cornerstone for successful results and satisfied patients in eyelid surgery. Lower lid blepharoplasty can successfully correct excess skin, excess fat, and hypertrophied muscle. Problems such as exophthalmos, eyelid edema, eyelid dyschromias or other lesions, and prominent orbital rims are not correctable by blepharoplasty alone.

RELEVANT ANATOMY

Section 4 of 9  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Multimedia
• References

The anatomy and innervation of the lower lid (see Image 1) has been described in detail previously in numerous articles and texts.^{15, 13, 21, 12, 22}

• Superficial anatomy: The lower lid margin ideally rests 1-2 mm above the lower level of the limbus and makes a gentle S curve; it defines the lower half of the palpebral fissure.
• Skin: The skin of the lower eyelid is relatively thin and closely attached in the pretarsal area and becomes relatively thicker and more loosely attached as the lid blends into the cheek. This region is susceptible to engorgement by edema fluid. Hester et al named the fibrous attachment from the orbital rim to the skin in the area of the lid-cheek junction the orbitomalar ligament (see Image 2).²¹ This attachment often contributes to a sharp definition between the cheek and lower lid that becomes more pronounced with aging.
• Muscle: The 3 components of the orbicularis oculi muscle are pretarsal, preseptal, and orbital. The muscle is densely adherent to the overlying skin. Medially, the preseptal orbicularis has 2 heads, of which the anterior head becomes the anterior crus of the medial canthal tendon and inserts on the frontal process of the maxilla. The posterior head inserts onto the posterior lacrimal crest. The orbicularis muscle is innervated primarily by the zygomatic branch of the facial nerve laterally and by the buccal branch of the facial nerve medially. These branches join to form a plexus of nerves that penetrate the deep surface of the muscle in a segmental fashion.
• Septum/fat: The orbital septum is a fibroelastic membrane that contains orbital fat. The attachment of the septum to the orbital rim is referred to as the arcus marginalis. From a surgical perspective, orbital fat is approached in 3 compartments: the lateral compartment rests slightly above the other 2 compartments, the central compartment and the medial compartment, which are separated from the lateral by the inferior oblique muscle. The lateral compartment is the most frequently missed fat compartment in aesthetic procedures of the lower lid. Resection of the lateral compartment alternatively may be performed through an upper lid approach. The relationship of the lower lid structures to the malar fat pad, superficial musculoaponeurotic system, and suborbicularis oculi fat is depicted in Image 3.

Signs of aging in the lower lid and midface include laxity and loss of elasticity of the skin that results in variable degrees of fine and coarse wrinkling and dyspigmentation, laxity of the tarsus with inferior displacement of the lid margin, pseudoherniation of orbital fat, and descent of the lid-cheek junction and the soft tissues of the cheek. Atrophy of subcutaneous fat destroys the youthful smooth transition between the lid and cheek and, combined with cheek descent, may result in prominence of the orbital rim and so-called skeletonization of the orbit. The orbicularis oculi muscle may become flaccid and redundant and contribute to the formation of festoons.

The classification of midfacial aging by Hester et al is quite helpful in the analysis and choice of surgical procedure for correction (see Image 5).²¹ As a general rule, a procedure confined to the lower lid is appropriate for types 1 and 2 aging but results in limited improvement and dissatisfaction if applied alone to types 3 and 4 aging. Aging beyond the lower lid requires treatment by cheek lift or face lift or perhaps fat injections or malar implants and is beyond the scope of this article. For expert viewpoints and journal articles on additional aesthetic procedures, visit Medscape's Aesthetic Medicine Resource Center. Click here for a CME activity on injectable fillers.

CONTRAINDICATIONS

Section 5 of 9  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Multimedia
• References

The major contraindication to this surgery is unrealistic patient expectations about the effect of lower lid blepharoplasty on facial appearance.

Patients with endocrinological and other medical conditions that lead to the appearance of lax and bulging lids are generally not candidates for surgical correction.

Patients with dry eye syndrome should be approached with great care, and consultation with an ophthalmologist is recommended for these patients. Only rarely should skin be resected at a secondary blepharoplasty if skin had been resected previously.

