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Management of the Lower Lid in Male Blepharoplasty
Management of the Lower Lid in Male Blepharoplasty Jose E. Barrera, MD, Sam P. Most, MD* KEYWORDS
ANATOMY OF THE LOWER EYELIDS The position, volume, and form of the lower eyelid have functional and esthetic implications in the rejuvenation of the aging male face. The lower eyelids serve to protect the visual system while incorporating a three-dimensional transition between the inferior orbital fold and malar and nasojugal folds. Esthetically, the youthful eyelid cheek complex consists of a single mildly convex line on profile. Aging causes descent of the globe and subsequent pseudoherniation of the orbital fat, producing a double convex lower eyelid contour on profile. In addition, increased distance between the lower lid margin and inferior orbicularis oculi muscle attributable to attenuation of the ligamentous support produces skeletonization of the orbital area and exposure of the inferior bony rim.1,2 The lower lid margin normally rests at the inferior limbus, with its low point just lateral to the pupil.3 The malar and nasojugal folds represent the cutaneous insertion of the orbitomalar ligament, a unique bony attachment of the orbicularis oculi.4 The lateral canthus lies 2 to 4 mm superior to the medial canthus. The adult palpebral fissure averages 10 to 12 mm vertically and 28 to 30 mm horizontally, with the distance from the lateral canthus to the orbital rim being 5 mm.3 The eyelid lamella can be divided into anterior, middle, and posterior lamellae. The anterior lamella is composed of skin and orbicularis oculi muscle. The middle lamella is occasionally described as the orbital septum. The posterior lamella is composed of the tarsus, septum, and underlying conjunctiva.3,5
The eyelid skin is thin, likely secondary to being devoid of subcutaneous fat. Deep to the skin lies the orbicularis oculi muscle, which is divided into orbital, preseptal, and pretarsal portions. The orbital portion arises from the medial canthal tendon (MCT) and interdigitates laterally with the skin, contributing to crow’s feet. The preseptal and pretarsal portions make up the palpebral section, which lies over the tarsal plate and orbital septum. The preseptal and pretarsal segments have two heads, one deep and one superficial. The deep heads arise from the posterior crest of the lacrimal fossa and fossa itself. The superficial ends come from the MCT, which itself inserts into the anterior lacrimal crest. Laterally, these fibers condense to become the Whitnall’s tubercle and the lateral canthal tendon.3 The orbital septum originates from the arcus marginalis along the orbital rim and is continuous with the orbital periosteum.3 It fuses with the capsulopalpebral fascia to form a single fascial layer and fuses into the tarsal base. The capsulopalpebral base of the inferior rectus attaches to the tarsal base and allows for lower lid retraction during downward gaze. Further, the inferior oblique muscle also contributes to Lockwood’s ligament at its most forward extension (Fig. 1). Behind the orbital septum is fat, which is traditionally divided into lateral, central, and medial compartments. The lateral fat pad is smaller and more superiorly placed. The central and medial fat pads are divided by the inferior oblique muscle. The medial fat pad is lighter in color, more fibrous, and more compact. A sizeable blood vessel is often present in the medial compartment.
Division of Facial Plastic and Reconstructive Surgery, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94305, USA * Corresponding author. E-mail address: [email protected] (S.P. Most). Facial Plast Surg Clin N Am 16 (2008) 313–316 doi:10.1016/j.fsc.2008.05.001 1064-7406/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
Blepharoplasty Eyelid Transconjunctival Lower
314
Barrera & Most
Inferior tarsus
Inferior tarsal muscle Capsulopalpebral fascia (CPF) Orbital septum Inferior oblique muscle Orbital fat Orbitomalar ligament Orbicularis muscle Malar fat pad Suborbicularis oculi fat (SOOF)
Fig. 1. Cross-sectional diagram of the lower eyelid.
Sensory innervation to the lower lid derives from the infraorbital nerve (V2) with minor contributions from V1 and the zygomaticofacial nerve branches of V2. The blood supply comes from angular, infraorbital, and transverse facial arteries. The marginal arcade condenses between the orbicularis and the tarsus.
