Color Atlas of Cosmetic Oculofacial Surgery

103
The Suture Ligation Method
Figure 7.39 Transcutaneous intradermal and intratarsal
suturing technique. L, levator aponeurosis; O, orbicularis.
(Reproduced with permission from Chen WPD. Asian
blepharoplasty: a surgical atlas. Newton, MA: Butterworth
and Heinemann; 1995:39.)
Tarsus
Conjunctiva
Thru tarsus
Thru skin (dermis)
Levator aponeurosis
Pretarsal orbicularis
Pretarsal orbicularis
Dermis
Tarsus
Dermis
Epidermis
Levator aponeurosis

The Advanced Concept of Triangular,
Trapezoidal, and Rectangular
Debulking of Eyelid Tissues, as
Applied in Asian Blepharoplasty – by
William Chen MD
In the past, double eyelid procedures were carried out
through various external incision methods, which
may have involved removing skin,8 skin with orbicu-
laris,9,10 skin with pretarsal fat,11 or excision of skin,
muscle, orbital septum, and preaponeurotic fat.12,13
They were all attempts at creating a clear platform
for the formation of adhesions between fibers of the
levator aponeurosis and the subcutaneous structure
of the surgically created crease. However, because the
excision may not be uniformly carried out over the
width of the crease, often an irregular platform of
tissues anterior to the superior tarsal border is left
behind and this will interfere with the definition and
formation of the crease.
The author’s method5 of triangular and trapezoidal
debulking allows a systematic and uniform cleaning
of the preaponeurotic platform over and along the
superior tarsal border. As Figure 7.40 shows:
104
Chapter 7: Asian Blepharoplasty of the Upper Eyelid
Figure 7.40 Cross-sectional drawing of an Asian upper eyelid
without upper lid crease. Black dots correspond to lines of skin
incision. The oblique solid arrows correspond to the
transorbicularis vector from skin to orbital septum. Dotted
arrows show possible plane of dissection through the
preaponeurotic fat pads. Trapezoidal debulking of
preaponeurotic tissues in Asian blepharoplasty may include all
tissues bounded by the lower and oblique transorbicularis
vectors, and that between the skin and the orbital septum.
Minimal fat excision may also be included. (Reproduced with
permission from Chen WPD. Asian blepharoplasty: a surgical
atlas. Newton, MA: Butterworth and Heinemann; 1995:165.)
Skin
Orbicularis
muscle
Preaponeurotic
fat
Septum
Levator
aponeurosis
Müller's
muscle
Conjunctiva
More skin excision
Includes skin excision
Single incision

1. When skin excision (<2mm) is performed in
conjunction with placement of the lid crease,
retracting the upper skin incision edge permits an
upwardly beveled plane of dissection to proceed
across the supratarsal orbicularis oculi muscle and
the lower portion of the orbital septum. (In Asians
without a crease in the upper lid, the orbital
septum is often fused to the levator aponeurosis at
2–4mm above the superior tarsal border, and it
can be as low as halfway down the anterior
surface of the tarsus.) The septum and underlying
preaponeurotic fat pads may be easily identified.
2. The septum orbitale is opened horizontally. This
trapezoid (viewed in cross-section) of
preaponeurotic tissues, including sometimes a
minimal amount of preaponeurotic fat, the
orbital septum, supratarsal orbicularis,
subcutaneous fat, and overlying skin (<2mm), all
of which hinges along the superior tarsal border,
may be debulked. The anterior surface of this
conceptual trapezoid consists of the skin, while
the posterior portion of the trapezoid is wider
and includes all preaponeurotic tissues from the
opened orbital septum down to the superior
tarsal border.
3. A small strand of the pretarsal orbicularis along
the inferior skin incision may be trimmed off.
4. The trapezoidal debulking allows simple inward
folding of the skin edges towards the underlying
aponeurosis, facilitating the surgical formation of
the crease. (The microscopic study by Collin
et al.2 described insertions of distal strands of the
levator aponeurosis into the septa in between
pretarsal orbicularis oculi muscle fibers, rather
than into any subdermal tissue along the lid
crease in those eyelids that had crease. If true,
formation of a crease may be facilitated by the
above surgical maneuver, as it links the
aponeurosis to the upper boundary of the pretarsal
zone.) Vigorous dissection and debulking of
pretarsal tissues is to be avoided for reasons
mentioned previously.
When debulking is carried out without including
any skin excision, the block of tissue removed will
resemble a triangular configuration in cross-sectional
view.
Should there be significant skin redundancy, the
amount of skin included for excision is increased by
moving up the upper line of skin incision. The plane
of dissection through the orbicularis then becomes
less beveled and the trapezoidal debulking gradually
transforms into more of a rectangular configuration.
Figure 7.41 shows the transorbicularis vector (Step
2) for the dissection plane rotating counter-clockwise
and leveling off as one takes away more skin and the
upper line of skin incision – 1(U) – moves further
away from the superior tarsal border (level of STB).
105
Advanced Concept of Triangular, Trapezoidal, and Rectangular Debulking of Eyelid Tissues
4
2
1 (U)
1 (L)
Orbicularis
Triangle
3
Orbital septum
Skin
Level of STB
Transorbicularis vector
Trapezoid
Orbicularis
Figure 7.41 Schematic drawing showing anterior lamella of upper eyelid,
with orbicularis of the supratarsal region and skin lying anterior to the
orbital septum. The first surgical step involves upper and lower lines of
incisions, 1(U) and 1(L), above the superior tarsal border (STB). The
second step involves an oblique transection through the orbicularis (2) via
the transorbicularis vector line. For the third step (3), upon reaching and
opening of the orbital septum, one dissects inferiorly towards the superior
tarsal border. Step 4 shows a leveled excision of orbicularis and
redundant skin above the superior tarsal border. The transorbicularis
vector rotates and levels off as more skin needs to be removed, such that
the cross-section of soft tissues that are debulked changes from a
triangular, to a trapezoidal, and finally to a rectangular configuration.
(Reproduced with permission from Chen WPD. Asian blepharoplasty:
a surgical atlas. Newton, MA: Butterworth and Heinemann; 1995:166.)