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Multimedia
• References

Intraoperative Details

Patient preparation, marking, and incision

• The procedure may be performed with the patient under local or general anesthesia. If local anesthesia is chosen, intravenous sedation with appropriate monitoring is recommended.
• Prepare the face with povidone-iodine (Betadine) paint. Dry the skin and mark the incision with a fine-tip marker approximately 2 mm below the ciliary margin in the first natural crease below the lash line (see Image 7). Extend the incision laterally in a natural crease but not past the orbital rim.
• Using a 27-gauge needle on a small-volume syringe, carefully infiltrate 1% lidocaine (Xylocaine) with 1:200,000 parts epinephrine and 8% sodium bicarbonate combined in a 1:5 ratio subcutaneously in the area of the incision and subcutaneously down to the orbital rim. No deep injections are made. Repeat the method on the contralateral side and allow at least 5-7 minutes for the local anesthetic to take effect.

Flap elevation

• If a skin flap is chosen, score the incision across the lower lid as marked and deepen the incision laterally through the skin.
• With a small hook for retraction, use scissors to develop a subcutaneous plane across the subciliary margin, with care to protect the lashes. Then use sharp scissors to complete the incision and skin hooks to retract the flap.
• The Frost suture of 5-0 silk placed in the gray line lateral or medial to the limbus facilitates retraction and protects the globe. Alternatively, a lubricated corneal shield may be inserted (see Image 8).
• Elevate the flap off the orbicularis muscle down below the last wrinkle or to the orbital rim. Obtain hemostasis using fine-tip cautery under low power.
• If a skin muscle flap is chosen, the original incision is the same. Raise the skin flap to preserve attachment of 4 mm of pretarsal orbicularis muscle (see Image 8).
• Divide the orbicularis muscle; the retro-orbicular plane is identified readily and raised down to the orbital rim.

Management of orbital fat

• The presence or absence of excess orbital fat is a critical determination. This is best assessed by examining the patient preoperatively while he or she is in the erect position and by studying preoperative photographs. Once the patient is supine, judgment regarding excess fat is much more difficult. Gentle pressure on the globe with the eyelids closed causes excess fat to bulge anterior to the orbital rim.
• If a skin flap has been elevated, open the orbicularis by incision over the medial, central, and lateral compartments. If a skin muscle flap is chosen, the exposure of all the compartments is in plain view. Open the compartments and tease out orbital fat with fine forceps and a small cotton-tip applicator.
• If the patient is under local anesthetic, inject a minute amount of local anesthetic before resection. Fine-tip insulated cautery has proven to be an effective tool for resection of excess retroseptal fat (see Image 9).
• The inferior oblique muscle is identified readily, separating the medial and central components, and it is protected easily. The lateral compartment is slightly higher than the central component and should be identified carefully because it is the most common compartment to be overlooked.
• In the case of a prominent nasojugal fold and/or malar fold, an arcus marginalis release may be performed, as described by Hamra in 1996 (see Image 9).⁸
• Open the periosteum along the orbital rim; a small amount of the septum may be resected. Mobilize the orbital fat and resect any extra fat. Preserve the lateral fat in particular. Attach the fat over the orbital rim with interrupted 5-0 Vicryl sutures.
• Alternative means of management of pseudoherniation of orbital fat have been described. Huang proposed supporting pseudoherniation of orbital septum by plication (see Images 10-11).¹⁶ Comparable aesthetic results with arguably less morbidity have been demonstrated. Long-term follow-up observation and more general application of this technique are awaited.

Orbicularis muscle and modified cheek lift

• After management of orbital fat, elevation and fixation of the orbital orbicularis muscle and soft tissue have been used to improve the aesthetic appearance of the lid in selected individuals. Furnas described elevating the skin of the superior rim of the skin muscle flap, resecting the excess muscle, and attaching or plicating excess orbicularis to the lateral orbital rim (see Image 13-14).⁶
• Hamra described using a laterally based pendant of orbicularis and suspending this pendant through an upper lid incision to avoid mass scar effect underneath the lateral skin closure (see Image 15).⁸
• Hester et al expanded the use of the subciliary incision for rejuvenation of the lower lid and midface.²¹ Division of the orbital malar ligament and mobilization of the upper cheek soft tissues in the preperiosteal or subperiosteal plane allow for more complete release of the lateral cheek soft tissues and vertical elevation. The orbicularis muscle and soft tissue are suspended to the lateral orbital rim and temporalis fascia (see Images 16-17). Secure suspension of this tissue along with lower lid support with a canthopexy or canthoplasty; conservative lower lid skin excision is emphasized to avoid complications.

