Lower Blepharoplasty With Direct Excision of Skin Excess: A Five-Year Experience Pietro Bellinvia, MD, Francesco Klinger, MD, Giacomo Bellinvia, MD
INTERNATIONAL CONTRIBUTION Oculoplastic Surgery Lower Blepharoplasty With Direct Excision of Skin Excess: A Five-Year Experience Aesthetic Surgery Journal 30(5) 665 670 2010 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www.sagepub.com/ journalspermissions.nav DOI: 10.1177/1090820X10381989 www.aestheticsurgeryjournal.com Pietro Bellinvia, MD; Francesco Klinger, MD; and Giacomo Bellinvia, MD Abstract Background: Many patients present for aesthetic treatment of their lower eyelid region. Although traditional lower blepharopasty can successfully correct prominent lower eyelid bags, tissue excesses in the lower periorbital region (such as crepe-like skin and festoons) can cause distress for patients both aesthetically and physically, as they may cause discomfort. The skin that can be removed from this area (below the eyelashes) with a traditional incision is limited since tension on the lower eyelid must be avoided. Objective: The authors report the results of their five-year experience performing lower blepharoplasty with a direct skin excision in the lower periorbital region. Methods: Fifty-five patients were treated with the authors method of blepharoplasty between Ferbruary 2004 and February 2009. After precise preoperative marking, each patient was placed under local anesthesia and the excess of tissue in the lower periorbital region was removed. When necessary, removal of fat bags was performed. When the tissue in excess was significant, this kind of direct incision allowed the removal of more skin than the traditional method, without tension on the lower eyelid. Results: No major complications or even temporary scleral show was observed in any of the patients in this series. In addition, no patients complained of any exaggerated visibility of postoperative scarring. The high rate of patient satisfaction with this procedure has led the authors to apply this type of incision with increasing frequency in their blepharoplasty patients. Conclusions: The authors direct incision technique for lower blepharoplasty, when selected with the appropriate indications, can provide a successful and safe alternative to traditional methods. Options for treatment of the lower lid are few since the area is a very challenging one to treat and the authors believe that this additional alternative will be helpful to both surgeons and patients alike. Keywords lower blepharoplasty; festoons; malar bags Accepted for publication March 26, 2010. Many potential cosmetic surgery patients present with complaints about their lower eyelid area. In fact, according to American Society for Aesthetic Plastic Surgery statistics from 2009, blepharoplasty is currently the third most common surgical procedure in the United States. 1 With these procedures, common patient concerns are often age related. With aging, we see a loss of skin elasticity; the skin becomes thinner and begins to droop, leading to wrinkles, crepe-like skin, texture changes, tear trough depression, and the formation of malar bags and festoons. Traditional blepharoplasty may not be the best treatment for the age-related skin symptoms underneath the eye, as successful treatment depends on the avoidance of tension on the lid margin, particularly in the elderly patient, who often displays lid laxity and a reduction of muscle orbicularis tonus. As a solution, other surgeons have suggested the idea of correcting skin excess in this area with direct skin excision. 2,3 Herein, we describe a similar method of incision in a group of primarily elderly patients with skin laxity and wrinkles. Dr. P. Bellinvia and Dr. G. Bellinvia are plastic surgeons in private practice in Milan, Italy. Dr. Klinger is assistant in the Department of Plastic Surgery, University of Milan, Milan, Italy. Corresponding Author: Dr. Giacomo Bellinvia, Via Monte Amiata, 3 20149 Milan, Italy. E-mail: giacomobellinvia@fastwebnet.it
666 Aesthetic Surgery Journal 30(5) Figure 1. (A) The patient is marked in a sitting position with a fine-point surgical marking pen. (B) Following a pinch test to measure the amount of excision, the patient is asked to look upward to account for the progression of lid laxity that might limit the excision. Figure 2. (A) This 40-year-old man presented for treatment of lower eyelids region. (B) The patient s preoperative markings are shown. (C) One year after direct excision blepharoplasty with the author s technique. Methods Between February 2004 and February 2009, 55 patients were treated in the senior author s (PB) private clinic with direct excision lower blepharoplasty. In 19 patients, the procedure was combined with upper blepharoplasty. In six patients, the type of incision was compulsory because of the presence of xanthelasmas. The direct cutaneous excision was