Triangular debulking

Trapezoidal debulking

Rectangular debulking

As more tissue needs to be removed
In triangular debulking (without skin removal):
Amount of Orbicularis
Amount of Skin
= Infinity
(or n, with n > 1)
(Vertical measurement of tissues)
As you proceed to trapezoidal and rectangular
debulking, the ratio of orbicularis to skin removal, as
measured vertically, approaches 1:1 (with n=1).
The ratio will be below 1.0 only when the amount
of skin redundancy is truly excessive, as in an elderly
person, allowing the removal of excessive skin with-
out compromising wound closure and predisposition
to ectropion and lagophthalmos of the upper lid. In
this situation, a ‘reverse’ trapezoidal block of tissue is
removed, with the height over the skin side greater
than the height of the preseptal orbicularis removed.
Even in this case with a large amount of skin removal,
the traverse through the orbicularis muscle (trans-
orbicularis vector) should still be perpendicular to
the levator palpebrae superioris muscle. Therefore:
In young individuals,
d [Orbicularis]
d [Skin]
> 1.0
In elderly individuals,
d [Orbicularis]
d [Skin]
= 1:1,

and, occasionally, <1.0 (where d = amount of
resection)
In summary, the applications of trapezoidal
debulking of the preaponeurotic platform in Asian
blepharoplasty and its advantages are as follows:
■ Easier approach through the orbital septum and
preaponeurotic space when the plane of
dissection is beveled. It lessens the possibility of
injury to the levator aponeurosis when there is a
buffer of preaponeurotic fat pad under the
septum and on top of the levator.
■ It allows for a controlled, uniform debulking of
the junctional platform of tissues in the
supratarsal and pretarsal area.
■ It allows optimal formation of attachments
between the levator aponeurosis and the inferior
subcutaneous tissues, or to the intermuscular
septa within pretarsal orbicularis oculi fibers
(pretarsal zone).
■ It allows crease formation to be based on the
individual’s tarsus height.
■ It reduces the rate of complications, including
problems with asymmetry, shape, height,
continuity, permanency, segmentation of crease
caused by uneven planes of dissection, fading and
late disappearance of crease, multiple creases, and
persistent edema.5
In conclusion, this concept of triangular, trape-
zoidal, and rectangular debulking of the preapo-
neurotic platform is applicable universally to upper
eyelid surgery in all ethnic groups, and in cases with
challenging lid crease management problem. This
latter topic will be covered in Chapter 15.
106
Chapter 7: Asian Blepharoplasty of the Upper Eyelid

REFERENCES
1. Chen WP. Asian blepharoplasty – anatomy and
technique. J Ophthalmic Plast Reconstr Surg
1987;3:135–40.
2. Collin JR, Beard C, Wood I. Experimental and
clinical data on the insertion of the levator
palpebrae superioris muscle. Am J Ophthalmol
1978;85:792–801.
3. Chen WP. A comparision of Caucasian and
Asian blepharoplasty. Ophthalmic Pract
1991;9:216–22.
4. Chen WPD. Asian blepharoplasty: a surgical
atlas. Newton, MA: Butterworth and
Heinemann; 1995.
5. Chen WPD. Concept of triangular, rectangular
and trapezoidal debulking of eyelid tissues:
application in Asian blepharoplasty. Plast
Reconstr Surg 1996;97:212–8.
6. Chen WPD. Eyelid and eyelid skin diseases. In:
Lee D, Higginbotham E, eds. Clinical guide to
comprehensive ophthalmology. New York:
Thieme; 1998.
7. Chen WPD. Oculoplastic surgery: the essentials.
New York: Thieme; 2002.
8. Sayoc BT. Plastic construction of the superior
palpebral fold. Am J Ophthalmol
1954;38:556–9.
9. Hayashi, K. The double eyelid operation. Jpn
Rev Clin Ophthalmol 1938;33:1000–10 (Part
1);1098–110 (Part 2).
10. Fernandez LR. Double eyelid operation in the
Oriental in Hawaii. Plast Reconstr Surg
1960;25:257–64.
11. Inoue, S. The double eyelid operation. Jpn Rev
Clin Ophthalmol 1947;42:306.
12. Mitsui Y. Plastic construction of a double eyelid.
Jpn Rev Clin Ophthalmol 1950;44:19.
13. Sayoc BT. Anatomic considerations in the plastic
construction of a palpebral fold in the full upper
eyelid. Am J Ophthalmol 1996;63:155–8.
107
Advanced Concept of Triangular, Trapezoidal, and Rectangular Debulking of Eyelid Tissues