Lower lid support

• Understanding of lower lid malposition has evolved significantly over the past 20 years. The following are indications for lower lid support procedures:
• • Lid laxity is noted in the preoperative physical examination
  • A skin flap technique is performed
  • Moderate-to-deep skin resurfacing procedures are performed
  • A modified cheek lift is performed
• Historically, the Kuhnt-Szymanowski procedure with resection of the lower lid just lateral to the limbus was recognized as a straightforward way of improving lid laxity. Occasionally this resulted in noticeable notching of the lid. In individuals with prominent eyes or low position of the lateral canthus, a Kuhnt-Szymanowski procedure actually may worsen lower lid malposition.
• Fagien described an algorithm for management of the lower lid support that summarizes the current approach.¹⁵ The lateral retinacular suspension with a simplified canthopexy is appropriate as a prophylactic measure in most cosmetic blepharoplasties and is appropriate treatment for mild-to-moderate lower lid laxity. The technique has been well described and is illustrated in Image 19. If significant lower lid length excess is present, horizontal lower lid shortening at the level of the lateral canthus with a tarsal strip and canthoplasty is recommended (see Image 18).

Skin excision

• Excess skin excision is traditionally the most common cause of lower lid malposition after lower lid blepharoplasty.
• Perform skin excision conservatively with skin fully redraped over the underlying lower lid structures. If the patient is under local anesthesia, having the patient look up with the mouth open aids in conservative resection of lower lid skin.
• Make a vertical incision at the level of the lateral canthus and place a key suture. Trim medial and lateral excess. Place sutures to reapproximate the existing edges (see Image 20).

Postoperative Details

• Ice compresses are recommended for the first 24-48 hours to control swelling and bruising.
• Patients should stay in an observational area at the surgery suite for at least 1-2 hours, and they should avoid strenuous exertion.
• Ocular lubrication with artificial tears and nighttime lubrication are recommended, particularly if the patient has a preexisting history of dry eyes or if lagophthalmus is present.

Follow-up

• Clear lines of communication should exist between the patient and surgeon, particularly in the first few days after surgery. Any reports of unusual pain or visual disturbance merit careful attention and evaluation.
• Remove sutures 4-7 days following surgery.

COMPLICATIONS

Section 7 of 9  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Multimedia
• References

Blindness is the most devastating complication of cosmetic blepharoplasty. Fortunately, this is quite rare, with a prevalence rate of less than 1 case (0.0045%) in 22,000 procedures (Hass, 2005). Retrobulbar hemorrhage and retinal ischemia have been implicated as causative. Although acute orbital hemorrhage does not always result in permanent visual loss, it is always considered a true ocular emergency and requires urgent intervention. The prevalence of orbital hemorrhage after blepharoplasty is approximately 1 case (0.055%) in 2000 procedures and occurs most commonly in the first 24 hours postoperatively.²³ Measures to reduce the risk of acute hemorrhage include (1) intraoperative and postoperative control of blood pressure, (2) strict control of hemostasis intraoperatively, (3) resection of fat under direct vision, and (4) avoidance of deep injections. Patients must avoid aspirin or antiplatelet agents for a minimum of 2 weeks before surgery.

Postoperatively, orbital hemorrhage is recognized by patient reports of pain, swelling, and proptosis. Associated changes in light perception may also be present. This condition is a true emergency that requires an emergency evaluation by an ophthalmologist. Open the incision, evacuate clots, and control bleeding. Usually, no one bleeding point is defined. If increased orbital pressure is suspected, perform a lateral canthotomy with lateral cantholysis. Control hypertension and consider osmotic diuresis.

Corneal injury is preventable by careful attention to technique, adequate corneal lubrication, and use of shields. If injury is suspected, diagnosis can be confirmed with fluorescein staining and illumination with a Wood lamp. Superficial injuries are managed with topical antibiotics. Patients should be reevaluated every 24 hours initially. More extensive or persistent injuries should be referred to an ophthalmologist.