Topographic examination includes noting the nasojugal fold, malar fold, and inferior eyelid fold in addition to fat compartments (Fig. 2). Assessment of the fat pockets can be enhanced by directing the patient’s gaze while palpating the lower eyelid. In particular, superior gaze accentuates the medial and central pockets, whereas contralateral gaze enhances the lateral pocket. Vector determination, as described by Jelks, should be performed.6 A neutral vector (one in which the cornea is in line with the orbital rim) or positive vector (cornea posterior to the rim) is desired, whereas a negative vector (cornea anterior to the rim) may limit the amount of orbital fat that can be removed, due to the higher risk of ectropion postoperatively (Fig. 3). Recognizing orbital vectors alerts the surgeon to the risk for suboptimal esthetic result, and such information should be shared with the patient preoperatively. The most common cause of lower lid ectropion after blepharoplasty is failure to recognize lower lid laxity in the preoperative setting.5,7 Therefore, assessment of the lid supporting structures and vector must be done. One way of doing this is by performing the lid distraction test. Grasping the midportion of the lower lid with the thumb and index fingers and outwardly displacing the lid from the globe is called the snap test. The lid distraction test should also be performed. If the lid margin moves greater than 10 mm, there is abnormal laxity and a lid-shortening procedure may be entertained. Another way is by using the index finger
PREOPERATIVE EVALUATION A complete and thorough preoperative assessment must be performed when considering blepharoplasty, as has been detailed elsewhere.6 The evaluation targets the structural anatomy of the lower lid, including an ocular assessment, determination of fat volume, and determination of lower lid support, in addition to a basic ophthalmologic evaluation. As with any facial plastic surgery procedure, the ocular assessment begins with determination of any asymmetry. Eye position is assessed by the position of the inferior limbus to the lower eyelid margin and the degree of scleral show present. Visual acuity should be documented. Formal ophthalmologic consultation may be warranted in patients with an ocular history (eg, glaucoma, dry eye syndrome, prior ocular surgery). Extraocular movements, corneal reflexes, lagophthalmos, presence of Bell’s phenomenon, and visual fields should be assessed. Evidence of scars, festoons, or skin lesions is noted. At baseline, the amount of fine wrinkling is assessed.
Fig. 2. Topographic anatomy of the lower eyelid and cheek. The dotted line indicates the inferior eyelid fold: nasojugal fold (A) and malar fold (B).
Management of the Lower Lid in Male Blepharoplasty
Fig. 3. Globe position relative to orbital rim: positive vector (A), neutral vector (B), and negative vector (C).
alone to displace the lower lid inferiorly. If the puncta mobilizes more than 3 mm, a lax canthal tendon may be suspect, requiring possible tendoplication. A slow return of the lower lid or requiring multiple blinks heralds poor lid tone and support. A conservative approach is warranted. Once the examination is complete, a thorough discussion with the patient is made in regard to abnormalities noted during the examination. After this, a discussion of the expected outcome and the patient’s expectations should ensue. In recent years, and in particular for the male patient, a more conservative approach to rejuvenation of the upper one third of the face has evolved. Baseline esthetic norms for the male patient differ from those for the female patient. For example, overly taunt skin of the lower lid can have a feminizing effect. The authors’ typical discussion with the patient outlines the conservative approach used and the emphasis on managing the volume versus apparent skin excess or wrinkling of the lower lid.
