Master Techniques in Facial Rejuvenation 2

131
INTRODUCTION
Lower blepharoplasty has evolved significantly since its
early descriptions [1–6]. Traditional surgery involved an
open transcutaneous approach that allowed the excision
of skin, muscle, and fat sequentially through the same sub­
ciliary incision [7]. Although still a common approach to
lower blepharoplasty today, the transcutaneous route can
be associated with an increased incidence of lower eyelid
malposition and rounding of the canthal angle [8–12].
The addition of various canthal suspension techniques
has reduced the development of these complications
[10,13–15], but they can still occur at an unacceptably
high rate [11,12]. It has long been thought that unad­
dressed eyelid laxity, a “middle lamellar (orbital septal)
scar,” and anterior lamellar shortage associated with the
transcutaneous approach predisposed to these complica­
tions [8–10,16]. More recently it has been shown that
orbicularis weakness and negative vector eyelid configu­
ration may be even more significant in the development
of these issues [12]. Whatever the primary instigators
of these problems may be, the one common variable is
the propensity for occurrence after open transcutaneous
approach surgery [12,17,18]. A recent report evaluat­
ing the physical findings present on patients with post-
blepharoplasty lower eyelid retraction (PBLER) showed
that all patients (100%) presenting with this problem
had primary transcutaneous surgery [12]. For this reason
the transconjunctival approach to cosmetic lower eyelid
rejuvenation has become a standard alternative for the
aesthetic eyelid surgeon.
Transconjunctival blepharoplasty (TCB) has its origins
in the French literature in the 1920s [2]. It is a more
complex technique than traditional open approach surgery,
with limited surgical exposure, and it does not directly
address lower lid skin excess. The procedure generally fell
into disfavor for 50 years until 1973, when Tessier [3]
reported on its use for various reconstructive and cosmetic
applications. Soon after, with the desire of reducing the
incidence of lower eyelid retraction and ectropion after
standard transcutaneous surgery, TCB was elaborated
on by a number of authors. First, Tomlinson and Hovey
[4] described the preseptal transconjunctival approach,
and then Baylis et al. [5] the postseptal technique. The
difference between these conjunctival routes of dissection
was that the preseptal plane mandated septal division to
access fat, whereas the postseptal route preserved this
delicate tissue structure. It was thought that septal pres­
ervation was integral to preventing lower lid malposition
after surgery [19–21]. It has now been shown that when
approaching fat transconjunctivally, septal manipulation
does not play a role in postoperative eyelid malposition
[22]. Although septal scarring most assuredly is involved
in PBLER, it is the combined skin/muscle/septal incision
that predisposes to this complication and not an isolated
septal manipulation (as is seen in preseptal TCB) [22].
Until the latter part of the 20th century lower bleph­
aroplasty was primarily a fat-subtractive procedure
[17,18,23,24]. Postoperative volume depletion with a
hollow, gaunt, and skeletonized appearance was not
uncommon. With the more contemporary understand­
ing that volume loss is a critical component of facial/
eyelid aging [25–28], surgeons have come to understand
that excisional-based surgery can be a form of iatrogenic
aging rather than a recreation of youth [17,18,24]. Today
aesthetic lower blepharoplasty focuses on volume preser­
vation and augmentation to maintain the fullness, curves,
and contours of the youthful face and eyelids [17,29]. In
addition it is now clear that successful blepharoplasty
involves more than surgery on the lower eyelid alone,
but rather on the eyelid and its transition to the midface,
as these two structures are considered one aesthetic unit
[30]. These observations fueled the development of fat
transposition lower blepharoplasty variations, in which
native eyelid/orbital fat is redistributed from areas of rela­
tive excess “lower eyelid bags,” to areas of relative deficit
“underlying depressions,” with the goal of reducing lid
prominence, effacing adjacent hollows, and smoothing
the transition of the lower lid to the cheek.
Lower blepharoplasty with fat repositioning (LBFR)
was first described by Loeb in 1981 [31], and has been
elaborated on by many since [17,18,23,24,32–35]. It can
be performed through a transcutaneous [33] or transcon­
junctival approach [34], and the fashioned fat pedicles
can be placed in either the sub- or supraperiosteal planes
[17,23,36]. Although the techniques of sub- versus supra­
periosteal fat transposition differ, a recent study showed
that there is no difference in final aesthetic outcome
C H A P T E R 12 
Transconjunctival Lower
Blepharoplasty With and
Without Fat Repositioning
David B. Samimi, MD and Guy G. Massry, MD

132
MASTER TECHNIQUES IN FACIAL REJUVENATION
between the two approaches [23]. In this chapter the
authors detail and outline the critical aspects of trans­
conjunctival lower blepharoplasty with and without fat
repositioning. An overview of lower eyelid anatomy and
aging changes will be also be outlined.
RELEVANT ANATOMY
The lower lid is a complex structure composed of an
anterior and posterior lamella (Fig. 12.1). The anterior
lamella, which is composed of skin and orbicularis oculi
muscle, is consistent the full height of the eyelid from
the eyelid margin to the orbital rim. The composition of
the posterior lamella changes depending on its location
within the eyelid. Just below the lashes the posterior
lamella includes the tarsus and fused conjunctiva. Five
millimeters below the lashes (at the base of the tarsus) the
tarsus is replaced by a confluence of the orbital septum
and lower lid retractors. This also continues for approxi­
mately 5 mm. Below this point (fusion point of lower lid
retractors and orbital septum) the posterior lamella con­
sists of lower lid retractors and conjunctiva. The orbital
septum continues as the middle lamella until its origin at
the orbital rim. There are three fat pads in the lower lid:
nasal (medial), central, and lateral. These fat pads are
sandwiched between the orbital septum and lower lid
retractors. In the horizontal plane, the inferior oblique
muscle lies between the nasal and central pad, and the
arcuate ligament (an extension of Lockwoods’s ligament)
separates the central and lateral fat pad (Fig. 12.2).
At the orbital rim the orbital septum fuses with the
periosteum of the orbit and face of the maxilla. This
dense fusion point is called the arcus marginalis. Below
this point the eyelid transitions to the midface. The
midface consists (anterior to posterior) of the skin, malar
fat pad, muscle layer (orbicularis oculi throughout and
the zygomaticus muscles laterally and the levator labii
and its adjacent alaeque nasi medially), suborbicularis
oculi fat (SOOF) pad, and periosteum. The orbitomalar
ligament (OML) is an anterior-posterior osseocutaneous
connective tissue structure originating from just below
the orbital rim and inserting onto the orbicularis muscle
and dermis of the upper midface. The OML under­
lies the location of the periorbital hollows, which are
filled with lower blepharoplasty fat-repostioning surgery
(Fig. 12.3).
There are some critical anatomic features relevant
to transconjunctival surgery. First, transconjunctival
entry can be at the base of the tarsus through the fused
conjunctiva/retractor/septum layer. In this plane dissec­
tion proceeds preseptally, posterior to the orbicularis
muscle and anterior to the septum. Alternatively, entry
Fat pad
Tarsus
Conjunctiva
Lower lid retractors
Orbicularis
oculi muscle
ML,
Orbital
septum
AL
FP
PL
Figure 12.1  Sagittal section of the lower eyelid demonstrating the AL
(skin/muscle) and PL above (tarsus/conjunctiva) and below (lower lid
retractors/conjunctiva) the tarsus. The FP of the lower lid retractors and
orbital septum, the ML (orbital septum), and fat pads are also shown.
The FP is critical for incision placement during surgery. AL, Anterior
lamella; FP, fusion point; ML, middle lamella; PL, posterior lamella.
Figure 12.2  Inferior oblique muscle of left eye separating the nasal fat pad (in forceps) from central fat pad (under cotton-tip) (left). Arcuate
expansion of right lower lid (white band below insulated Desmarres retractor) separating prominent central fat from less prominent lateral fat pad
(right). (From Massry GG. Transconjunctival lower blepharoplasty: fat excision or repositioning. In: Massry GG, Murphy M, Azizzadeh B, editors.
Master techniques in blepharoplasty and periorbital rejuvenation. New York: Springer; 2011. p. 173–84. With permission.)