Diplopia following blepharoplasty can be transient, related to edema or hematoma. Permanent diplopia results from injury to the periocular muscles or nerves. The inferior oblique muscle is the most frequently injured structure in lower lid surgery.²⁴ Conservative management is recommended initially. Persistent reports of diplopia should be referred for strabismus surgery.²⁴

Mild lagophthalmos occurs frequently and is usually present in the first week after blepharoplasty. Reports of blurred vision and irritation are associated with early postoperative lagophthalmos. Conservative treatment such as taping, lubrication, and massage are typically used until the problem resolves spontaneously. Persistent lagophthalmos may be due to overresection of skin or anterior lamellar scarring. Definitive surgical correction is necessary to correct persistent corneal exposure due to lagophthalmos. Surgical release of the scar with full-thickness grafts is occasionally required.

Lid malposition can be avoided by recognition of preoperative risk factors and by intraoperatively performing canthopexy and canthoplasty as appropriate. Postoperatively, lower lid support may be improved with taping or a temporary Frost suture during the first 4 days of peak edema.

Aesthetic problems following blepharoplasty include a hollowed-out appearance of the socket from overresection of fat. Conservative fat resection, as advocated by Hamra, can prevent this problem.^{8, 25} Occasionally, the patient reports underresection of fat. According to Putterman, the lower lateral compartment is most likely to be underresected.²⁶ Patient dissatisfaction resulting from preexisting fine lines and shadows may be addressed with adjunctive laser treatment, chemical peels, fat injections, or selective use of botulinum toxin (BOTOX®-A, Allergan), depending on the individual problem.

MULTIMEDIA

Section 8 of 9  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Multimedia
• References

Media file 1:  Anatomy of the periorbital region.
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Media file 2:  Cross-sectional anatomy of the mid face.
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Media file 3:  Cross-sectional anatomy of the mid face. SOOF indicates suborbicularis oculi fat; SMAS indicates superficial musculoaponeurotic system.
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Media file 4:  Topographic anatomy of the eyelid. No. 1 is superior eyelid fold, 2 is inferior eyelid fold, 3 is malar fold, 4 is nasojugal fold, and 5 is nasolabial fold. Adapted from Jelks, 1993.
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Media file 5:  Classification of midfacial aging by Hester et al.
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Media file 6:  Lateral view showing positive, neutral, and negative vector relationships between the globe and orbit.
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Media file 7:  Incision marking for subciliary approach as reported by Rees and Dupuis.
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Media file 8:  Technique of flap elevation from Rees and Dupuis. Note that this sketch depicts elevation of muscle flap. The author would like to use this perspective of depicting the skin muscle as shown and for elevation of the skin flap. For the skin muscle flap, the only other modification the author would make is to allow more pretarsal orbicularis to be left on the tarsus. For the skin flap, the incision is subcutaneous down to the orbital rim, and orbicularis is left intact.
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Media file 9:  Fat resection.
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Media file 10:  Huang's technique for septum plication.
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Media file 11:  Huang's technique for septum plication.
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Media file 12:  Hamra's arcus marginalis release.
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Media file 13:  Furnas' orbicularis resection and suspension.
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Media file 14:  Furnas' orbicularis resection and suspension.
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Media file 15:  Hamra's lateral orbicularis orbital suspension.
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Media file 16:  Modified cheek lift from Hester et al.
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Media file 17:  Modified cheek lift from Hester et al. SOOF indicates suborbicularis oculi fat; SMAS indicates superficial musculoaponeurotic system.
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Media file 18:  Fagien's lateral canthoplasty.
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Media file 19:  Fagien's simplified lateral canthopexy.
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Media file 20:  Skin excision and closure.
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REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Multimedia
• References