OPERATIVE TECHNIQUES Detailed descriptions of the approaches for lower lid blepharoplasty can be found elsewhere.5 Here, the authors describe the two approaches that they primarily advocate for use in the male patient: transconjunctival and skin-muscle flap. The transconjunctival approach to lower eyelid blepharoplasty was first described in 1924 by Dr. Bourquet.8 It is a conservative technique in preserving the integrity of the orbicularis oculi muscle, thus minimizing the risk for ectropion and need for an external incision. It is ideal in the older male patient who had pseudoherniation of lower eyelid fat and limited skin excess, in revision cases, and in patients who do not want an external scar or have a history of hypertrophic scarring or hypopigmentation. The transconjunctival approach offers many advantages for lower blepharoplasty. It addresses bulging fat directly, minimizes late lid retraction problems, permits skin resection if
indicated, and retains the natural appearance of the palpebral fissure. The technique is straightforward and is easily mastered once the relevant anatomy is understood.9 In cases in which there is excessive wrinkling in the lower lid or in cases associated with crow’s feet and excessive pseudoherniation of lower lid fat, a transconjunctival approach may be combined with a skin rejuvenative procedure, such as 35% trichloroacetic acid peel or laser rejuvenation. Alternatively, a pinch blepharoplasty may be performed to recontour the eyelid skin in combination with transconjunctival removal of herniated orbital fat. The authors’ recommendation is to undercorrect with resurfacing procedures, because overtightening of the lower lid can have a feminizing effect on the upper one third of the male face. Furthermore, men generally do not have the option of covering these areas with makeup. An overly smooth skin texture tends to give an operated-on or ‘‘plastic’’ look to the lower lid, which is often incongruous with the remainder of the mature male face. The skin-muscle flap approach is a popular approach ideal for patients who have an excess of skin, orbicularis oculi, and herniated orbital fat. It takes advantage of the relatively avascular submuscular plane and is limited by how much skin can safely be removed without risking scleral show or ectropion. A subciliary incision is made 2 mm under the lash line or eyelid margin starting 1 mm lateral to the inferior punctum and extending approximately 6 mm past the lateral canthus. Care must be taken to preserve at least 10 mm from the lower lid incision and accompanying upper lid incision to avoid prolonged lymphedema. There are three described techniques in treating pseudoherniation of orbital fat: fat reduction, fat repositioning, and fat mobilization. Removal of orbital fat should be conservative and targeted according to the preoperative assessment. A small incision is made in the septum from the particular compartment addressed, and
315
316
Barrera & Most the fat is teased out using external digital pressure or a cotton-tipped applicator. The exposed fat stalk is clamped with a mosquito clamp and cauterized and is then removed with scissors across the cauterized segment. Some surgeons prefer to reduce fat volume using electrocautery ‘‘sculpting’’ instead of removing fat. After removal of fat from each compartment, the surgical field is examined for hemostasis. As previously described, aging results in attenuation and descent of midface fat and orbicularis oculi muscle, leading to ptosis and exposure of the inferior bony rim.2,3 Hamra10 described mobilizing all three compartments of the lower eyelid to camouflage the bony orbital rim, thus restoring a thicker soft tissue coverage of the rim. The technique of fat mobilization can be performed through a transcutaneous or transconjunctival approach. It aims at releasing the arcus marginalis, mobilizing fat over the bony orbital rim, and suturing it to the periosteum of the maxilla and the suborbicularis oculi fat (SOOF).11 Fat transfer is a more recently described concept for improving the double contour of the lower lid attributable to midface descent.12 As with other type of facial fat transfer, autologous fat is harvested, purified, and injected to ‘‘fill in’’ areas of deficiency. Although relatively simple, the technique is not without potential complications.13
SUMMARY The issues addressed in male blepharoplasty are similar to those in any lower lid blepharoplasty: contour of the lower lid and texture of the lid skin. A variety of techniques are available, including traditional blepharoplasty and skin resurfacing procedures in addition to newer techniques, such
Fig. 4. Preoperative and postoperative photographs of male subject before (upper panel) and after (lower panel) transconjunctival lower blepharoplasty. No skin resurfacing was performed. Note that although the contour is more youthful, rhytids remain, preserving a natural look for the older male patient.
as fat transfer or repositioning. Each has its place in rejuvenation of the lower eyelid, and combinations of conservative fat excision and repositioning or fat transfer are becoming more commonplace. Techniques to rejuvenate the skin must take into consideration the more ‘‘rugged’’ esthetic norm of male facial skin. For example, periorbital rhytids and crow’s feet in men are more the esthetic norm in comparison to women. In the authors’ experience, a conservative approach to blepharoplasty in the male patient often leads to greater patient satisfaction (Fig. 4). Ultimately, the goal is to create a more esthetically pleasing youthful but natural contour and texture to the lower lid.