12  Transconjunctival Lower Blepharoplasty With and Without Fat Repositioning
133
can be more than 5 mm below the base of the tarsus,
through the conjunctiva and retractors only (Fig. 12.4)
to access orbital fat post(retro)septally. The authors
prefer the latter (postseptal) dissection, although both
approaches lead to excellent results with infrequent com­
plications. Second, as mentioned, the inferior oblique
muscle separates the nasal and central fat pads. In cases
of fat-transposition surgery, these are the fat pads that
are fashioned into pedicles for translocation. It is impor­
tant to assure that there are no attachments of the fat
pedicles to the oblique muscle before fat transposition,
to prevent potential postoperative ocular motility issues.
This is achieved by lysing any obvious connective tissue
bands from the muscle. The authors employ a maneuver
that assures this step, which they have called the “inverse
shoe shine sign” (refer to surgical section later) (Fig. 12.5)
[17]. Third, by definition, the arcus marginalis is released
when fat is transposed subperiosteally (arcus marginalis
release is needed to create a subperiosteal pocket). Con­
versely, when supraperiosteal surgery is performed, the
periosteum and arcus are left attached, but the OML is
released. Some believe that release of the OML improves
lid/cheek interface depression effacement better than
when the OML is left intact [36]. This has yet to be
studied in an evidence-based manner. In either instance,
fat is placed where the age-related depressions (eyelid/
cheek junction) are present.
LOWER EYELID AGING CHANGES
Patients presenting with “eyelid bags” typically have
age-related structural alterations to the eyelid and its
adjacent middle face. Lower eyelid/midface aging is a
multifactorial process involving degenerative changes in
the skin and muscle, loss of soft tissue volume, bone
remodeling, and tissue descent [24]. The aged lower
eyelid/midface demonstrates true or relative fat hernia­
tion, septal attenuation, volume loss over the infraorbital
rim, and midface descent/deflation (Fig. 12.6) [18,24,30].
These changes convert the topography of the eyelid/cheek
OMG
V deformity
NJG
Figure 12.3  Lower periorbital hollows: red, NJG; black, V deformity;
yellow, OMG. NJG, Nasojugal groove; OMG, orbitomalar groove.
(From Massry GG, Azizzadeh B. Periorbital fat grafting. Facial Plast
Surg 2013;29:46–57. With permission.)
Fat
Transconjunctival Post-septal Approach
Transconjunctival Pre-septal Approach
Conjunctiva
Lower lid
retractors
Orbicularis oculi
Infraorbital rim
Orbital septum
Fat
Conjunctiva
Lower lid
retractors
Orbicularis oculi
Infraorbital rim
Orbital
septum
Figure 12.4  Dissection plane for both postseptal (top) and preseptal
(below) transconjunctival dissection.
transition from the concavity/convexity of youth to the
double convexity of age [18,24,36]. In between these
convexities are depressions or periorbital hollows, which
require surgical effacement to attain appropriate cosmetic
surgical outcomes (see Fig. 12.3). Traditional fat-excision
lower blepharoplasty often leads to postoperative volume
depletion (eyelid hollows) and exacerbation of the
unmasked orbital rim (periorbital hollows) [23,24]. Fat
repositioning is added to lower blepharoplasty to cam­
ouflage these adjacent eyelid/cheek interface depressions
[17,23,24,29–36]. The technique allows preservation of
eyelid volume, filling of periorbital hollows, and recre­
ation of the youthful transition of the lower lid to the
midface [17,18,23,24].
INDICATIONS
LBFR is indicated in patients demonstrating lower lid
fat prominence with adjacent periorbital hollows. In the

134
MASTER TECHNIQUES IN FACIAL REJUVENATION
muscle placation, and canthal suspension can be added
to enhance surgical results.
SURGICAL TECHNIQUE
All procedures are performed under conscious sedation or
general anesthesia depending on patient preference and
associated procedures. If fat transposition is planned, the
tear trough (nasojugal fold) and central lid depression are
marked in the preoperative area, with the patient in the
sitting position, for reference during surgery (Fig. 12.7). It
is often helpful to have the patient look up when assessing
the fat pads. This maneuver tends to better delineate the
degree of relative fat prominence, and allows a visualized
separation of the central from lateral fat pad, as in upgaze
this delineation by the arcuate expansion (which is ante­
rior in the orbit) is more obvious. Conversely the nasal
and central pads appear continuous as their dividing
anatomic structure, the inferior oblique muscle, is more
posteriorly located in the orbit and the anterior extent of
the fat pads overrides the muscle (Fig. 12.8) [17]. Once
the patient is prepped and draped, the eyelid is infiltrated
transconjunctivally with 2 mL of lidocaine (Xylocaine)
1% with 1 : 100,000 epinephrine. If fat repositioning is
planned, an injection is also given transcutaneously over
the nasojugal groove to the periosteum. If a preseptal
plane of dissection is preferred, an incision is made below
the tarsal border but above the fusion point of the orbital
septum and lower eyelid retractors. A Desmarres retrac­
tor is used to displace the eyelid inferiorly for initiating
an incision 5 mm or less below the tarsus (Fig. 12.9)
[17,22,35,36]. The dissection then proceeds in a plane
between the orbicularis anteriorly and septum posteriorly
until reaching the arcus marginalis at the orbital rim (Fig.
12.10). In this instance the orbital septum will be in direct
view and will need to be incised to enter the fat compart­
ment. For the purposes of this chapter the authors will
describe the retroseptal approach to fat, as this is their
preferred approach. The steps after fat access are the
same for both approaches.
In the retroseptal approach, an incision is made
through the conjunctiva and lower lid retractors greater
than 5 mm below the tarsus to directly access orbital fat
lower lid/midface transition these hollows have been
named according to their anatomic location. The naso­
jugal groove (tear trough) is most nasal, the V-deformity
central, and the orbito (palpebro) malar groove most
lateral (see Fig. 12.3) [30]. Typically the nasal and central
lower lid fat pads are transposed to the tear trough and
central lid hollow. There are two critical factors that must
be present for effective performance of the procedure: (1)
adequate fat to transpose; and (2) a noticeable depression
to efface. In cases when primarily fat protrusion is present
without an associated depression, standalone subtrac­
tive lower blepharoplasty is adequate. When the primary
deficit is an eyelid/cheek depression without appropriate
fat to reposition, fat grafting [27–29] or soft tissue fillers
[37] are better options. LBFR, in itself, does not address
skin excess, reduced orbicularis tone, or eyelid laxity.
However, when indications are present, skin excision,
Figure 12.6  Typical age-related changes of the lower eyelid/cheek
transition. (From Massry GG. Transconjunctival lower blepharoplasty:
fat excision or repositioning. In: Massry GG, Murphy M, Azizzadeh B,
editors. Master techniques in blepharoplasty and periorbital rejuvena­
tion. New York: Springer; 2011. p. 173–84. With permission.)
Figure 12.7  The tear trough (nasojugal groove) is demarcated with
a solid line. This area will undergo fat repositioning. The remaining
lid/cheek depressions (dotted lines) will undergo fat grafting. (From
Massry GG. Transconjunctival lower blepharoplasty: fat excision or
repositioning. In: Massry GG, Murphy M, Azizzadeh B, editors. Master
techniques in blepharoplasty and periorbital rejuvenation. New York:
Springer; 2011. p. 173–84. With permission.)
Figure 12.5  Free movement of nasal and central fat on the undersur­
face of the inferior oblique muscle: the “inverse shoe shine sign.” (From
Massry GG. Transconjunctival lower blepharoplasty: fat excision or
repositioning. In: Massry GG, Murphy M, Azizzadeh B, editors. Master
techniques in blepharoplasty and periorbital rejuvenation. New York:
Springer; 2011. p. 173–84. With permission.)