Bellinvia et al 667 Figure 3. (A) This 62-year-old woman presented for treatment of upper and lower eyelids region. (B) The patient s preoperative markings are shown. (C) Six months after direct excision blepharoplasty with the author s technique with fat bag removal and simultaneous upper blepharoplasty. accompanied by the removal of fat bags in 29 patients. In none of the cases was it accompanied by canthopexy. In one case, the procedure was carried out monolaterally as a result of asymmetry. In another case, the cutaneous excision was carried out after blepharoplasty with an incision below the eyelashes because the patient desired a greater correction of the excessive skin. All procedures were performed under local anesthesia. Preoperative Markings The patient was marked in a sitting position, with a finepoint surgical marking pen (Figure 1A). The quantity of skin to be removed is determined by pinching, 4-6 drawing up the greatest amount of skin compatible with the absence of any traction whatsoever on the lower lid margin. During this maneuver, the patient was asked to look upward (Figure 1B), to account for the progression of lid laxity that might limit the excision. To minimize scarring, it is essential that excision of the thin, elastic skin immediately below the eyelid be limited. Widening the marking to encompass the lower malar skin, which is thicker, carries a greater risk of visible cicatricial results because two types of skin with different characteristics would be brought together. Operative Technique Once local anesthesia had been administered, the cutaneous excision was carried out very superficially without any décollement of the margins in areas of thin skin. If the incision was lengthened into the zygomatic area, where the skin is thicker, a modest décollement was considered appropriate. Since the anatomical alterations that accompany aging of the lower lid primarily involve the cutaneous surface, 7 with little association of the orbicularis muscle, that muscle was never resected or plicated. Even in the case of fat bag removal, the muscular fibers were delicately spread apart locally to allow the resection of adipose hernias, without subsequent suturing. An accurate suture is one of the most important aspects of this method; a continuous, subcuticular intradermal (continuous subcuticular) 6-0 nylon suture was placed with very short stitches, very close to one another.
668 Aesthetic Surgery Journal 30(5) Figure 4. (A) This 59-year-old man presented for treatment of lower eyelids region. (B) The patient s preoperative markings are shown. (C) Six months after direct excision blepharoplasty with the author s technique and removal of fat bags. The average duration of the procedure was about 30 minutes, after which the patient was observed for a short period of time and discharged. No dressings or Steri-strips were applied, but each patient was given an antibiotic cream to apply to the wound until the removal of the stitches, which took place on the fifth or sixth postoperative day. After removal of the stitches, each patient was followed up between six and 12 months. Results Of the 55 patients included in this series, 12 were men and 43 were women. The average patient age was 57 years, with a range of 34 to 79. Although some of the patients included in our study are relatively young, these should be considered anomalies who were treated with this method as a result of unusual deformity in that area, as the ideal patient for this procedure is elderly (as mentioned previously). No major complications or even cases of temporary scleral show were observed in any of the patients in this series. Some patients experienced pronounced edema in the immediate postoperative period in the area directly above the scar, making the incision site more evident. However, this edema tended to become insignificant over the course of a few weeks. Postoperative pain associated with this procedure is so limited that it does not usually require the prescription of painkillers. In the majority of cases in both patients and surgeons opinion, the results have been excellent, with no detectable scars. For cases in which the patient was not completely satisfied, the primary complaint was that preoperative expectations exceeded the actual result. Importantly, no patient in this series complained about excessive visibility of the postoperative scar. The high rate of patient satisfaction with this procedure has led us to apply this type of incision with increasing frequency in our blepharoplasty patients. Discussion Initially, we limited ourselves to carrying out this type of incision in the presence of lesions in the lower orbital area, above all xanthelasmas. Noting the positive aesthetic result and the lack of visible cicatricial results, we then extended the indications to include patients who presented with difficult-to-correct blemishes or symptoms in the lower eyelid area. We obtained good results in the case of festoons (or marked cutaneous excess), a complaint
