Histopathological Characteristics of the Orbicularis Oculi Muscle After Lower Blepharoplasty With or Without Myotomy

  • S. LessaEmail author
  • J. Pontello
  • R. Wanick
  • E. Flores
  • W. Costa
  • F. J. Sampaio
Original Article Oculoplastic


Lower blepharoplasty is a challenging aesthetic procedure. Despite advances in clinical and neuroanatomical studies related to orbicularis oculi muscle innervation, no study has examined its histopathological aspects in different lower blepharoplasty procedures. This study aimed to assess changes in the pretarsal muscle complex in patients treated with transcutaneous lower blepharoplasty with orbicularis myotomy versus those treated with transconjunctival blepharoplasty without myotomy.


A total of 268 patients underwent blepharoplasty performed by a single surgeon: transcutaneous lower blepharoplasty in 112 (41.7%) and transconjunctival lower blepharoplasty with retroseptal access in 156 (58.2%). Subsequent minor blepharoplasty procedures were performed in 32 patients with lower pretarsal orbicularis oculi muscle biopsy. Connective tissue, fibrillar elastic system, nerves, blood vessels, fiber diameter, and sarcomeres were analyzed.


Without myotomy: collagen, 9.46 ± 0.41%; elastin, 7.03 ± 0.62%; blood vessels, 4.25 ± 0.06%; nerves, 5.2 ± 0.55%; fiber diameter, 62 ± 8.0 μm; and sarcomere, 1.9 ± 0.11 μm. With myotomy: collagen, 19.02 ± 1.66%; elastin, 7.88 ± 1.10%; blood vessels, 5.13 ± 0.70%; nerves, 2.9 ± 0.48%; fiber diameter, 49 ± 6.5 μm; and sarcomere, 1.8 ± 0.17 μm.


Excess endomysial connective tissue, particularly between muscle fibers, should be considered pathological. The pathological changes in the pretarsal muscle complex after blepharoplasty with myotomy may have resulted from innervation interruptions as well as vascularization blockages.


Surgeries with myotomy caused significant changes in collagen, nerves, and muscle fiber diameter. These observations strongly suggest the superiority of a technique that preserves orbicularis oculi muscle integrity.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors


Pretarsal orbicular complex Histopathology Myotomy 


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflicts of interest to disclose.

Ethical Approval

All surgical procedures were performed in the author senior private practice and were in accordance with the ethical standards of the institutional and for national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed Consent

All persons involved in this study have given informed consent to include muscle sample for scientific or education purpose and for publication of the results of this study.