12  Transconjunctival Lower Blepharoplasty With and Without Fat Repositioning
135
The conjunctiva and retractors are then secured to the
head drape with a traction suture (authors use 4-0 silk)
and a Desmarres retractor is used to displace the tarsus/
muscle/skin inferiorly. These two steps allow appropriate
exposure of the surgical field. In cases of standard TCB,
direct and graded fat excision proceeds. Care is taken to
err on conservative fat excision as to avoid the “surgical
stigmata” of postoperative volume depletion. When fat
is to be transposed, the fat flaps must be created. The
nasal and central fat pads are isolated and fashioned
into free pedicles by lysing all connective tissue attach­
ments at their base and to the inferior oblique muscle
and orbital rim (Fig. 12.12). This frees the fat pedicles
from their connection to the orbital motility complex. Fat
flap isolation is verified by engaging the nasal and central
fat pad with a toothed forceps and pulling one and the
[22]. Exposure can be enhanced with simultaneous infe­
rior eyelid displacement and globe retropulsion. This can
be performed with the aid of a surgical assistant [5] as
originally described, or unimanually by the surgeon only.
This unimanual variant allows the surgeon the ability
to titrate the degree of conjunctival exposure with two
fingers of one hand, and has been referred to as the “globe
retropulsion eyelid depression” maneuver (Fig. 12.11)
[38]. In a recent report the optimal placement of this inci­
sion was evaluated. With the posterior lamellar exposure
described, the yellow fat underlying the conjunctiva and
retractors is visible. When the conjunctival incision is
made just inferior to this location, direct access to retro­
septal fat occurs in 82% of cases [39]. In this study the
average measured distance from inferior tarsus to con­
junctival incision was 6.5 mm, a distance similar to that
which has been shown in cadaveric anatomic study [40].
However, the authors’ suggestion was to base the incision
placement on visualized fat rather than a constant mea­
sured distance, as anatomic variations exist [39].
A
A
Figure 12.8  In upgaze nasal and central fat pads appear continuous, but central and lateral fat pads are separated by an indentation (arrows)
caused by arcuate (A) expansion (left). Surgical photo showing central fat pad (adjacent to tip of cautery) overriding the inferior oblique muscle,
which makes the nasal and central fat pad appear continuous in upgaze (right). (From Massry GG. Transconjunctival lower blepharoplasty: fat
excision or repositioning. In: Massry GG, Murphy M, Azizzadeh B, editors. Master techniques in blepharoplasty and periorbital rejuvenation. New
York: Springer; 2011. p. 173–84. With permission.)
Fusion
Point
Figure 12.9  Preseptal approach. Transconjunctival entry begins below
the inferior tarsal border and above the fusion point of the lower lid
retractors and orbital septum. Moving inferiorly from the tarsal border
the fusion point can be seen clinically where the conjunctival hue transi­
tions from pink (underlying orbicularis) to yellow (underlying orbital
fat). (Courtesy David B. Samimi, MD.)
Figure 12.10  Preseptal dissection. A plane is developed between the
orbital septum and undersurface of orbicularis toward the arcus margi­
nalis. The demarcation between orbicularis (pink) and septum (yellow)
is highlighted here (blue arrow). Additional control by the surgeon
during this dissection may be facilitated by swinging a tied traction
suture through the retractors with the surgeon’s fifth digit. (Courtesy
David B. Samimi, MD.)

136
MASTER TECHNIQUES IN FACIAL REJUVENATION
reduce any degree of prominence. There are surgeons who
create temporal fat flaps for transposition. The authors of
this chapter do not, as they have found temporal fat to
be dense and less amenable to transposition.
Fat can be transposed into either the subperiosteal
or supraperiosteal plane [23]. If fat is repositioned sub­
periosteally, an incision is made at the inferior orbital
rim through the periosteum (arcus marginalis) from the
nasal to the central extent of the orbital rim (Fig. 12.13).
other in successive fashion in opposite directions, sliding
the fat freely under the muscle (see Fig. 12.5). As stated,
the authors refer to this as the “inverse shoe shine sign”
[17,41], as it resembles shining a shoe in an inverted
fashion. Whether or not complete fat pedicle mobiliza­
tion is needed to prevent potential postoperative motility
issues is unknown. However, as diplopia is such a wor­
risome complication, measures to prevent it are prudent
[42]. The temporal fat pad is conservatively sculpted to
A
B
C
D
Figure 12.11  The “globe retropulsion eyelid depression” maneuver. Simultaneous unimanual globe retropulsion and lower eyelid depression with
two fingers of one hand allows a controlled exposure on the conjunctival entry for direct postseptal fat access. Artist’s drawing (left) and surgeon’s
view (right) of this manipulation. The arrow demonstrates location of fat maximally balloted forward corresponding to transconjunctival incision
location. (From Peng GL, Jacono A, Massry, GG. Re: “Globe retropulsion and eyelid depression (GR)” – a surgeon controlled, unimanual maneuver
to access post-septal fat in transconjunctival lower blepharoplasty. Ophthal Plast Reconstr Surg 2014;30:273–4. With permission.)
Figure 12.12  Creation and isolation of nasal and central fat flap with inferior oblique muscle in between (left). Robust nasal fat pedicle (right).
(Courtesy Guy G. Massry, MD.)

12  Transconjunctival Lower Blepharoplasty With and Without Fat Repositioning
137
Dissection ensues around the infraorbital neurovascular
bundle with a Freer elevator. A 4-0 Prolene suture on a
PS-2 needle is passed through the skin into the wound
below the demarcated tear trough. The needle is retrieved
and passed in a horizontal mattress fashion through the
nasal fat flap and then back into the wound and exiting
the skin (Fig. 12.14). This is repeated for the central
fat pedicle. Both sutures are tied over a bolster (Fig.
12.15). Conversely, the suture can be run through both
the nasal and central fat, creating a single continuous fat
flap (Fig. 12.16). In this case only one bolster is needed
to reposition the orbital fat. The authors have employed
both techniques and have not noted a difference in final
outcome. They prefer the single suture pass combined
flap transposition as it is reduced a step and is faster. It
is important not to tie the suture too tight as this can
strangulate the fat flap with subsequent atrophy, or too
loose, as this can allow the flaps to retract. Appropriate
suture tension comes with experience. In cases when fat
Figure 12.13  Cotton-tip applicator displacing fashioned fat flaps
away from exposed subperiosteal dissection. (From Massry GG. Trans­
conjunctival lower blepharoplasty: fat excision or repositioning. In:
Massry GG, Murphy M, Azizzadeh B, editors. Master techniques in
blepharoplasty and periorbital rejuvenation. New York: Springer; 2011.
p. 173–84. With permission.)
Figure 12.14  Prolene suture engaging nasal fat flap. (Courtesy Guy
G. Massry, MD.)
Figure 12.15  Final fat flap bolsters in place. (From Massry GG. Trans­
conjunctival lower blepharoplasty: fat excision or repositioning. In:
Massry GG, Murphy M, Azizzadeh B, editors. Master techniques in
blepharoplasty and periorbital rejuvenation. New York: Springer; 2011.
p. 73–84. With permission.)
Figure 12.16  Both fat pedicles engaged with one double-armed 5-0
chromic suture prior to transposition. (Courtesy David B. Samimi,
MD.)
is placed supraperiosteally, the dissection plane is below
the orbicularis muscle and above the SOOF centrally and
the nasal lip elevators levator labii superioris and levator
labii superioris alaeque nasi (LLS and LLSAN) nasally.
Another option is to create a pocket below the nasal lip
elevators at the nasal extent of the lid/cheek junction to
create a thicker tissue layer above the dissection pocket.
It is important to note that the SOOF, while robust in
the central lid, is attenuated or absent nasally, making
the nasal supraperiosteal dissection less defined, more
traumatic, and cumbersome (Fig. 12.17). In this location
subperiosteal surgery is more anatomically precise. Fat
pedicle suture suspension is the same as with subperi­
osteal surgery. When the pedicle suture(s) are tied, the
implant effect of the fat flaps can be seen externally. The
silk traction suture is removed and the transconjunctival
incision allowed to heal by secondary intent, or it can
be closed with 1 to 2 interrupted, buried 6-0 plain gut