REFERENCES 1. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 1995;96(2):354–62. 2. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 2002; 110(3):873–84 [discussion: 897–911]. 3. Most SP, Mobley SR, Larrabee WF Jr. Anatomy of the eyelids. Facial Plast Surg Clin North Am 2005;13(4): 487–92. v. 4. Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophthal Plast Reconstr Surg 1996;12(2):77–88. 5. Rankin B, Arden R, Crumley R. Lower eyelid blepharoplasty. 2nd edition. New York: Thieme; 2002. 6. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient. Bypassing the pitfalls. Clin Plast Surg 1993;20(2):213–23 [discussion: 224]. 7. Murakami CS, Plant RL. Complications of blepharoplasty surgery. Facial Plast Surg 1994;10(2):214–24. 8. Bourquet J. Les hernies graisseuses de l’orbite: notre traitment chirurgical. Bull Acad Natl Med 1924;92:1270–2. 9. Zarem HA, Resnick JI. Minimizing deformity in lower blepharoplasty. The transconjunctival approach. Clin Plast Surg 1993;20(2):317–21. 10. Hamra ST. The role of orbital fat preservation in facial aesthetic surgery. A new concept. Clin Plast Surg 1996;23(1):17–28. 11. Baker SR. Orbital fat preservation in lower-lid blepharoplasty. Arch Facial Plast Surg 1999;1(1):33–7. 12. Kranendonk S, Obagi S. Autologous fat transfer for periorbital rejuvenation: indications, technique, and complications. Dermatol Surg 2007;33(5):572–8. 13. Spector JA, Draper L, Aston SJ. Lower lid deformity secondary to autogenous fat transfer: a cautionary tale. Aesthetic Plast Surg 2008;32(3):411–4.
ANATOMY OF THE LOWER EYELIDS The position, volume, and form of the lower eyelid have functional and esthetic implications in the rejuvenation of the aging male face. The lower eyelids serve to protect the visual system while incorporating a three-dimensional transition between the inferior orbital fold and malar and nasojugal folds. Esthetically, the youthful eyelid cheek complex consists of a single mildly convex line on profile. Aging causes descent of the globe and subsequent pseudoherniation of the orbital fat, producing a double convex lower eyelid contour on profile. In addition, increased distance between the lower lid margin and inferior orbicularis oculi muscle attributable to attenuation of the ligamentous support produces skeletonization of the orbital area and exposure of the inferior bony rim.1,2 The lower lid margin normally rests at the inferior limbus, with its low point just lateral to the pupil.3 The malar and nasojugal folds represent the cutaneous insertion of the orbitomalar ligament, a unique bony attachment of the orbicularis oculi.4 The lateral canthus lies 2 to 4 mm superior to the medial canthus. The adult palpebral fissure averages 10 to 12 mm vertically and 28 to 30 mm horizontally, with the distance from the lateral canthus to the orbital rim being 5 mm.3 The eyelid lamella can be divided into anterior, middle, and posterior lamellae. The anterior lamella is composed of skin and orbicularis oculi muscle. The middle lamella is occasionally described as the orbital septum. The posterior lamella is composed of the tarsus, septum, and underlying conjunctiva.3,5
The eyelid skin is thin, likely secondary to being devoid of subcutaneous fat. Deep to the skin lies the orbicularis oculi muscle, which is divided into orbital, preseptal, and pretarsal portions. The orbital portion arises from the medial canthal tendon (MCT) and interdigitates laterally with the skin, contributing to crow’s feet. The preseptal and pretarsal portions make up the palpebral section, which lies over the tarsal plate and orbital septum. The preseptal and pretarsal segments have two heads, one deep and one superficial. The deep heads arise from the posterior crest of the lacrimal fossa and fossa itself. The superficial ends come from the MCT, which itself inserts into the anterior lacrimal crest. Laterally, these fibers condense to become the Whitnall’s tubercle and the lateral canthal tendon.3 The orbital septum originates from the arcus marginalis along the orbital rim and is continuous with the orbital periosteum.3 It fuses with the capsulopalpebral fascia to form a single fascial layer and fuses into the tarsal base. The capsulopalpebral base of the inferior rectus attaches to the tarsal base and allows for lower lid retraction during downward gaze. Further, the inferior oblique muscle also contributes to Lockwood’s ligament at its most forward extension (Fig. 1). Behind the orbital septum is fat, which is traditionally divided into lateral, central, and medial compartments. The lateral fat pad is smaller and more superiorly placed. The central and medial fat pads are divided by the inferior oblique muscle. The medial fat pad is lighter in color, more fibrous, and more compact. A sizeable blood vessel is often present in the medial compartment.
