Comprehensive Considerations in Blepharoplasty in an Asian Population: A 10-year Experience
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- Guo, L., Bi, H., Xue, C. et al. Aesth Plast Surg (2010) 34: 466. doi:10.1007/s00266-010-9478-x
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This article discusses the effectiveness, patient selection criteria, complications, and the appropriate procedures for lower blepharoplasty in an Asian population.
During the past 10 years (1998–2008), a total of 2400 patients underwent lower blepharoplasty in our department. Four different types of lower-blepharoplasty procedures were performed, including the traditional transcutaneous skin flap procedure (n = 862), the transcutaneous skin-muscle flap procedure (n = 738), the transconjunctival procedure (n = 433), and Hamra’s procedure (septal reset and fat-replacing technique) (n = 367). Among these 2400 patients, 925 were available for follow-up. The length of follow-up ranged between 1 month and 10 years.
Most of the patients were satisfied with the result, but 32 patients had some postoperative complications, including five patients with ectropion, five with hollow eyes, two with dry eyes, and 20 with retraction.
Transconjunctival blepharoplasty is the first choice for primary eyelid bags. Transcutaneous lower blepharoplasty (skin flap or skin-muscle flap procedures) is indicated for the senile eyelid with excess skin and muscles. If supporting structures (skin, muscle, and septum) show laxity and other aging stigma are present, including tear trough deformity and obvious skeleton rim, Hamra’s procedure (septal reset and fat-replacing technique) is performed.
KeywordsTransconjunctival lower blepharoplastyTranscutaneous lower blepharoplastyHamra’s lower blepharoplastyAsian population
The well-known saying “eyes are a window to the soul” reflects the perception that a beautiful face begins with the eyes. The lower-eyelid contour in youth is smooth, but with advanced age it is disturbed by dermatochalasis, herniated fat, tear trough deformity, nasojugal groove, static rhytides in the periorbital region, and crow’s feet. The periorbital area is a cosmetically sensitive area of the face, and lower blepharoplasty is currently one of the most commonly performed aesthetic procedures. Lower blepharoplasty has been introduced in China to rejuvenate the lower eyelid since the late 1970 s and includes the traditional skin flap transcutaneous procedure, the skin-muscle flap transcutaneous procedure, the transconjunctival procedure, and Hamra’s procedure (the septal reset and fat-replacement technique).
Before the operation, the plastic surgeon must carry out a comprehensive analysis of the patient and choose the proper rejuvenation procedure to obtain a satisfactory aesthetic result. During the last 10 years (1998–2008), a total of 2400 patients underwent lower blepharoplasty in our department. Among these 2400 patients, 925 were available for follow-up. Reviewing our experience with lower-eyelid blepharoplasty from the last 10 years, we conclude that the principles and the choice of appropriate procedures are different for Asians compared to Caucasians. The aim of this study is to demonstrate the effectiveness, patient selection criteria, complications, and the appropriate procedures of lower-eyelid blepharoplasty in an Asian population.
The surgical anatomy of the lower eyelid is composed of an anterior and a posterior lamella. The anterior lamella is composed of the orbital septum, the orbicularis oculi muscle, and the skin. The orbicularis oculi muscle is further divided into pretarsal, preseptal, and orbital segments. The posterior lamella is composed of the tarsus, lower-eyelid retractor (or lower capsulopalpebral fascia), and the conjunctiva. The anterior lamella (skin, orbicularis oculi muscle, and septum) inserts into and supports the tarsal plate, which is responsible for the proper position of the lower-eyelid tarsus. When the supporting structures are vertically shortened, commonly as a result of overresection in blepharoplasty, lower-eyelid retraction, or ectropion, will occur. Laxity of the tarsus or the canthal ligament (especially lateral) will result in senile retraction or ectropion.