138
MASTER TECHNIQUES IN FACIAL REJUVENATION
It is normal to have a degree of bloody tears for the
first 48 hours after surgery, and occasionally a subcon­
junctival hemorrhage can occur. Patients can be reassured
that this will resolve over a few weeks. Various degrees
of chemosis manifest in 1% to 12% of patients [43,44].
Most cases are self-limiting and spontaneously resolve
within 10 days. Rarely chemosis can persist and cause
corneal surface irregularities, foreign body sensation,
and visual disturbance. More severe chemosis can lead
to mechanical lid malposition. In these instances more
frequent application of topical and/or oral steroids, lid
massage, tarsorrhaphy, and conjunctival cut downs may
be needed. Cicatricial entropion can rarely occur with
or without associated trichiasis. Oral mucosal grafting
and electrolysis are considered when appropriate. Lower
eyelid retraction is rare when skin excision is not added.
The authors have seen two cases of obvious lid retraction
after standalone TCB. In both cases this was related to
over-resected fat in patients with negative vector globe/
midface topography. The assumption was that postopera­
tive volume deficit destabilized the mechanically disad­
vantaged lower lid, predisposing to retraction.
Persistent postoperative diplopia is a rare occurrence
typically related to inferior oblique trauma or imbrica­
tion when fat transposition is performed. Oral/injectable
steroids or injectable fluorouracil are given as needed.
sutures. Figs. 12.18 through 12.20 show representative
examples of surgical outcomes.
POSTOPERATIVE COURSE AND CARE
AND COMPLICATIONS
The authors instruct patients that bruising and swell­
ing typically lasts for 2 weeks. When fat transposition
is added recovery is longer. For the first 48 hours after
surgery ice is applied for 10 minutes every hour while
awake, and patients are asked to sleep inclined with
two pillows behind their heads. After 2 days warm com­
presses replace the ice packs for 10 minutes three times
a day. A steroid antibiotic eye drop is given three times
a day for 1 week after surgery and then twice a day for
the next week. When appropriate, such as in patients
with a preoperative inflammatory condition, a history of
allergy, thyroid-related eyelid/orbital disease, or signifi­
cant swelling from previous surgery, an oral steroid taper
is suggested. Patients can shower the day after surgery,
with care to keeping the eyelid as dry as possible (baths
preferred). Bending, stooping, lifting, and more than mild
to moderate activities are avoided for the first 10 days
after surgery, and contact lens use is held for 2 weeks.
The bolster sutures are removed at 5 to 7 days.
B
A
D
C
Figure 12.17  Supraperiosteal dissection. (A) Forceps pointing to robust suborbicularis oculi fat (SOOF) under the orbicularis muscle. (B) Forceps
pointing to levator labii muscle nasally. (C) Scissors spreading centrally creating an intra-SOOF pocket. (D) Scissors spreading nasally below the
lip elevators. (From Yoo DB, Peng G, Massry GG. Transconjunctival lower blepharoplasty with fat repositioning: a retrospective comparison of
transposing fat to the subperiosteal versus supraperiosteal planes. JAMA Facial Plast Surg 2013;15:176–81. With permission.)

12  Transconjunctival Lower Blepharoplasty With and Without Fat Repositioning
139
fashion. This is most commonly seen with the temporal
fat pad.
CONCLUSION
TCB is now a time-honored and well-studied procedure
that has become a mainstream option for the aesthetic
lower eyelid surgeon. It is a more complex procedure
than its transcutaneous counterpart as the surgical space
is small, exposure is limited, bleeding can obscure the
field, and more precise comprehension of eyelid anatomy
is required. It is less disruptive of native eyelid architec­
ture than the traditional open approach, can preserve
the orbital septum if desired, often allows avoidance
of canthal manipulation (eyelid suspension), and has
a much lower incidence of postoperative eyelid mal­
position, reported as 6% to 20% with transcutaneous
surgery [11,12]. It is limited in that it does not directly
address skin excess and orbicularis muscle “sagging.”
However, an adjunctive skin pinch excision [45] or orbi­
cularis placation [24] can be added as needed. In the
authors’ view this bilamellar approach (access fat trans­
conjunctivally and manipulate skin and muscle exter­
nally) adequately addresses these issues, with a reduced
Rarely reoperation with release of cicatrix is required
when diplopia is related to restrictive motility deficit
[42]. This is an uncommon event and postoperative
forced duction testing may identify this problem intra­
operatively for immediate intervention. Diplopia in the
immediate postoperative period is typically a result of
local anesthetic-related extraocular muscle paresis and
will resolve spontaneously. Induration of the transposed
fat flaps in cases where fat repositioning is added is a
normal finding. This typically resolves over the first 3
weeks after surgery. When persistent, or if objectionable
early on to the patient, the induration can be injected
with steroid (triamcinolone [Kenalog] 5 mg/mL) or (fluo­
rouracil 50 mg/mL) 0.2 to 0.3 cm3 every few weeks for
three to four sessions based on clinical response [23,24].
Mechanical massage and time typically allow resolution
in most patients.
Finally, over-resection of fat can lead to orbital and
periorbital hollows, new or worsened skin wrinkling,
and “dark circles.” Appropriate surgical planning with
conservative fat excision and adjunctive fat preservation
(transposition) are the best way to avoid these issues.
Undercorrection of relative fat herniation is less trouble­
some, as revision fat excision can be added in a staged
Figure 12.18  Frontal view (above) and oblique view (below) of a woman who underwent lower blepharoplasty with supraperiosteal fat reposi­
tioning. Preoperative photos (left); postoperative photos (right). Note improvement in lower eyelid appearance and eyelid/cheek contour. (Courtesy
Guy G. Massry, MD.)

140
MASTER TECHNIQUES IN FACIAL REJUVENATION
with appropriate knowledge of both surgical and clinical
anatomy. Although the learning curve for this adjunct can
be steep, the benefits and rewards of surgical outcomes
are noteworthy. As such, aesthetic facial surgeons should
familiarize themselves with the procedure so that it is an
option in their surgical armamentarium for the appropriate
patient.
incidence of lower eyelid retraction and ectropion. Fat
repositioning [17,18,31–36], an advanced technique that
preserves precious orbital fat, promotes a smooth tran­
sition of the lower eyelid to the cheek, and reduces or
eliminates periorbital hollows, can be added with some
experience [17,30]. The procedure, though more complex
than standard lower blepharoplasty, can be mastered
Figure 12.19  Another woman with same presentation as patient in Fig. 12.18, but fat was repositioned subperiosteally. (Courtesy Guy G. Massry,
MD.)
Figure 12.20  Patient from Figs. 12.9, 12.10, and 12.16 where the preseptal approach was used to reposition fat supraperiosteally. (Courtesy
David B. Samimi, MD.)