Division of Facial Plastic and Reconstructive Surgery, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94305, USA * Corresponding author. E-mail address: [email protected] (S.P. Most). Facial Plast Surg Clin N Am 16 (2008) 313–316 doi:10.1016/j.fsc.2008.05.001 1064-7406/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
Blepharoplasty Eyelid Transconjunctival Lower
314
Barrera & Most
Inferior tarsus
Inferior tarsal muscle Capsulopalpebral fascia (CPF) Orbital septum Inferior oblique muscle Orbital fat Orbitomalar ligament Orbicularis muscle Malar fat pad Suborbicularis oculi fat (SOOF)
Fig. 1. Cross-sectional diagram of the lower eyelid.
Sensory innervation to the lower lid derives from the infraorbital nerve (V2) with minor contributions from V1 and the zygomaticofacial nerve branches of V2. The blood supply comes from angular, infraorbital, and transverse facial arteries. The marginal arcade condenses between the orbicularis and the tarsus.
Topographic examination includes noting the nasojugal fold, malar fold, and inferior eyelid fold in addition to fat compartments (Fig. 2). Assessment of the fat pockets can be enhanced by directing the patient’s gaze while palpating the lower eyelid. In particular, superior gaze accentuates the medial and central pockets, whereas contralateral gaze enhances the lateral pocket. Vector determination, as described by Jelks, should be performed.6 A neutral vector (one in which the cornea is in line with the orbital rim) or positive vector (cornea posterior to the rim) is desired, whereas a negative vector (cornea anterior to the rim) may limit the amount of orbital fat that can be removed, due to the higher risk of ectropion postoperatively (Fig. 3). Recognizing orbital vectors alerts the surgeon to the risk for suboptimal esthetic result, and such information should be shared with the patient preoperatively. The most common cause of lower lid ectropion after blepharoplasty is failure to recognize lower lid laxity in the preoperative setting.5,7 Therefore, assessment of the lid supporting structures and vector must be done. One way of doing this is by performing the lid distraction test. Grasping the midportion of the lower lid with the thumb and index fingers and outwardly displacing the lid from the globe is called the snap test. The lid distraction test should also be performed. If the lid margin moves greater than 10 mm, there is abnormal laxity and a lid-shortening procedure may be entertained. Another way is by using the index finger
PREOPERATIVE EVALUATION A complete and thorough preoperative assessment must be performed when considering blepharoplasty, as has been detailed elsewhere.6 The evaluation targets the structural anatomy of the lower lid, including an ocular assessment, determination of fat volume, and determination of lower lid support, in addition to a basic ophthalmologic evaluation. As with any facial plastic surgery procedure, the ocular assessment begins with determination of any asymmetry. Eye position is assessed by the position of the inferior limbus to the lower eyelid margin and the degree of scleral show present. Visual acuity should be documented. Formal ophthalmologic consultation may be warranted in patients with an ocular history (eg, glaucoma, dry eye syndrome, prior ocular surgery). Extraocular movements, corneal reflexes, lagophthalmos, presence of Bell’s phenomenon, and visual fields should be assessed. Evidence of scars, festoons, or skin lesions is noted. At baseline, the amount of fine wrinkling is assessed.
