An integrated approach to lower blepharoplasty.

BACKGROUND Limitations associated with traditional skin-muscle flaps and later with transconjunctival fat resection combined with carbon dioxide laser resurfacing have led to newer concepts in lower blepharoplasty that emphasize fat preservation, blending of the lid-cheek junction, simplified skin excision, and less morbid resurfacing techniques. Avoiding incision through the orbicularis muscle to preserve its innervation and reduce translamellar scarring is favored, as is a more liberal use of lateral canthal tightening procedures. This study investigates the use of a transconjunctival approach to resect and transpose fat combined with a skin flap technique that permits skin excision and simultaneous resurfacing with 30% trichloroacetic acid. The orbicularis is not violated and lateral canthal support is used as necessary. METHODS Lower blepharoplasty performed in 248 patients over a 4-year period was studied. The technique consisted of component procedures that varied based on individual anatomy. RESULTS Fat excision was performed in 91 percent, fat transposition was performed in 61 percent, skin excision was performed in 63 percent, trichloroacetic acid peels were performed in 62 percent, temporary tarsorrhaphy was performed in 31 percent, and lateral canthopexy was performed in 18 percent of patients. Average follow-up was 5.5 months. There were three complications and six revisions. CONCLUSIONS Lower blepharoplasty that integrates component techniques tailored to individual anatomical problems and spares the orbicularis muscle is effective and associated with few complications and revisions. Fat transposition achieves effacement of the tear trough deformity. A skin flap approach effectively treats rhytides and is safe for simultaneous resurfacing with a mild peeling agent. Selective use of lateral canthal support improves lower eyelid tone and prevents malposition problems.