109
Chapter 8
Lower Lid Blepharoplasty by
Skin–muscle Flap Approach
The traditional lower blepharoplasty is indicated for
patients who have aging changes, with underlying
skin laxity and some gravitional descent of structures.
It is also indicated for some males with aging changes
who want a conservative approach.
The procedure starts by placement of a 4-0 silk as a
traction suture over the central portion of the lower
eyelid margin. An incisional line is marked approxi-
mately 1mm below the cilia from the medial canthus
towards the lateral canthus; it is then slanted infero-
laterally for approximately 6–8mm after reaching the
lateral canthal angle. Ideally, the inferolateral incision
would merge with one of the crow’s-feet lines there
(Fig. 8.1A & B).
The initial skin incision starts over the infero lateral
portion and is best performed using a No. 15 Bard-
Parker blade. Small amounts of capillary bleeding are
controlled using bipolar cautery. A cutting Bovie
cautery is then used to incise through the orbicularis
layer to fashion a myocutaneous flap, starting at the
lateral canthal area. Once a small space is initiated, a
small Blair retractor is inserted and turned laterally so
that the traction is lateral. Straight sharp scissors are
then inserted beneath the skin over the pretarsal
region, undermining the skin beneath the lashes. The
incision over the infraciliary region is then completed
using the straight scissors. Next, the orbicularis
is undermined, and incised approximately 2–3mm
below the inferior border of the tarsus, thereby avoid-
ing the inferior tarsus arcade. The orbicularis muscle
overlying the tarsus in the pretarsal region is not
incised – this helps in preserving the lower lid tone.
The myocutaneous flap is retracted with the Blair
retractor inferiorly, while the lid margin is retracted
superiorly with the traction suture or the surgeon’s
finger on a gauze pad.
Lower Blepharoplasty and
Primary Cheeklift
Clinton D McCord Jr
Figure 8.1 (B) (upright view) right lower eyelid.
Figure 8.1 (A) Infraciliary incision line for lower blepharoplasty.
A
B
8.1
8.2

Gentle pressure on the globe allows any fat to
protrude forward. A needle-tipped Bovie cautery is
then used to incise the septum (Fig. 8.2). Incision into
the central fat pocket is done first. Prolapsing and
redundant fat may be excised using a combination of
bipolar cautery first, followed by excision using the
Bovie needle on coagulation mode. The retractor is then
repositioned towards the nasal direction, retracting
the medial edge of the lower lid incision nasally, and
with downward pressure the nasal fat pad is made to
protrude. The capsule is incised and the nasal fat pad,
which is usually pale white, may protrude. The fat is
similarly excised using bipolar cautery as well as the
Bovie needle on coagulation mode. Any visible blood
vessels should be carefully cauterized before allowing
them to be reposited. Between the central and nasal
fat pads lies the inferior oblique muscle and this
should be protected. The lateral fat pocket is
removed, if necessary, after the lateral canthoplasty
procedure is performed.
110
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
Figure 8.2 Drawing showing prolapse of fat through right lower
eyelid incision.

Surgical technique of lateral canthoplasty
Often a patient will exhibit age-related laxity of the
lower lid margin as well as lateral canthal dehiscence.
The addition of this maneuver allows the surgeon
to stabilize the eyelid fissure, correct for horizontal
laxity of the lower eyelid, as well as adjust for the
prom inent-eye patient as seen in thyroid eye disease.
This is performed before the lateral fat pad excision
because it will affect the prominence of the lateral
fat pad.
A lateral canthotomy is performed using scissors,
connecting the incision with the inferolateral exten-
sion of the skin incision line. An inferior cantholysis
is performed over the superficial and deep portion
of the lateral canthal tendon. The freed lower lid
segment is draped under mild tension against the
globe and directed towards a point just above the lat-
eral orbital tubercle in the area of the lateral orbital
rim. A redundant segment of the lower lid, measuring
between 2 and 4mm, may be excised, depending on
individual findings. Capillary oozing from the inferior
tarsal arcade is easily stopped with bipolar cautery.
The reanchoring of the lateral portion of the tarsus
may be performed using either a 5-0 Vicryl or an 5-14
needle or 4-0 Prolene suture on a P-2 needle (Ethicon)
(Fig. 8.3A & B). The needle is inserted through the
inferior portion of the tarsus, taking an intratarsal
bite and then exiting through the upper portion of the
tarsal plate, just below the lid margin so that it will
remain buried when tied. This upper end of the suture is
then passed through the inner periorbita just above the
lateral orbital tubercle and brought from inside the
lateral orbital rim outward. It is then reinserted from
outside the lateral orbital rim inward and tightened
with a double throw until the lower lid margin rests
along the lower corneal limbus with the desired ten-
sion. Lid tension is tested intraoperatively to confirm
approp riate tightness. In persons who do not show
any horizontal laxity and in whom lower lid tighten-
ing is not performed, the tied suture may even contain
slack. When the knots are tied, care is taken to make
sure that the suture knot will not protrude and irri-
tate the overlying skin.
111
Lower Lid Blepharoplasty by Skin–muscle Flap Approach
Figure 8.3 (B) Upright view of right lower lid following resection of a
lateral segment.
Figure 8.3 (A) Right lower lid following resection of a lateral segment.
A
B
8.3