Fig. 2. Topographic anatomy of the lower eyelid and cheek. The dotted line indicates the inferior eyelid fold: nasojugal fold (A) and malar fold (B).
Management of the Lower Lid in Male Blepharoplasty
Fig. 3. Globe position relative to orbital rim: positive vector (A), neutral vector (B), and negative vector (C).
alone to displace the lower lid inferiorly. If the puncta mobilizes more than 3 mm, a lax canthal tendon may be suspect, requiring possible tendoplication. A slow return of the lower lid or requiring multiple blinks heralds poor lid tone and support. A conservative approach is warranted. Once the examination is complete, a thorough discussion with the patient is made in regard to abnormalities noted during the examination. After this, a discussion of the expected outcome and the patient’s expectations should ensue. In recent years, and in particular for the male patient, a more conservative approach to rejuvenation of the upper one third of the face has evolved. Baseline esthetic norms for the male patient differ from those for the female patient. For example, overly taunt skin of the lower lid can have a feminizing effect. The authors’ typical discussion with the patient outlines the conservative approach used and the emphasis on managing the volume versus apparent skin excess or wrinkling of the lower lid.
OPERATIVE TECHNIQUES Detailed descriptions of the approaches for lower lid blepharoplasty can be found elsewhere.5 Here, the authors describe the two approaches that they primarily advocate for use in the male patient: transconjunctival and skin-muscle flap. The transconjunctival approach to lower eyelid blepharoplasty was first described in 1924 by Dr. Bourquet.8 It is a conservative technique in preserving the integrity of the orbicularis oculi muscle, thus minimizing the risk for ectropion and need for an external incision. It is ideal in the older male patient who had pseudoherniation of lower eyelid fat and limited skin excess, in revision cases, and in patients who do not want an external scar or have a history of hypertrophic scarring or hypopigmentation. The transconjunctival approach offers many advantages for lower blepharoplasty. It addresses bulging fat directly, minimizes late lid retraction problems, permits skin resection if
indicated, and retains the natural appearance of the palpebral fissure. The technique is straightforward and is easily mastered once the relevant anatomy is understood.9 In cases in which there is excessive wrinkling in the lower lid or in cases associated with crow’s feet and excessive pseudoherniation of lower lid fat, a transconjunctival approach may be combined with a skin rejuvenative procedure, such as 35% trichloroacetic acid peel or laser rejuvenation. Alternatively, a pinch blepharoplasty may be performed to recontour the eyelid skin in combination with transconjunctival removal of herniated orbital fat. The authors’ recommendation is to undercorrect with resurfacing procedures, because overtightening of the lower lid can have a feminizing effect on the upper one third of the male face. Furthermore, men generally do not have the option of covering these areas with makeup. An overly smooth skin texture tends to give an operated-on or ‘‘plastic’’ look to the lower lid, which is often incongruous with the remainder of the mature male face. The skin-muscle flap approach is a popular approach ideal for patients who have an excess of skin, orbicularis oculi, and herniated orbital fat. It takes advantage of the relatively avascular submuscular plane and is limited by how much skin can safely be removed without risking scleral show or ectropion. A subciliary incision is made 2 mm under the lash line or eyelid margin starting 1 mm lateral to the inferior punctum and extending approximately 6 mm past the lateral canthus. Care must be taken to preserve at least 10 mm from the lower lid incision and accompanying upper lid incision to avoid prolonged lymphedema. There are three described techniques in treating pseudoherniation of orbital fat: fat reduction, fat repositioning, and fat mobilization. Removal of orbital fat should be conservative and targeted according to the preoperative assessment. A small incision is made in the septum from the particular compartment addressed, and