  1. 1.
    American Society for Aesthetic Plastic Surgery, Cosmetic Surgery National Data Bank; Statistics 2012.
  2. 2.
    Castanãres S (1951) Blepharoplasty for herniated intra-orbital fat: anatomical basis for a new approach. Plast Reconstr Surg 8:46–58CrossRefGoogle Scholar
  3. 3.
    Beare R (1967) Surgical treatment of senile changes in the eyelids: the McIndoe–Beare technique. In: Smith B, Converse JM (eds) Proceedings of the second international symposium on plastic and reconstructive surgery of the eye and adnexa. Mosby, St. Louis, pp 262–366Google Scholar
  4. 4.
    Tomlinson FB, Hovey LM (1975) Transconjunctival lower lid blepharoplasty for removal of fat. Plast Reconstr Surg 56:314–318CrossRefGoogle Scholar
  5. 5.
    Schwarz F, Randall P (1980) Conjunctival incision for herniated fat. Ophthalmic Surg 11:276–279Google Scholar
  6. 6.
    Baylis HI, Long JA, Groth MJ (1989) Transconjunctival lower eyelid blepharoplasty: technique and complications. Ophthalmology 96:1027–1032CrossRefGoogle Scholar
  7. 7.
    Aston SJ (1988) Skin-muscle flap lower lid blepharoplasty. Clin Plast Surg 15:305–308Google Scholar
  8. 8.
    Zaren HA, Resnick JJ (1991) Expanded applications for transconjunctival lower eyelid blepharoplasty. Plast Reconstr Surg 88:215–220CrossRefGoogle Scholar
  9. 9.
    Codner MA, Wolfli JN, Anzarut A (2008) Primary transcutaneous lower blepharoplasty with routine lateral canthal support: a comprehensive 10-years review. Plast Reconstr Surg 121:241–250CrossRefGoogle Scholar
  10. 10.
    Rohrich RJ, Ghavami A, Mojallal A (2011) The five-step lower blepharoplasty: blending the eyelid–cheek junction. Plast Reconstr Surg 128:775–783CrossRefGoogle Scholar
  11. 11.
    Hamako C, Baylis HI (1980) Lower eyelid retraction after blepharoplasty. Am J Ophthalmol 89:517–521CrossRefGoogle Scholar
  12. 12.
    Carraway JH, Mellow CG (1990) The prevention and treatment of lower lid ectropion following blepharoplasty. Plast Reconstr Surg 85:971–981CrossRefGoogle Scholar
  13. 13.
    Mc Graw BL, Adamson PA (1991) Post blepharoplasty ectropion. Prevention and management. Arch Otolaryngol Head Neck Surg 117:852–856CrossRefGoogle Scholar
  14. 14.
    Baylis HI, Nelson ER, Goldberg RA (1992) Lower eyelid retraction following blepharoplasty. Ophthalmic Plast Reconstr Surg 8:170–175CrossRefGoogle Scholar
  15. 15.
    Seiff SR (1992) Complications of upper and lower blepharoplasty. Int Ophthalmol Clin 32:67–77CrossRefGoogle Scholar
  16. 16.
    Palmer FR, Rice DH, Churukian MM (1993) Transconjunctival blepharoplasty complications and their avoidance: a retrospective analysis and review of the literature. Arch Otolaryngol Head Neck Surg 119:993–999CrossRefGoogle Scholar
  17. 17.
    Ramirez OM, Santamarina R (2000) Spatial orientation of motor innervation to the lower orbicular oculi muscle. Aesthet Surg J 20:107–113CrossRefGoogle Scholar
  18. 18.
    Hwang K, Lee DK, Chung IH, Lee SI (2001) Innervation of the lower eyelid in relation to blepharoplasty and mid face lift: clinical observation on cadaveric study. Ann Plast Surg 47:1–7CrossRefGoogle Scholar
  19. 19.
    Lowe JB, Cohen M, Hunter DA, Mackinmon SE (2005) Analysis of the nerve branches to the orbicularis oculi muscle of the lower eyelid in fresh cadavers. Plast Reconstr Surg 116:1743–1749CrossRefGoogle Scholar
  20. 20.
    Byrd HS (2005) Discussion of analysis of the nerve branches to the orbicularis oculi muscle of the lower eyelid in fresh cadavers. Plast Reconstr Surg 116:1750–1751CrossRefGoogle Scholar
  21. 21.
    Nemoto Y, Sekino Y, Kaneko H (2001) Facial nerve anatomy in eyelids and periorbit. Jpn J Ophthalmol 45:445–454CrossRefGoogle Scholar
  22. 22.
    McCord S, Codner M, Nahai F et al (2006) Analysis of the nerve branches of the orbicularis oculi muscle of the lower eyelid in fresh cadavers. Plast Reconstr Surg 118:556–557CrossRefGoogle Scholar
  23. 23.
    Ouattara D, Vacher C, De Vasconcellos JJ et al (2004) Anatomical study of the variations in innervation of the orbicularis oculi by the facial nerve. Surg Radial Anat 26:51–53CrossRefGoogle Scholar
  24. 24.
    Di Francesco LM, Anjema CM, Codner MA et al (2005) Evaluation of conventional subciliary incision used in blepharoplasty: preoperative and postoperative videography and electromyography findings. Plast Reconstr Surg 116:632–639CrossRefGoogle Scholar
  25. 25.
    Nestscher DT, Patrinely JR, Peltier M et al (1995) Transconjunctival versus transcutaneous lower lid blepharoplasty: a prospective study. Plast Reconstr Surg 96:1053CrossRefGoogle Scholar
  26. 26.
    Codner MA, Mc Cord CD (2016) Eyelid and periorbital surgery. CRC Press, Boca RatonGoogle Scholar
  27. 27.
    Cumming WJK, Fullthorpe JJ, Hudgson P, Mahon M (1994) Muscle pathology. Mosby-Wolfer, London, pp 15–17Google Scholar
  28. 28.
    Stuzin JM, Baker TJ, Baker TM (1999) Expanded applications for transconjunctival lower lid blepharoplasty (discussion). Plast Reconstr Surg 103:1044–1045CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2019

Authors and Affiliations

  1. 1.Plastic Surgery DivisionState University of Rio de JaneiroRio de JaneiroBrazil
  2. 2.Department of OpthalmologyState University of Rio de JaneiroRio de JaneiroBrazil
  3. 3.Urogenital Research UnitState University of Rio de JaneiroRio de JaneiroBrazil

Personalised recommendations