Undermining of the skin–muscle flap
It is important to undermine the skin–muscle flap
over the malar area separating the septal strands and
periosteum from the myocutaneous flap (Fig. 8.4A &
B). This allows for further smoothing of the malar
area. Failure to do this will cause anterior distortion
of the lateral fat pocket, requiring more resection.
Once the myocutaneous flap is dissected free, the
lateral fat pocket may be resected if necessary.
Lateral fat pad excision
The lateral fat pad may be trimmed with a combina-
tion of bipolar and Bovie cautery following horizon-
tal tightening and undermining of the skin–muscle
flap. It is important to preserve the arcuate portion of
the orbital septum laterally, to prevent recurrence of
the lateral fat pad prolapse. The lateral fat and the
central fat are connected and can be teased from
behind this portion of the septum without severing it.
112
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
Figure 8.4 (B) Upright view of left lower lid.
Figure 8.4 (A) View of right lower lid.
A
B

Resection of the skin–muscle flap and
periosteal fixation
The tip of the skin–muscle flap is stretched towards
the superior tip of the ear to determine how much the
lateral portion of the flap overlaps the underlying
incision (Fig. 8.5A). The first triangle of excess tissue
is excised from the lateral portion of the skin–muscle
flap. The flap is sutured at the lateral canthal angle’s
lateral periosteum to create a desired level of tension
over the cheekbone and correct for any hollowing
effect in the lower lid. Trial positioning of the flap to
the lateral rim may be performed until the desired
level of tension is obtained. For this maneuver, a 4-0
silk suture is used: it passes through the anchoring
point located on the skin–muscle flap, then into the
lateral periosteum at the desired position, and is then
brought out through the skin–muscle layer of the
upper edge of the incision at the lateral canthal area
(Figs 8.5B & 8.6). The second triangle of excess skin–
muscle flap is then trimmed along the infraciliary
incision line. This is usually a long and thin triangular
strip.
Trimming of the orbicularis muscle fibers from
beneath the skin–muscle flap may be performed if
there seems to be excess, to further thin the lid down.
These are orbicularis fibers that overlap the muscle
fibers preserved on the pretarsal area from the origi-
nal incision. This is more applicable to women, to
give a smooth look; in men, it is often left in place, to
avoid an overly thinned appearance. The flap is
everted and examined for bleeders; any vessels that are
actively bleeding are cauterized with bipolar cautery.
113
Lower Lid Blepharoplasty by Skin–muscle Flap Approach
Figure 8.6 Upright view of right lower lid.
Figure 8.5 (B) Right lower lid (upright view)
Figure 8.5 (A) Segment of redundancy removed in lower blepharoplasty.
A
B

Wound closure
Closure of the skin flap is performed using 7-0 silk
sutures. The inferolateral region of the incision is best
closed using a vertical mattress suture, taking care that
both the skin edge and the deeper orbicularis are closed.
An alternative to this is the utilization of a ‘far–near
near–far’ type of baseball stitching using 7-0 silk, which
gives good wound approximation as well as tension con-
trol (Fig. 8.7). Meticulous closure is essential in this
conspicuous area in order to avoid scarring. A small dog-
ear may be seen laterally and can be trimmed off.
114
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
Figure 8.7 Closure of blepharoplasty wound in right
lower lid (upright view). The steristrip is retracting the
right upper lid.

The Primary Cheeklift
The traditional lower blepharoplasty has only limited
value in addressing anyone with significant gravi-
tational ptosis of the midface or cheek, which is
present in the majority of middle-aged patients. The
lower eyelid should not be considered as a structure
that ages in isolation and behaves independently of
the supporting contiguous structures beneath it. It
is therefore best evaluated as part of the midface
structure which is subjected to the same involutional
laxity, ligamentous dehiscences, and atrophy, as well
as gravitational sagging. Lower blepharoplasty can
therefore be performed as part of the midface
rejuvenation made possible through a cheeklift.
The cheeklift addresses the aging changes that
occur in the triangular area from the nasolabial fold
to the eyelids:
■ eyelid fat protrusion;
■ laxity and sagging of eyelid skin and midface skin;
and
■ descent of subcutaneous face fat and midface
structures.
Subcutaneous sagging of orbicularis muscle and
dropping of the malar fat pad cause a good part
of the changes that occur with age – when they are
repositioned, this restores the face to a more
youthful appearance (see Fig. 2.14).
The trans-lid cheeklift (Fig. 8.8A) repositions the
cheek in a more anatomically correct vector than
the facelift. The traditional facelift (Fig. 8.8B) should
be more properly called a necklift with oblique
vectors towards the ear – the vertical-upward vector
is the proper direction to restore the cheek and
midface contours.
115
The Primary Cheeklift
Figure 8.8 (A) Trans-lid cheeklift.
Figure 8.8 (B) Traditional facelift.
A
B
8.4