12  Transconjunctival Lower Blepharoplasty With and Without Fat Repositioning
141
transposing fat to the subperiosteal versus supraperiosteal planes.
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29. Massry GG, Azizzadeh B. Periorbital fat grafting. Facial Plast Surg
2013;29:46–57.
34. Goldberg RA. Transconjunctival orbital fat repositioning: trans­
position of orbital fat pedicles into a subperiosteal pocket. Plast
Reconstr Surg 2000;105:743–58.
35. Mohadjer Y, Holds JB. Cosmetic lower eyelid blepharoplasty
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nique and initial outcomes. Ophthal Plast Reconstr Surg 2006;22:
409–13.
43. Weinfeld AB, Burke R, Codner MA. The comprehensive manage­
ment of chemosis following cosmetic lower blepharoplasty. Plast
Reconstr Surg 2008;122:579–86.
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35. Mohadjer Y, Holds JB. Cosmetic lower eyelid blepharoplasty
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Springer; 2011. p. 3–11.
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blepharoplasty: technique and complications. Ophthalmology
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6. Zarem HA, Resnick JI. Expanded applications of transconjunctival
lower lid blepharoplasty. Plast Reconstr Surg 1991;88:215–20.
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eyelid blepharoplasty: experience, indications, and technique in 300
patients. Arch Otolaryngol Head Neck Surg 1994;120:172–7.
8. Marshak H, Morrow DM, Dresner SC. Small incision preperiosteal
midface lift for correction of lower eyelid retraction. Ophthal Plast
Reconstr Surg 2010;26:176–81.
9. Edgerton MT Jr. Causes and prevention of lower lid ectropion fol­
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11. Rosenberg DB, Lattman J, Shah AR. Prevention of lower eyelid
malposition after blepharoplasty: anatomic and technical consid­
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2007;9:434–8.
12. Griffin G, Azizzadeh BA, Massry GG. New insights into physical
findings associated with post blepharoplasty lower eyelid retrac­
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plasty with fat repositioning: a retrospective comparison of trans­
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Facial Plast Surg 2013;15:176–81.

142
INTRODUCTION
The transcutaneous skin-muscle flap blepharoplasty has
a long history in the field of cosmetic eyelid surgery. As
with any surgical approach, it has distinct advantages
and disadvantages. The chief advantage of the transcuta­
neous approach is the capacity to treat excess skin and
orbicularis muscle that requires redraping for adequate
lid recontouring and superior lower eyelid rejuvenation,
the major limitation of the transconjunctival approach.
The transcutaneous approach also allows for broad
exposure for wide release of the orbitomalar retaining
ligaments, fat transposition (or septal reset), as well as a
myriad of midface lift procedures. The disadvantages to
this approach include a higher risk of lower eyelid mal­
position reported in the 10% to 15% ranges, orbicularis
denervation atrophy, and a frank ectropion rate of 1%.
It is our goal in this chapter to elucidate how the
aesthetic surgeon can still utilize the transcutaneous tech­
nique and minimize risk. In the modern era of plastic
surgery, studies have revealed key anatomic risk factors,
intraoperative technical details, and postoperative care
regimens that allow for safe employment of the transcu­
taneous technique. What follows is a description of the
relevant anatomy, indications and contraindications, our
modified approach to transcutaneous skin-muscle flap
blepharoplasty, and how to avoid complications with
meticulous postoperative care.
AGING EYELID ANATOMY
The lower eyelid is formed by three lamellae: the anterior,
middle, and posterior lamella. The anterior lamella is
the skin and orbicularis oculi muscle, the middle lamella
is the tarsal plate and orbital septum, and the posterior
lamella is the conjunctiva and the lower lid retractors. The
orbicularis oculi muscle is comprised of two parts, the
outer orbital and inner palpebral portion. The palpebral
portion contains a pretarsal component and a preseptal
component. The upper and lower pretarsal components
of the orbicularis oculi muscle join medially and insert
onto the lacrimal crest as the medial canthal tendon. The
two lateral components of the pretarsal orbicularis join
together to form the lateral canthal tendon, which inserts
onto Whitnall’s tubercle. Immediately deep to the orbicu­
laris oculi muscle is the orbital septum, a continuation of
the orbital periosteum. The lower eyelid retractors insert
onto the orbital septum approximately 5 mm inferior to
the inferior-most aspect of the tarsal plate.
Orbital fat is contained within the orbital septum.
The lower eyelid has three fat pads: medial, central, and
lateral. The inferior oblique muscle runs between the
medial and central fat compartments, and is an impor­
tant anatomical marker to identify and preserve. The
medial fat pad is distinct in that it contains denser fat
that appears whiter in coloration. Both genetics and aging
play a role in the size of these fat pads, and these fat pads
do not fluctuate in size with changes in body habitus.
Age-related changes in the periorbital area are mul­
tifactorial, and are best understood by the contribut­
ing counterparts. The aged periorbital appearance is
the result of cumulative changes in skin texture, volume
depletion, loss of elasticity, formation of rhytids, droop­
ing of the skin, and ptosis. This milieu of changes result
in the characteristic findings of the aged lower eyelid, one
that is marred by dermatochalasia, pseudoherniation of
the orbital fat, malar festooning, and atonia of the lower
eyelid that affects lateral canthal position.
The tear trough is an area of particular concern in the
aging eyes. The tear trough is the concave area caudal to
the inferior orbital fat. First described as the nasojugal
fold by Duke-Elder and Wybar in 1961 [1], the modern-
day name “tear trough deformity” was coined in 1969
by Flowers [2], when it was observed that tears would
track down this dependent area. There have been several
explanations regarding the etiology of this tear trough
deformity, which was considered to be multifactorial [3].
More recently, evidence has suggested that the tear trough
occurs as a result of skin tethering by an osteocutaneous
ligament, which is situated between the origins of the
palpebral and orbital parts of the orbicularis muscle.
This ligament extends from the level of the insertion
of the medial canthal tendon to the line of the medial
pupil, where it continues laterally as the orbitomalar
retaining ligament [4]. This tethering effect is exacerbated
with aging due to an increasing bulge of orbital fat from
above, and atrophy with descent of the malar fat below
(Fig. 13.1) [5–8]. This ligament also tethers the redundant
orbicularis muscle that develops with age, creating malar
festoons and mounding.
The midface is an important yet often overlooked con­
tributing factor to periorbital aged appearance. Gravi­
tational descent and volume depletion of the midface
indirectly affects the periorbita and plays a significant
role in the aged appearance of the lower lids. The midface
descends with synchronous deflation of the suborbicu­
laris oculi fat, creating a deepening of the tear trough.
C H A P T E R 13 
Transcutaneous Lower
Blepharoplasty
Andrew A. Jacono, MD, FACS and Melanie H. Malone, MD