1. Wolfort FG, Kanter WR. History of blepharoplasty. In: Wolfort FG, Kanter WR, eds. Aesthetic Blepharoplasty. Boston, Mass: Little Brown & Co; 1995.
2. Miller CC. Cosmetic Surgery. In: The Correction of Featural Imperfections. Chicago, Ill: Oak Printing; 1908.
3. Bourguet J. Notre traitement chirurgical de "poches" sous les yeux sans cicatrice. Arch Fr Belg Chir. 1928;31:133.
4. Noel A. La chirurgie esthetique. Clermont (Oise); Theron et cie. 1928.
5. Castanares S. Blepharoplasty for herniated intraorbital fat; anatomical basis for a new approach. Plast reconstr surg (1946). Jul 1951;8(1):46-58. [Medline].
6. Furnas DW. The orbicularis oculi muscle. Management in blepharoplasty. Clin Plast Surg. Oct 1981;8(4):687-715. [Medline].
7. Loeb R. Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg. Oct 1981;8(4):757-76. [Medline].
8. Hamra ST. The role of orbital fat preservation in facial aesthetic surgery. A new concept. Clin Plast Surg. Jan 1996;23(1):17-28. [Medline].
9. Seckel BR, Kovanda CJ, Cetrulo CL Jr, Passmore AK, Meneses PG, White T. Laser blepharoplasty with transconjunctival orbicularis muscle/septum tightening and periocular skin resurfacing: a safe and advantageous technique. Plast Reconstr Surg. Oct 2000;106(5):1127-41; discussion 1142-5. [Medline].
10. Netscher DT, Patrinely JR, Peltier M, Polsen C, Thornby J. Transconjunctival versus transcutaneous lower eyelid blepharoplasty: a prospective study. Plast Reconstr Surg. Oct 1995;96(5):1053-60. [Medline].
11. Zarem HA, Resnick JI. Minimizing deformity in lower blepharoplasty. The transconjunctival approach. Clin Plast Surg. Apr 1993;20(2):317-21. [Medline].
12. DiFrancesco LM, Anjema CM, Codner MA, McCord CD, English J. Evaluation of conventional subciliary incision used in blepharoplasty: preoperative and postoperative videography and electromyography findings. Plast Reconstr Surg. Aug 2005;116(2):632-9. [Medline].
13. Glat PM, Jelks GW, Jelks EB, Wood M, Gadangi P, Longaker MT. Evolution of the lateral canthoplasty: techniques and indications. Plast Reconstr Surg. Nov 1997;100(6):1396-405; discussion 1406-8. [Medline].
14. Jelks GW, Glat PM, Jelks EB, Longaker MT. The inferior retinacular lateral canthoplasty: a new technique. Plast Reconstr Surg. Oct 1997;100(5):1262-70; discussion 1271-5. [Medline].
15. Fagien S. Algorithm for canthoplasty: the lateral retinacular suspension: a simplified suture canthopexy. Plast Reconstr Surg. Jun 1999;103(7):2042-53; discussion 2054-8. [Medline].
16. Huang T. Reduction of lower palpebral bulge by plicating attenuated orbital septa: a technical modification in cosmetic blepharoplasty. Plast Reconstr Surg. Jun 2000;105(7):2552-8; discussion 2559-60. [Medline].
17. May JW Jr, Zenn MR, Zingarelli P. Subciliary malar augmentation and cheek advancement: a 6-year study in 22 patients undergoing blepharoplasty. Plast Reconstr Surg. Dec 1995;96(7):1553-9. [Medline].
18. Ellenbogen R. Fat transfer: current use in practice. Clin Plast Surg. Oct 2000;27(4):545-56. [Medline].
19. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient. Bypassing the pitfalls. Clin Plast Surg. Apr 1993;20(2):213-23; discussion 224. [Medline].
20. McKinney P, Byun M. The value of tear film breakup and Schirmer's tests in preoperative blepharoplasty evaluation. Plast Reconstr Surg. Aug 1999;104(2):566-9; discussion 570-3. [Medline].
21. Hester TR Jr, Codner MA, McCord CD, Nahai F, Giannopoulos A. Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: maximizing results and minimizing complications in a 5-year experience. Plast Reconstr Surg. Jan 2000;105(1):393-406; discussion 407-8. [Medline].
22. Mowlavi A, Neumeister MW, Wilhelmi BJ. Lower blepharoplasty using bony anatomical landmarks to identify and avoid injury to the inferior oblique muscle. Plast Reconstr Surg. Oct 2002;110(5):1318-22; discussion 1323-4. [Medline].
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Article Last Updated: Apr 2, 2008