With our development of the trans-lid cheeklift, we
now limit the dissection for facelift towards the neck
area (Fig. 8.8C), while the midface area is addressed
exclusively through the lower lid.
To briefly review the anatomic layers of the mid-
face (see Figs 2.15–2.22):
■ The first layer, facial bone, shows the sensory
nerves and origin of some facial mimetic muscles
(Fig. 2.15).
■ The next layer shows the mimetic muscles in
place – the levator labii insertions at the orbital
rim nasally are included in the dissection
(Fig. 2.16).
■ Then, on top of the mimetic muscles and under
the orbicularis muscle, is a layer of fat called the
sub-orbicularis oculi fat (SOOF), which extends
to the brow to become the retro-orbicularis oculi
fat (ROOF) (Fig. 2.17).
■ The next layer is the orbicularis muscle (Fig. 2.18).
■ A deep portion of the malar fat pad lies on top of
the orbicularis and is just under and permeated
by the superficial musculo-aponeurotic system
(SMAS) (Fig. 2.19).
■ The SMAS overlies the previous deep portion of
the malar fat – and in turn the superficial portion
of the malar fat lies above it. The SMAS is blocked
inferiorly by the nasolabial fold (Fig. 2.20).
■ And on top of that is the skin (Fig. 2.21).
One other structure that is important, which origi-
nates from the orbital rim and combines with (and is
considered to be part of) the SMAS, is the orbital
malar ligament (Fig. 2.22).
116
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
Figure 8.8 (C)
C

Surgical steps of the cheeklift
The cheeklift mechanics should be thought of as
consisting of two important steps:
■ anchoring of the canthus, which mainly controls
the shape of the eyelid fissure; and
■ anchoring of the cheek flap itself (inferior
orbicularis arc), which really supports the lower
lid and cheek
The skin–muscle flap is elevated and dissected to
the inferior rim where the periosteum is incised.
Figure 8.9 shows the subperiosteal dissection of the
flap from the rim, elevating the cheek tissue from the
cheekbone.
The subperiosteal elevation is carried out over the
zygomatic area but stops short of the nerve nasally –
the periosteum usually needs release, particularly
over the zygomatic area (Fig. 8.10A & B).
117
The Primary Cheeklift
Figure 8.10
Figure 8.9
Orbicularis
Periosteum
SMAS
Inferior orbital rim
Periosteum
SOOF
Orbicularis
muscle
A
B

Further release is obtained by finger stretching
(Fig. 8.11).
The first of the two anchoring procedures is at the
lateral canthus. Anchoring at the canthus controls the
shape of the eyelid fissure. In patients with standard
eye prominence, unmodified canthal anchoring can
be used (Fig. 8.12). The canthus is anchored at the
level of inferior pupil edge and inside the lateral
orbital rim. It is important always to include the
upper lid in the fixation, for alignment and function
of eyelid closure.
118
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
Figure 8.11 Finger stretching to loosen cheek flap.
Figure 8.12 Canthal anchoring – standard eye prominence.
• Align with inferior pupil edge
• Suture inside lateral orbital rim,
and include upper lid tendon

With a deep-set or enophthalmic eye, and the
prominent (or proptotic) eye, the horizontal direction
of pull must be modified to prevent the clotheslining
upward in the deep-set eye, or, conversely, the clothes-
lining downward in the prominent eye (Fig. 8.13).
119
The Primary Cheeklift
Figure 8.13 Effect of horizontal vector with lateral canthoplasty orbicularis–cheek tightening.
Enophthalmic eye results
in clotheslines up
Prominent eye results
in clotheslines down

Upward clotheslining in the deep-set eye produces
an overly narrow fissure – a ‘squinty’ eye. Thus,
with the deep-set eye, canthal anchoring is shifted
downward and more internal, to prevent such effect
(Figs 8.14 & 8.15).
120
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
Figure 8.15 A patient with a deep-set eye – Hertel 15 – before and after
a cheeklift with modification of canthal anchoring.
Figure 8.14 Canthoplasty – enophthalmic eye.
inside of rim
• Shift canthal fixation
downward, well inside rim
A
B