Bellinvia et al 669 Figure 5. (A) This 63-year-old woman presented for treatment of lower eyelids region. (B) The patient s preoperative markings are shown. (C) Six months after direct excision blepharoplasty with the author s technique and removal of fat bags. that has a distinct lack of alternative treatments. Even malar bags and marked edema were treated successfully with direct cutaneous excision. Although we apply the classic incision under the eyelashes in the overwhelming majority of cases, this direct type of incision allows the removal of a greater quantity of excess skin and avoids traction on the lower lid margins, even in the case of marked lid laxity. All of the patients in this series came to us requesting an improvement of the lower orbital region; none complained about problems linked to lower lid laxity such as lachrymation, the sensation of a foreign body, or recurring conjunctivitis. As a result, adding a step to retension the lower lid was not appropriate since that technique is often associated with complications and may have interfered with the aesthetic result. Many other well-documented techniques for rejuvenating the orbital area exist. Canthopexy 8-10 and midfacelifts allow the correction of cutaneous excess without the danger of malpositioning of the lower lid. However, we still prefer the technique we describe here because of its simplicity. In properly selected patients, it is possible to obtain results comparable to those of more complex operations. Since our technique is less invasive, it thereby carries a lower percentage of complications. The predictability of the result is guaranteed by the preoperative evaluation with the pinch test, which also means that preoperative patient expectations are easier to manage. Although patients and surgeons may be concerned about the presence of scars in such an important area of the face, certain steps may be taken to minimize the postoperative deformity. First, each patient s skin thickness, elasticity, and pigmentation should be preoperatively evaluated to ensure that they are a good candidate for this type of procedure. Specifically, considerable pigmentation in the lower lid area (even in fair-skinned patients) would be a criterion for exclusion. Second, patient communication is fundamental; his or her willingness to accept slight visibility of the scar must be assessed. Finally, some technical observations can contribute to scar minimization, including precise accuracy in placement of the sutures, avoidance of traction at the margins and exaggerated incisions, and the extension of the incision only into the thin skin of the orbital area (without involving the thicker, lower skin). Further studies of this procedure would benefit from longer term follow-up and a larger cohort of patients.
670 Aesthetic Surgery Journal 30(5) Figure 6. (A) This 35-year-old woman presented for treatment of lower eyelids region. (B) The patient s preoperative markings are shown. (C) Six months after direct excision blepharoplasty with the author s technique. Conclusion A direct incision technique for lower blepharoplasty can provide a successful and safe alternative to traditional methods for properly selected patients. The lower lid area is very challenging to treat, but this technique provides a viable alternative that, in this series of 55 patients, was associated with predictable and natural postoperative results with no complications and acceptable scarring. Disclosures The authors declared no conflicts of interest with respect to the authorship and/or publication of this article. Funding The authors received no financial support for the research and/or authorship of this article. References 1. American Society for Aesthetic Plastic Surgery. Top five procedures: surgical & nonsurgical. http://www.surgery. org/sites/default/files/2009top5_surg_nonsurg.pdf 2. Furnas DW. Festoons of orbicularis muscle as a cause of baggy eyelids. Plast Reconstr Surg 1978;61: 540-546. 3. Netscher DT, Peltier M. Ancillary direct excisions in the periorbital and nasolabial regions for facial rejuvenation revisited. Aesthetic Plast Surg 1995;19:193-196. 4. Rosenfield LK. The pinch blepharoplasty revisited. Plast Reconstr Surg 2005;115:1405-1412. 5. Taban M, Taban M, Perry JD. Lower eyelid position after transconjunctival lower blepharoplasty with versus without a skin pinch. Ophthal Plast Reconstr Surg 2008;24:7-9. 6. Kim EM, Bucky LP. Power of the pinch: pinch lower lid blepharoplasty. Ann Plast Surg 2008;60:532-537. 7. Goldberg RA, McCann JD, Fiaschetti D, Ben Simon GJ. What causes eyelid bags? Analysis of 114 consecutive patients. Plast Reconstr Surg 2005;115:1395-1402. 8. Rosenfield L. Pinch blepharoplasty: a safe technique with superior results. Aesthetic Surg J 2007;27:199-203. 9. Carraway JH, Grant MP, Lissauer BJ, Patipa M. Selection of canthopexy techniques. Aesthetic Surg J 2007;27: 71-79. 10. Jelks GW, Glat PM, Jelks EB, Longaker MT. The inferior retinacular lateral canthoplasty: a new technique. Plast Reconstr Surg 1997;100:1262-1270.