13  Transcutaneous Lower Blepharoplasty
143
The ptotic midface creates another bulge inferior to the
tear trough. The cumulative effect of these changes is
psuedoherniation and apparent orbital fat excess that
accentuates the tear trough, volume loss, and hollow­
ing in the infraorbital and lateral orbital areas, and a
midface bulge creating a double convexity of profile view
(Fig. 13.2).
Addressing the tear trough is important for success­
ful rejuvenation of the lower periorbital area, which is
why we recommend release of the orbitomalar retaining
ligaments to allow for both redraping excess orbicularis
muscle as well as volumizing the depth of the tear trough
with transposed orbital fat.
PREOPERATIVE EVALUATION, INDICATIONS,
AND CONTRAINDICATIONS
Preoperative planning has been lauded by some as the
most important aspect of blepharoplasty, and is vital
to achieving successful outcomes [9,10]. The eyes are a
focal point of the face and serve as the natural transition
between the upper and middle face. Prior to surgical
manipulation of the eyes, it is prudent to evaluate the
aging processes of the upper face and midface, specifi­
cally with regards to their contribution to the stigmata
of periorbital aging. Oftentimes there is contemporane­
ous aging of the midface and brow that influence how
the periorbital area is perceived, and it is important to
diagnose the contribution of the brow and midface in
order to address them concurrently. Thorough preop­
erative evaluation will identify the best surgical candi­
dates for blepharoplasty, as well as steer the surgeon
and patient away from unwanted potential postopera­
tive pitfalls. This evaluation is inclusive of the medical
comorbidities of patients, as well as their psychological
well-being and emotional disposition. It is important to
have a frank discussion with patients and record consul­
tations with photographic documentation. This process
is aimed towards setting realistic expectations, as well
as pointing out any preexisting asymmetries for both
patients and physicians to acknowledge. Smoking should
be discontinued for 2 weeks prior to surgery. All antico­
agulants or herbal medications that can interfere with
blood clotting should be discontinued 2 weeks prior to
surgery. Thyroid disorders should be investigated and
noted, as hypothyroid and hyperthyroid states can cause
disparate influences on the periorbital area that cannot
be addressed with routine blepharoplasty. Any history
of dry eyes should be investigated, with comprehensive
ophthalmological assessment including Schirmer’s test,
visual acuity, extraocular movements, intraocular pres­
sure, cornea and ocular adnexa evaluation. Complaint
of dry eyes despite normal Schirmer’s test should prompt
further ophthalmologic and systemic evaluation to seek
out any potential underlying collagen vascular disorders
or autoimmune diseases.
Physical examination warrants special observation of
all dermatological and structural changes in the peri­
orbital area. Volume changes in the orbit should be
evaluated. A relative volume excess is present in the
pseudoherniation of the orbital fat. This accentuates the
relative volume deficiency in the nasojugal groove and
infraorbital hollows immediately inferior to the orbital
fat pseudoherniation. In cases where the lower eyelids
have less significant dermatochalasia and orbicularis
muscle redundancy, the transconjunctival approach is a
more appropriate choice, leaving the orbicularis muscle
untouched. Mild skin redundancy can then be treated
with resurfacing with a peel or laser.
Excessive lower eyelid laxity should be assessed, defined
as a snap test greater than 1 second and distraction test
Pseudoherniated
orbital fat
Orbitomalar
ligament/
tear trough
Descended and
devolumized midface
Figure 13.1  A 63-year-old patient with classic periorbital stigmata
of aging. This figure is labeled to show the pseudoherniated orbital
fat, which causes the under eye bags that are characteristic of aged
eyes. The tear trough deformity is demarcated with the purple stippled
line. The tear trough deformity is the result of the orbitomalar liga­
ment attachments, and causes the characteristic “dark circles” in the
under eye. The aged appearance of the periorbitum is also attributed to
the devolumized and descended midface tissues. Comprehensive lower
eyelid rejuvenation should address all three of these findings.
Figure 13.2  A 63-year-old patient interested in periorbital rejuvena­
tion. This image shows the classic “double convexity deformity” on
profile, with a bulge of pseudoherniated orbital fat above a deep trough
created by orbital retaining ligament insertion. Immediately below the
trough of the orbital retaining ligament is the bulge of the cheek, created
by the descended midface tissues.

144
MASTER TECHNIQUES IN FACIAL REJUVENATION
cannot open the patient’s eyelids. With more degenerative
changes and age, the eyes are easily pried apart. In both
of these situations we elect to approach the orbitomalar
ligament and orbital fat transconjunctivally, and address
the skin externally by pinch technique and suspending the
orbicularis muscle redundancy with suture fiction to the
orbital rim and/or plicating the lateral orbicularis muscle.
SURGICAL PROCEDURE
Our lower blepharoplasty technique is an extended trans­
cutaneous submuscular blepharoplasty with orbitomalar
ligament release and orbital fat repositioning. Depend­
ing upon the patient’s preoperative degree of infraorbital
volume loss, this approach can be utilized including infra­
orbital ligament release with fat removal, partial removal
and transposition, or complete transposition. Utilizing
this method of periorbital volume replenishment is predi­
cated on the presence of sufficient orbital fat volume for
transposition. In cases where there is a lack of orbital fat,
autologous fat injections can be utilized. We prefer orbital
fat transposition when orbital fat is available because it
is a vascularized, pedicled fat flap that has an essentially
100% take rate, whereas injected autologous fat is a
free graft and fails to incorporate in as high as 35% of
patients, in our experience. To minimize the risk of lower
eyelid malposition, our approach preserves a robust orbi­
cularis oculi sling, and incorporates periosteal fixation of
the lateral canthus and skin-muscle flap. What follows is
our description of the techniques in six steps.
Step 1.  Skin Flap Elevation and Preservation
of Orbicularis Muscle
The patient is marked in the upright position, making
note of the pseudoherniated orbital fat and the hollowed
tear trough. The lower lid is injected with 1% lidocaine
with epinephrine 1 : 100,000. The skin is incised with a
(being able to distract the lower eyelid from the globe)
greater than 10 mm. On close inspection of those patients
with excessive skin laxity, preoperative scleral show is
often seen (Fig. 13.3). Excessive laxity is a relative contra­
indication to transcutaneous lower blepharoplasty. When
utilizing the transcutaneous approach, lower eyelids with
increased laxity could lead to postoperative eyelid mal­
position on a spectrum from lateral canthal rounding to
frank ectropion. In these cases the surgical plan should
include a concomitant canthopexy or horizontal lower
eyelid-shortening procedure (such as a lateral tarsal strip
procedure), depending upon the degree of laxity. It is
our preference to utilize a closed canthopexy (described
later), suturing the lateral tarsus to the orbital rim, to
tighten the lower eyelid margin because it does not
change the horizontal aperture of the eye. In cases of
more extreme laxity, a lower eyelid-shortening procedure
will be required.
Indications for transcutaneous lower blepharoplasty
include excess skin and orbicularis muscle that requires
redraping for adequate lid recontouring and superior
lower eyelid rejuvenation. This approach also provides
broad exposure for wide release of the orbitomalar
retaining ligaments and orbital fat transposition.
In our practice absolute contraindications include
patients with a negative vector and preoperative orbicu­
laris weakness. These two preoperative physical findings
have been noted in studies on postblepharoplasty lower
eyelid retraction to have a high risk of this complication
[11]. A negative vector eyelid is noted when the patient’s
profile is examined (sagittal view) and the cornea proj­
ects more anteriorly than the midface (Fig. 13.4). This is
often present in patients with thyroid eye disease. When
tightening the eyelid skin and orbicularis muscle, the ten­
dency is for the redraped tissue to fall under the globe in a
negative vector eyelid, similar to the way pants fall under­
neath a “beer gut”. Patients with preoperative orbicularis
weakness are also predisposed to lower eyelid retraction
as skin-muscle flap surgery further weakens the muscle,
causing denervation, loss of strength, and lower eyelid
margin eversion. Orbicularis strength can be assessed by
trying to pry the patient’s eyelids open during forceful
closure by the patient. In a normal situation the examiner
Figure 13.3  Preoperative lower eyelid laxity with scleral show. Note
the problem is greater on the right. Asymmetry such as this is normal
to see in patients.
Negative
vector
Figure 13.4  This patient has not undergone lower blepharoplasty
and is shown in profile to demonstrate a negative vector (arrow). This
patient’s midface skeletal structure is posterior to the palpebral opening.
Identifying patients with a negative vector preoperatively is imperative
to proper surgical planning and execution.