121
The Primary Cheeklift
Figure 8.17 A patient with prominent eyes – Hertel 18mm a little over a
week after a canthoplasty modified for the prominent eye.
Downward clotheslining in the prominent eye pro-
duces scleral show. Thus, with a prominent eye, can-
thal anchoring is shifted upward, usually with slack,
to prevent such effect (Figs 8.16 & 8.17).
Figure 8.16 Canthoplasty – prominent eye.
• Supraplace
• May need to leave
some slack
A
B

122
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
With lower lid laxity (redundancy), tightening of
the tarsoligamentous sling prevents buckling of the
lower lid and ectropion (Fig. 8.18).
• Common in older people

(enophthalamic eyes)
• Tighten posterior lamella with

lysis and resection
Figure 8.18 Canthoplasty – lower lid laxity.
A
B
C

With increasing prominence of the globe, I routinely
release the inferior retractors (capsulo-palpebral
fascia) (Fig. 8.19).
123
The Primary Cheeklift
CPF
A
Figure 8.19 Recession of capsulo-palpebral fascia.
B
C

124
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
With cases of more severe prominence, use of a
primary spacer prevents postoperative scleral show –
Figure 8.21 A patient with prominent eyes – Hertel 19 – after cheeklift with primary spacer.
Figure 8.20 Primary spacer.
currently, Alloderm seems to work well (Figs 8.20
& 8.21).
A
B
A
B

125
The Primary Cheeklift
Figure 8.22
The other major anchoring step is anchoring the
inferior arc of the orbicularis muscle in the cheeklift
flap. This supports the lower lid and the cheek.
To isolate a portion of the inferior arc of the orbic-
ularis muscle, a subcutaneous dissection is performed
down to the inferior edge of the muscle into the
SMAS (Fig. 8.22).
A
B
C

The muscle flap usually will be pulled in a different
vector than the skin flap (Fig. 8.23).
The anchoring of the orbicularis muscle is very
important – it is the handle of the cheeklift. With its
fixation and anchoring, it redrapes the cheek and it
also provides a sling-like support for the lower lid.
Also, with its redraping, the eyelid fat is repositioned
126
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
by tension of the flap on the orbital septum which
lines the inner surface of the flap.
Double anchoring is necessary – the base of the
orbicularis muscle arc is anchored at the orbital rim
at the level of the lateral canthus, while the tip of the
orbicularis muscle arc is anchored at varying places in
the deep temporal fascia (Fig. 8.24).
Figure 8.23 Development of orbicularis flap.
Figure 8.24 Anchoring of orbicularis muscle flap to periosteum and deep temporal fascia.
Base
Tip
Anchoring of base
Anchoring
of tip

127
The Primary Cheeklift
Figure 8.25 Non-prominent eye.
Before fixation of the muscle occurs, there are
variations in the redraping of the orbicularis muscle
flap.
In the non-prominent eye, an oblique or more
horizontal vector can be used for attachment of the
base of the flap for optimal smoothing of the cheek
and the nasolabial fold (Fig. 8.25).

In patients with a prominent eye, a vertical vector
must be used to prevent the clotheslining effect on the
lower lid (Fig. 8.26).
128
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
Figure 8.26 Prominent eye.
A
B

Before the suture is placed in the flap, the anchor-
ing suture is first double-loop stitched in the peri-
osteum at the lateral orbital rim (Fig. 8.27A).
129
The Primary Cheeklift
Figure 8.27 Periosteal stitch.
The fixating suture for anchoring the base of the
flap is placed at the inferior edge of the orbicularis –
in the SMAS (Fig. 8.27B).
A
B

It is then brought through the muscle–SMAS flap
with a quilting suture (Fig. 8.28A,B).
130
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
Figure 8.28 Anchoring of the base of the orbicularis flap.
A
B

131
The Primary Cheeklift
Figure 8.29 Fixation of tip of flap.
Lateral
Deep temporal
Tip
fascia
orbital rim
After anchoring the base of the flap at the orbital
rim, the tip of the flap is then fixated to the deep tem-
poral fascia (Fig. 8.29A,B).

Figure 8.30 shows suturing the tip of the flap to
the deep temporal fascia – some redundant muscle is
usually trimmed.
132
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
Figure 8.30
A
B
C

133
The Primary Cheeklift
Figure 8.31
A good bit of skin is usually vertically recruited
over the lateral half of the lid margin; it may be
excised after careful assessment (Fig. 8.31A & B).
A
B

134
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
Figure 8.32 (A) Before and (B) after.
Figure 8.33 Oblique views. (A) Before
and (B) after.
A
B
A
B

135
The Primary Cheeklift
Figure 8.34 (A) Before and (B) after.
A
B

136
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
Figure 8.35 (A) Before and (B) after.
A
B

137
The Primary Cheeklift
Figure 8.36 Frontal view. (A) Before and (B)
after.
Figure 8.37 Oblique view. (A) Before and
(B) after.
A
B
A
B

138
Chapter 8: Lower Blepharoplasty and Primary Cheeklift
Figure 8.40 (A) Before and (B) after.
Figure 8.41 (A) Before and (B) after.
Figure 8.38 (A) Before and (B) after.
Figure 8.39 (A) Before and (B) after.
A
B
A
B
A
B
A
B