The infraorbital fat, located between the anterior and the posterior lamella, is bound anteriorly by the infraorbital septum and posteriorly by the lower-eyelid aponeurosis. The infraorbital fat is divided arbitrarily into three compartments, medial, central, and lateral, by means of the inferior oblique muscle and Lockwood’s ligament. Eyelid bags arise from the pseudoherniation of the orbital fat due to gravity or the lengthening and attenuation of support structures (skin, orbicularis oculi muscle, and septum).
Preoperative Evaluation and Selection of Procedures
Signs of aging in the periorbital area and selection of proper procedures
Orbicularis oculi muscle
Tear trough deformity
Tight, no rhytides
Chalasis, obvious rhytides
Transcutaneous skin flap blepharoplasty
Chalasis, obvious rhytides
Transcutaneous skin-muscle flap blepharoplasty, either combined with lateral canthus anchoring procedures or not
Chalasis, obvious rhytides
Hamra septal reposition method, either combined with lateral canthus anchoring procedures or not
Traditional Transcutaneous Blepharoplasty: Skin Flap Procedure
Transcutaneous Blepharoplasty: Skin-Muscle Flap Procedure
Hamra’s Septal Reposition Procedures
The patients are instructed to apply ice compresses during the first 24 h to minimize welling. One to two eye drops are used every 4–6 h for 2–3 days. Chloramphenicol eye drops are avoided because some patients could be allergic. The skin incision site should be cleaned with hydrogen peroxide and antibiotic ointment the next day. Oral antibiotics (Cephalexin) and discutientia are used for 3 days. The skin sutures are removed 5 days after the operation.
Complications of the four types of lower blepharoplasty procedures
No. of patients
Transcutaneous skin flap procedures
Transcutaneous skin-muscle flap procedures
Hamra’s septum reposition procedures
To date, blepharoplasty is one of the most commonly performed cosmetic surgeries . The procedures vary and include transconjunctival and transcutaneous procedures, the latter also including skin flap procedures, skin-muscle flap procedures and Hamra’s procedure (septal reset and fat-replacing technique). The proper choice of procedure for a particular patient and achievement of satisfactory aesthetic results are problems that haunt the plastic surgeon.
Congenital excessive orbital fat and laxity of the supporting structures of the lower eyelid contribute to palpebral bags [4–6]. About 10% of patients seeking lower blepharoplasty have primary eyelid bags that result from excess congenital orbital fat, which occurs mostly in the young. Over 90% of lower-eyelid bags can be ascribed to laxity of the supporting structures (skin, orbicularis oculi muscle, orbital septum, tarsus, and the lateral canthal tendon), with or without excess orbital fat . Other aging stigma of the lower eyelid include obvious tear trough deformity, aging double-convex lid-cheek complex, the deep and wide orbit, obvious skeleton rim, and the appearance of eyelid bags [5, 7]. Thorough assessment of the cause and expression of palpebral bags is necessary for optimal and safe selection of the surgical rejuvenation procedure to use.
Some plastic and aesthetic surgeons prefer the transconjunctival procedure, which was first described by Bourquet in 1924 and popularized since 1974 . The advantages of the transconjunctival procedure include avoidance of external incisions and scars, less swelling, and fast recovery. The integrity and innervation of the orbicularis oculi muscle are maintained in the transconjunctival procedure. Therefore, the strength of the muscle is retained, and the potential for scar contraction on both the skin and the orbicularis is avoided. The chance of lower-eyelid retraction or ectropion is decreased. In contrast, excess skin and muscle and periorbital rhytides cannot be treated with transconjunctival surgery. In a Caucasian patient with such conditions, chemical peeling or laser resurfacing should be used. Because chemical peeling or laser resurfacing can be used to improve the skin quality of the lower eyelids, it is believed by some surgeons that if orbital fat resection is indicated, transconjunctival lower blepharoplasty can also be performed on patients with skin laxity, even in the elderly [9, 10]. We do not think this method is suitable for Chinese patients because of the difference in skin type between Caucasians and Asians, who have a higher risk of hyperpigmentation after chemical peeling or laser resurfacing. Rather, transcutaneous blepharoplasty is a reliable and effective procedure for older Asian patients .