13  Transcutaneous Lower Blepharoplasty
145
a composite skin-muscle flap is elevated off the orbital
septum to the orbital rim. At the orbital rim, the orbital
retaining ligaments are released using bipolar cautery
in a plane just superficial to the suborbicularis oculi
fat [12,13], with dissection extending further than the
inferior-most aspect of the marked tear trough. Care
is taken to preserve the infraorbital nerve. This space
created inferior to the orbital rim is the recipient site
for transposed orbital fat (Figs. 13.7 and 13.8). Releas­
ing the tear trough ligaments allows for repositioning of
redundant orbicularis inferior to the insertion point, and
allows for better redraping than could be accomplished
in a transconjunctival approach.
Step 3.  Volumization With Fat Transposition
The skin-muscle flap is retracted inferiorly with a Des­
marres retractor, and gentle manual retropulsion of the
globe can help identify the orbital fat compartments.
Figure 13.5  The skin flap is elevated inferiorly with sharp iris scis­
sors for approximately 1.5 cm, preserving an intact sling of functional
orbicularis muscle.
Figure 13.6  Illustration depicting the critical elements of the procedure. SOOF, Suborbicularis oculi fat.
Figure 13.7  The composite skin-muscle flap is elevated off the orbital
septum to the orbital rim. The orbital retaining ligaments are released
beyond the inferior-most aspect of the marked tear trough.
#15 blade 1 mm below the lash line from 2 mm lateral
to the punctum past the lateral canthus for approximately
10 mm in a crow’s foot rhytid.
A retraction suture is placed through the midline lower
eyelid and retracted superiorly. A skin flap is elevated infe­
riorly with sharp iris scissors for approximately 1.5 cm,
preserving an intact sling of functional orbicularis muscle
(Figs. 13.5 and 13.6). In traditional skin-muscle flap
blepharoplasty, only 2 to 3 mm of pretarsal orbicularis
is preserved. We believe that maintaining this wider func­
tional sling of orbicularis oculi and minimizing trauma to
the muscle minimizes risk of lower lid retraction.
Step 2.  Submuscular Dissection and Release
of Orbital Retaining Ligaments
The orbicularis muscle is pierced just below the elevated
skin flap. The muscle is incised for the length of the
orbit from medial to lateral. From this point inferiorly,

146
MASTER TECHNIQUES IN FACIAL REJUVENATION
Step 4.  Support of Lateral Retinaculum With
Tarsal Fixation
Small sharp scissors are used to dissect down to the
periosteum of the lateral orbital rim and then superiorly
under the lateral aspect of the incision superior to the
attachment of the lateral canthal tendon. Here, two 6-0
nylon sutures are passed through the periosteum of the
internal superior aspect of the lateral orbital rim (Fig.
13.10). A closed canthopexy is performed by passing
one of these sutures through the lateral tarsal plate [16].
The medial, central, and lateral fat compartments are
identified by blunt dissection with a cotton tip applica­
tor, identifying the inferior oblique muscle between the
medial and central compartments. The orbital septum of
the central and medial fat compartments is opened with
sharp scissors at its inferior-most point, teasing out the
herniated fat pads. These fat pads are rotated inferiorly
over the orbital rim into the tear trough, and sutured to
the supraperiosteal plane with interrupted 5-0 chromic
sutures. More sutures are placed to sculpt the transposed
fat to smoothly efface the tear trough and to blend the
lower eyelid into the upper midface. This camouflages the
bony inferior orbital rim that is a hallmark of aging [14].
The transposed fat also fills the medial tear trough defect
[3] and smoothes the lower eyelid-cheek contour [12,15].
It is critical to make sure the fat flap fans out and is not
lumpy or bumpy, as these irregularities will show through
the redraped skin-muscle flap. We usually smooth out
any irregularities, melting them away by contouring with
bipolar cautery forceps (Fig. 13.9).
Excessive fat of the lateral fat pad is resected rather
than transposed. In the authors’ experience, the lateral
fat pad is more fibrous and creates contour irregularities
when transposed, so it is conservatively excised to the
level of the superficial aspect of the orbital rim. Special
care must be taken in patients with prominent globes or
hypoplastic malar eminences, since they are at risk of
having a deep sulcus postoperatively. In these cases, we
will use the resected lateral fat pad and suture it to the
orbital rim as an autograft, or fill the lateral orbit with
injected autologous fat.
Figure 13.8  This cross-section illustration shows the release of the orbitomalar ligament and transposition of the orbital fat into the tear trough
depression. SOOF, Suborbicularis oculi fat.
Figure 13.9  The medial and central fat pads are rotated inferiorly
over the orbital rim and fixated to the supraperiosteal plane to ablate
the deep hollow of the tear trough. The lateral fat pad has been con­
servatively excised.

13  Transcutaneous Lower Blepharoplasty
147
skin flap is left to naturally approximate the cut skin
edge beneath the lash line medially, only 1 to 2 mm of
skin usually needs to be removed medially. Resecting
most of the skin lateral to the canthus, with minimal
excision subcillarily, further reduces the risk of lower
eyelid margin retraction. The skin is closed with a 6-0
interrupted nylon suture lateral to the lateral canthus
and with a 7-0 running locking silk suture medially (Figs.
13.12–13.15).
COMPLICATIONS AND MANAGEMENT
After experience with over 2000 transcutaneous blepha­
roplasty patients, we believe that this procedure can be
performed safely and with an acceptable rate of compli­
cations. The key to performing the procedure safely with
a low risk of lower eyelid malposition is vigilant preoper­
ative screening, incorporating intraoperative lateral can­
tonal tightening procedures, and vigilant postoperative
Figure 13.10  This illustration demonstrates the closed canthopexy
suture, creating lateral retinacular tightening of the tarsus to the orbital
periosteum.
Figure 13.11  The skin is redraped superolaterally to naturally approx­
imate the cut skin edge of the incision. This technique fills the medial
tear trough defect and blends the lower eyelid-cheek junction.
Figure 13.12  A 56-year-old woman who underwent periorbital rejuvenation with transcutaneous lower blepharoplasty with fat transposition, as
well as upper blepharoplasty. The classic triad of lower eyelid signs of aging: pseudoherniated orbital fat, tear trough deformity, and descended
midface tissues is demonstrated in her preoperative picture. Her postoperative image shows periorbital rejuvenation with a smooth contour of the
lower eyelid with a smooth transition to between her lower eyelids and midface.
Overtightening of this suture should be avoided to prevent
lateral canthal distortion and buckling. Overtightening
can also pull the lid margin below the globe, creating
scleral show.
Step 5.  Superior Midface Elevation With Orbicularis
Flap Redraping and Periosteal Fixation
The superior midface was released due to the dissection
of the orbital retaining ligaments freeing the orbicularis
oculi muscle. The second 6-0 nylon suture placed in the
lateral orbital periosteum is sutured to the superior cuff
of the skin-muscle edge of the lower eyelid flap, elevating
the superior midface.
Step 6.  Conservative Superolateral Skin Resection
The skin is redraped superolaterally into the part of the
skin incision lateral to the lateral canthus (Fig. 13.11).
Skin excess laterally ranges from 6 to 10 mm. As the