A special case – a patient with facial dystrophy
and severe eye prominence. Dermis fat grafts were
placed in the malar area as a cheek filler. I was
responsible for the eyelids and cheek and used a pri-
mary spacer of autogenous dermis to normalize the
eyelid fissure.
Recently, I reviewed 195 cheeklift procedures
performed over approximately 18 months, 151 of
which were primary cheeklifts. Using the described
techniques, only four cases (2.6%) required any
revision – a rate that is quite acceptable for a cosmetic
procedure.
139
The Primary Cheeklift
Figure 8.42.
After
Before
A
B
C
D

141
Chapter 9
Anchoring techniques are the heart of not only the
prevention of problems but also the correction of
problems.
The term ‘anchoring’ refers to the two main fixa-
tion points in a cheeklift:
■ anchoring of the lateral eyelid tendons –
canthoplasty or -pexy, which controls the shape
of the eyelid fissure; and
■ anchoring of the inferior arch of the orbicularis
muscle, which provides support for the lower lid
and positions the mid-cheek.
The approach to the lower lid surgery is to perform
cheeklifts through transcutaneous eyelid incisions
with optimum redraping of skin.
The two most common problems after cheeklift
are:
■ abnormalities in the shape of the eyelid fissure
from failure of canthal anchoring; and
■ retraction and sagging of the lower lid and cheek
from failure of anchoring of the inferior
orbicularis muscle.
Eyelid fissure shape is the result of the position and
curvature of the upper and lower lids. Excellent stud-
ies have shown mathematically that upper lid curva-
ture is almost solely the result of the indentation of
the globe on the lid. This is not so with the lower lid,
where indentation does play some role, but the tone
and position and laxity of the canthal attachments of
the lower lid are the most important.
Normal eyelid fissure shape varies, but, in general,
the lower lid edge reaches the inferior limbus – the
canthal angle is as high as the inferior pupillary edge.
The downward displacement of the canthus and
lower lid that occurs with age is a constant.
Avoidance of Complications
with Lower Lid Blepharoplasty
Cheeklift
Clinton D McCord Jr

Figure 9.1 summarizes the variety of modifications
that must be made in lateral canthoplasties with the
varying conditions of:
■ a standard positioned eye;
■ a lower lid with horizontal laxity;
■ a prominent eye; and
■ an enophthalmic eye.
142
Chapter 9: Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
Figure 9.1 Variations in canthal anchoring (lateral canthoplasty) technique.
Prominent eye
Enophthalmos
Standard
Laxity

Patients with a greater degree of eye prominence
usually will require additional steps to prevent scleral
show. Loosening of the retractors in the lower lid by
recession of the capsulo-palpebral fascia will gain
some upward movement of the lid edge in prominent-
eyed patients (see Fig. 8.19). Those with very prom-
inent eyes will require primary insertion of spacer
material (see Fig. 8.20). This may include autogenous
fascia lata or autologous dermis (Alloderm) primarily
to elevate the lower lid margin to prevent scleral
show.
It is the anchoring of the flap of the inferior arc of
the orbicularis muscle that is the handle of the cheek-
lift and acts as a sling to support the lower lid.
The sub-orbicularis oculi fat (SOOF) and malar
fat are fused to the muscle by the interdigitation of
the superficial musculo-aponeurotic system (SMAS)
and are redraped upward as the muscle is redraped.
Periorbital eyelid fat and prolapsed anterior orbital
fat are repositioned by the tension of the reanchored
flap on the orbital septum, which is on the posterior
surface of the muscle flap.
Double anchoring of the orbicularis muscle flap is
necessary: the base of the muscle flap is anchored in
the periosteum at the lateral rim, while the tip of the
muscle flap is anchored at varying places in the deep
temporal fascia superolateral to the lateral orbital
tubercle (see Fig. 8.24).
The vector of redraping of the muscle flap must vary
according to eye prominence. In the non-prominent
eye, a more oblique vector can be used for maximum
smoothing (Fig. 9.2). With prominent eyes, a vertical
vector of redraping must be used to prevent the down-
ward clotheslining effect.
There are many techniques described to perform
the cheeklift from a distant incision, with different
vectors needed for canthal anchoring and muscle flap
anchoring. However, because of the variations in eye
prominence and laxity, it is difficult to see how per-
forming a cheeklift from a single remote vector can
take into account these needed variations.
143
Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
Figure 9.2
Muscle-anchoring
vectors
Canthoplasty
vectors
Single remote
vector