During the last 10 years, a total of 2400 patients underwent lower blepharoplasty in our department. Transconjunctival and transcutaneous procedures were performed. Among these 2400 patients, 925 were available for follow-up. The length of follow-up ranged between 1 month and 10 years. A great majority of the patients were satisfied with the results, but 32 patients had some postoperative complications, including hollow eyes, dry eyes, ectropion, and retraction. Ectropion and retraction were serious complications and mainly occurred after transcutaneous blepharoplasty, as the integrity of the orbicularis muscle and sometimes the innervation of the muscle were destroyed . Some patients (about 5%), who had undergone traditional skin flap procedures or skin-muscle flap procedures, obtained ordinary results because other aging stigma such as tear trough deformity and scleral show were not corrected.
Reviewing our 10 years of experience with lower-eyelid blepharoplasty, we conclude with the indications, advantages, and disadvantage of the different types of blepharoplasty in an Asian population.
For the primary baggy eyelid, mostly in young patients with fat herniation but without excess skin and muscle redundancy, the transconjunctival blepharoplasty technique is the first choice. Since it cannot treat laxity of the orbicularis oculi muscle and wrinkles, results in older patients are always unsatisfactory.
Excess skin and orbital fat can be removed at the same time with the transcutaneous blepharoplasty skin flap procedure, while the strength of the orbicularis oculi muscle is retained, which is an advantage of this procedure. Its shortcomings are that laxity of the muscle and tear trough deformity cannot be corrected and that the scar is obvious in some patients. Therefore, this procedure is suitable for patients with protruding palpebral bags and obvious rhytides but without laxity in the muscularis and tear trough deformity.
Transcutaneous skin-muscle flap procedures cannot only remove excess orbital fat, but can also correct laxity of the skin and the muscle. A disadvantage of this procedure is that the orbicularis oculi muscle is destroyed, resulting in lower-eyelid retraction and even ectropion in some cases. To avoid these annoying complications, the orbicularis oculi muscle is excised 2-3 mm lower than the skin incision line in skin-muscle flap procedures so that the strength of the pretarsal orbicularis oculi muscle is retained and the scar constrictions of the skin and the muscle are in different planes . Lateral canthal anchoring is advised in patients with lateral canthal laxity and prominent eyes, otherwise retraction and ectropion are possible [2, 14]. Another disadvantage of this procedure is that the tear trough deformity cannot be corrected. Thus, in our experience skin-muscle flap procedures are performed primarily in patients with skin and muscle laxity but without tear trough deformity and obvious scleral show.
Hamra’s septum reposition procedures can remove excess orbital fat, correct tear trough deformity, and mask the obvious skeleton rim. This procedure can refresh the appearance of periorbital aging, lift the cheek at the same time, rejuvenate the lid-cheek complex, and provide long-lasting results . This procedure, however, is complicated and difficult to perform, and the recovery time is long. Therefore, the indication for its use should be strict. In the authors’ opinion, Hamra’s septum reposition should be restricted to patients with laxity of the anterior lamella (skin, muscle, and septum) of the lower eyelid accompanied by obvious tear trough deformity and scleral show.
Transconjunctival blepharoplasty is the first choice for the treatment of primary eyelid bags. Transcutaneous lower blepharoplasty (skin flap or skin-muscle flap procedure) can remove excess orbital fat and correct laxity of the skin and the muscle at the same time, and is indicated for the older eyelid with excess skin and muscle. Hamra’s procedure is performed if supporting structures (skin, muscle, and septum) show laxity and other aging stigma such as tear trough deformity and obvious scleral show are present. Comprehensive consideration of the characteristics of eyelid bags in Asian populations, choosing suitable procedures, and performing them carefully are critical in achieving satisfactory aesthetic results.