315
316
Barrera & Most the fat is teased out using external digital pressure or a cotton-tipped applicator. The exposed fat stalk is clamped with a mosquito clamp and cauterized and is then removed with scissors across the cauterized segment. Some surgeons prefer to reduce fat volume using electrocautery ‘‘sculpting’’ instead of removing fat. After removal of fat from each compartment, the surgical field is examined for hemostasis. As previously described, aging results in attenuation and descent of midface fat and orbicularis oculi muscle, leading to ptosis and exposure of the inferior bony rim.2,3 Hamra10 described mobilizing all three compartments of the lower eyelid to camouflage the bony orbital rim, thus restoring a thicker soft tissue coverage of the rim. The technique of fat mobilization can be performed through a transcutaneous or transconjunctival approach. It aims at releasing the arcus marginalis, mobilizing fat over the bony orbital rim, and suturing it to the periosteum of the maxilla and the suborbicularis oculi fat (SOOF).11 Fat transfer is a more recently described concept for improving the double contour of the lower lid attributable to midface descent.12 As with other type of facial fat transfer, autologous fat is harvested, purified, and injected to ‘‘fill in’’ areas of deficiency. Although relatively simple, the technique is not without potential complications.13
SUMMARY The issues addressed in male blepharoplasty are similar to those in any lower lid blepharoplasty: contour of the lower lid and texture of the lid skin. A variety of techniques are available, including traditional blepharoplasty and skin resurfacing procedures in addition to newer techniques, such
Fig. 4. Preoperative and postoperative photographs of male subject before (upper panel) and after (lower panel) transconjunctival lower blepharoplasty. No skin resurfacing was performed. Note that although the contour is more youthful, rhytids remain, preserving a natural look for the older male patient.
as fat transfer or repositioning. Each has its place in rejuvenation of the lower eyelid, and combinations of conservative fat excision and repositioning or fat transfer are becoming more commonplace. Techniques to rejuvenate the skin must take into consideration the more ‘‘rugged’’ esthetic norm of male facial skin. For example, periorbital rhytids and crow’s feet in men are more the esthetic norm in comparison to women. In the authors’ experience, a conservative approach to blepharoplasty in the male patient often leads to greater patient satisfaction (Fig. 4). Ultimately, the goal is to create a more esthetically pleasing youthful but natural contour and texture to the lower lid.
REFERENCES 1. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 1995;96(2):354–62. 2. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 2002; 110(3):873–84 [discussion: 897–911]. 3. Most SP, Mobley SR, Larrabee WF Jr. Anatomy of the eyelids. Facial Plast Surg Clin North Am 2005;13(4): 487–92. v. 4. Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophthal Plast Reconstr Surg 1996;12(2):77–88. 5. Rankin B, Arden R, Crumley R. Lower eyelid blepharoplasty. 2nd edition. New York: Thieme; 2002. 6. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient. Bypassing the pitfalls. Clin Plast Surg 1993;20(2):213–23 [discussion: 224]. 7. Murakami CS, Plant RL. Complications of blepharoplasty surgery. Facial Plast Surg 1994;10(2):214–24. 8. Bourquet J. Les hernies graisseuses de l’orbite: notre traitment chirurgical. Bull Acad Natl Med 1924;92:1270–2. 9. Zarem HA, Resnick JI. Minimizing deformity in lower blepharoplasty. The transconjunctival approach. Clin Plast Surg 1993;20(2):317–21. 10. Hamra ST. The role of orbital fat preservation in facial aesthetic surgery. A new concept. Clin Plast Surg 1996;23(1):17–28. 11. Baker SR. Orbital fat preservation in lower-lid blepharoplasty. Arch Facial Plast Surg 1999;1(1):33–7. 12. Kranendonk S, Obagi S. Autologous fat transfer for periorbital rejuvenation: indications, technique, and complications. Dermatol Surg 2007;33(5):572–8. 13. Spector JA, Draper L, Aston SJ. Lower lid deformity secondary to autogenous fat transfer: a cautionary tale. Aesthetic Plast Surg 2008;32(3):411–4.