In many patients, there may be combined reasons
for problems. When selecting a procedure to correct a
problem following cheeklift, it is important to choose
one that is anatomically appropriate.
The complications that occur following cheeklifts
need to be accurately diagnosed as:
■ primarily an anchoring problem;
■ primarily a skin shortage problem; or
■ failure to recognize eye prominence.
To summarize the techniques needed to correct
postoperative problems following cheeklifts:
■ anchoring – muscle flap, canthus – through
lateral canthoplasty, orbicularis muscle flap,
periosteal flap;
■ skin recruitment – vertical skin recruitment with a
secondary cheeklift, by reanchoring the
orbicularis flap; and
■ use of spacer – for prominent eyes and in scarring.
With regards to problems arising from poor
anchoring at the canthus (canthal anchoring for fis-
sure abnormalities), three reconstructive procedures
are available:
■ a repeat simple canthoplasty, for simple shape
problems;
■ periosteal flap canthoplasty (Fig. 9.3A); and
■ canthoplasty with fascia sling to the lower lid
(Fig. 9.3B).
144
Chapter 9: Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
Figure 9.3 Reconstructive anchoring procedures for the lateral canthus. (A) Periosteal strip canthoplasty. (B) Fascia sling canthoplasty.
A
B

If stronger anchoring is needed:
■ Phimosis and too much upward slant is corrected
by reanchoring with a simple canthoplasty at
1 week (Fig. 9.4).
■ Too much downward slant is corrected by
reanchoring with a simple canthoplasty (Fig. 9.5).
145
Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
Figure 9.4
Figure 9.5
A
B
A
B

Good canthal anchoring is needed for eyelid clo sure.
Normally, there is a very firm attachment of the tarsal
plates at the lateral rim (Fig. 9.6), so that when the
circular orbicularis muscles contract, the circular con-
tracture is translated into a vertical vector, resulting in
apposition of the lid margins (upper lid coming down
and lower lid going up (Fig. 9.7)). With good anchor-
ing laterally, a vertical vector of closure is restored by
the firm canthal anchoring (Fig. 9.8). With poor
anchoring, the vertical vector of closure is lost, so that
when the circular muscles contract, it creates fish-
mouthing with poor closure of the eyelids (Fig. 9.9).
146
Chapter 9: Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
Figure 9.6
Tarsoligamentous
sling anchored
Figure 9.7
Preseptal orbic
Pretarsal orbic
Procerus
Frontalis
Corrugator
Orbital orbic
Figure 9.8 Normal blinking and closure of eyelids.
Figure 9.9 Poor closure – fishmouthing seen in poor canthal position or
anchoring.

147
Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
These closure problems can be subtle. For example,
this was a patient with chronic chemosis. Several
plastic surgeons and an experienced oculoplastic
surgeon referred her for evaluation. Her chemosis was
refractory to all medical treatment (Figs 9.10 & 9.11).
On close inspection, I noticed a mild fishmouthing
and poor closure. She did have corneal signs of mild
exposure. One week after canthal anchoring and
cheeklift revision, good eyelid closure and complete
clearing of the chemosis were achieved (Fig. 9.12).
Figure 9.10
Figure 9.11
Figure 9.12

The patient shown in Figure 9.13A exhibited
postoperative phimosis or narrowing of the fissure,
which was resistant to simple canthoplasty. This was
corrected by reanchoring with a periosteal strip
canthoplasty (B).
148
Chapter 9: Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
Figures 9.14 & 9.15 similarly show correction by
canthoplasty and fascia sling.
Figure 9.13
Figure 9.14 Canthoplasty with fascia sling.
(A) Before and (B) after.
A
B
A
B

149
Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
Figure 9.15 Canthoplasty with
fascia sling. (A) Before and (B) after.
A
B

The other major anchoring problem can occur in
the muscle flap supporting the cheek and lid – slip-
page can result in a relative shortage of skin. In
patients with severe skin deficiency, a secondary
150
Chapter 9: Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
cheeklift with vertical reanchoring of the muscle flap
will produce an amazing amount of vertical recruit-
ment of skin into the lower lid (Figs 9.16–9.22).
Figure 9.16 Secondary cheeklift. Vertical
reanchoring of the orbicularis muscle flap
with skin recruitment.

151
Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
Figure 9.17 Skin-deficient lids – correction by
secondary cheeklift. (A) Before and (B) after
correction.
Figure 9.18 Skin-deficient lids – correction by
secondary cheeklift. (A) Before and (B) after
correction.
A
B
A
B

152
Chapter 9: Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
Figure 9.19 Skin-deficient lids – correction by
secondary cheeklift. (A) Before and (B) after
correction.
Figure 9.20 A more challenging case for skin
recruitment. Correction by secondary cheeklift.
Reanchoring and recruitment twice was needed.
(A) Before and (B) after correction.
A
B
A
B

Dr Rod Hester of Atlanta and I used staged excision
of scars and skin recruitment with secondary anchor-
ing procedures on this patient with laser burn
(Fig. 9.21). I was responsible for the eyelids with anchor-
ing procedures. We were able to get to this point. The
patient has only recently had very small skin grafts at
the outside corner of the lids (Fig. 9.22).
153
Avoidance of Complications with Lower Lid Blepharoplasty Cheeklift
Figure 9.21 This was the greatest challenge to
date for skin recruitment – laser burns from
resurfacing.
Figure 9.22 After staged excision of scars, skin
recruitment with secondary anchoring proce-
dures, plus small skin grafts at the outer corner
of the lids.