148
MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 13.13  A 63-year-old woman who underwent extended transcutaneous submuscular blepharoplasty with orbitomalar ligament release and
orbital fat repositioning. Note the preoperative lower eyelid excess skin, pseudoherniated eyelid fat, and upper midface droop. These degenerative
changes have been addressed, while maintaining her natural preoperative lower eyelid position.
both patient and physician. In cases of more severe lower
eyelid laxity and a large amount of horizontal lower
eyelid redundancy and length, attempting this closed
approach will create a buckling of lower eyelid margin
by the lateral canthus. In these cases we will perform an
open lower eyelid-shortening procedure concomitantly
with the blepharoplasty. Our preference is to perform
a lateral tarsal strip procedure. We use a traditional
technique with lateral canthotomy, inferior cantholysis,
denuding the epithelium, and mucosa off the tarsus in the
area of redundancy where the eyelid is to be shortened,
and suturing the nude tarsus to the orbital periosteum on
its superior inner aspect above the lateral canthus (Figs.
13.18 and 13.19).
Ectropion from overaggressive skin excision may occur
even in the absence of preoperative lower lid laxity [17],
and is another complication to be avoided. As noted
earlier, we essentially remove no skin in the subciliary
care and treatment. As stated earlier, it is important
to identify patients at high risk and use an alternative
approach; that is, patients with a negative vector complex
and orbicularis weakness, where we will utilize a trans­
conjunctival approach.
When patients are identified preoperatively to have
excessive lower eyelid laxity, a plan for a lower eyelid-
tightening procedure should be incorporated into the pro­
cedure. Excessive lower eyelid laxity is identified with
a snap test greater than 1 second and distraction test
(being able to distract the lower eyelid from the globe)
greater than 10 mm. In all cases, we perform a closed
lateral retinacular tightening procedure by suturing the
lateral aspect of the tarsus to the orbital periosteum, as
noted in the Surgical Procedure section (Figs. 13.16 and
13.17). This helps support the lower eyelid margin during
the early phases of healing, where contracture can cause
mild lateral canthal rounding that can be distressing to
Figure 13.14  A 60-year-old patient with notable midface descent in
conjunction with the lower eyelid stigmata of aging. She underwent
transcutaneous lower blepharoplasty with fat transposition with reju­
venation of her lower eyelids. Note the smooth transition between the
lower eyelid and midface structures. The midfacial tissues have been
lifted due to release of the orbitomalar retaining ligaments. The fat
transposition revolumizes the upper midface and lower eyelid.
Figure 13.15  A 70-year-old woman with substantial midface descent
and devolumization preoperatively. She underwent transcutaneous
lower blepharoplasty with fat transposition. Note the smooth transition
between the lower eyelid and midface structures. The midfacial tissues
have been lifted due to release of the orbitomalar retaining ligaments.
The fat transposition revolumizes the upper midface and lower eyelid.

13  Transcutaneous Lower Blepharoplasty
149
margin in the midpupillary line, and almost all skin gets
removed lateral to the lateral canthus using a superolat­
eral flap-redraping vector.
Vigilant postoperative monitoring and early interven­
tion can prevent lower eyelid retraction. We see that
postblepharoplasty lower eyelid retraction is the result
of contraction and scar that can develop within the
orbicularis muscle and orbital septum postoperatively.
We believe that the number one nidus for this process is
excessive bruising and blood underneath the skin-muscle
flap after surgery. Because of this we always see patients
the day after surgery, and if excessive swelling and bruis­
ing is noted, we will evacuate a small amount of blood
underneath the flap using a 14-gauge IV catheter, snaking
Figure 13.16  A 62-year-old woman who underwent transcutaneous lower blepharoplasty with fat transposition as well as lateral canthopexy. Her
preoperative picture shows her inherent lower eyelid malposition with scleral show. Postoperatively her lower eyelid position is improved after use
of concomitant lateral canthopexy. Her scleral show is resolved while maintaining the size and natural shape of her eyes.
Figure 13.17  A 51-year-old woman who underwent transcutaneous lower blepharoplasty with fat transposition as well as lateral canthopexy.
Postoperatively her eyelid shape is maintained with improvement of her preoperative lower eyelid malposition and scleral show.

150
MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 13.18  This image shows the lateral tarsal strip technique
to effect lower eyelid shortening. This technique is undertaken con­
comitantly with lower lid blepharoplasty in patients with excessive
horizontal lower lid length that cannot be treated with a closed lower
eyelid-tightening procedure.
Figure 13.19  A 74-year-old woman who underwent transcutaneous lower blepharoplasty with fat transposition and lower lid tightening with a
tarsal strip procedure. Preoperatively this patient has lower eyelid malposition and scleral show, which is greater on the right side. Asymmetries
are common and it is important to identify this in your preoperative assessment so that it may be addressed at the time of surgery. Postoperatively
she has improved lower eyelid position.
noted and intervention can prevent any problems. With
a positive forced duction test we will begin 5-fluorouracil
50 mg/mL injections, usually 0.1 to 0.2 cc, to modulate
wound healing and minimize scar. The technique used
is simply to inject into any fibrosis felt with a 30-gauge
needle. We will also ask the patient to massage the eyelids
by forcing them upwards as in a forced duction test for 1
minute four to five times daily. Depending upon progress,
we will repeat these injections every 2 weeks.
When implementing the aforementioned preoperative,
intraoperative, and postoperative screenings and mea­
sures, we have had no cases of ectropion and retraction.
We see approximately a 1% to 2% rate of lateral central
it through the incision. We believe that even 1 cc of blood
left behind can cause this problem as the blood organizes
and scar contracture ensues. Additionally, we see patients
every week for the first month after surgery to monitor
whether any contracture is beginning to occur. This is
evaluated using a forced duction test, pushing the eyelids
up superiorly and noting if any resistance is felt (Fig.
13.20). The earliest time that some resistance can be felt
is 2 weeks after surgery, and we note it to occur in 5%
of patients. At this time there is no eyelid malposition
Figure 13.20  This image demonstrates the forced duction test. In this
patient the test is normal. If the eyelids are retracting the lower eyelid
will not move vertically with pressure.

13  Transcutaneous Lower Blepharoplasty
151
5. Lambros V. Observations on periorbital and midface aging. Plast
Reconstr Surg 2007;120(5):1367–76, discussion 1377.
6. Haddock NT, Saadeh PB, Boutros S, Thorne CH. The tear trough
and lid/cheek junction: anatomy and implications for surgical
correction. Plast Reconstr Surg 2009;123(4):1332–40, discussion
1341–2.
7. Paul MD, Calvert JW, Evans GR. The evolution of the midface lift in
aesthetic plastic surgery. Plast Reconstr Surg 2006;117(6):1809–27.
8. Hirmand H. Anatomy and nonsurgical correction of the tear trough
deformity. Plast Reconstr Surg 2010;125(2):699–708.
12. Rohrich RJ, Ghavami A, Mojallal A. The five-step lower blepha­
roplasty: blending the eyelid-cheek junction. Plast Reconstr Surg
2011;128(3):775–83.
13. Schiller JD. Lysis of the orbicularis retaining ligament and orbicu­
laris oculi insertion: a powerful modality for lower eyelid and cheek
rejuvenation. Plast Reconstr Surg 2012;129(4):692e–700e.
15. Baker SR. Orbital fat preservation in lower-lid blepharoplasty. Arch
Facial Plast Surg 1999;1(1):33–7.
16. McCord CD, Boswell CB, Hester TR. Lateral canthal anchoring.
Plast Reconstr Surg 2003;112(1):222–37, discussion 238–9.
17. Hester TR Jr, Codner MA, McCord CD, et al. Evolution of tech­
nique of the direct transblepharoplasty approach for the correction
of lower lid and midfacial aging: maximizing results and mini­
mizing complications in a 5-year experience. Plast Reconstr Surg
2000;105(1):393–406, discussion 407–8.
rounding that persists, which is often not noted by the
patient. In cases where this is distressing to the patient,
we will perform a second closed lateral canthal tightening
procedure, as noted earlier.
CONCLUSION
Lower eyelid aging is multifactorial and results from
changes in the periorbita and surrounding soft tissues
of the midface. Successful blepharoplasty should address
all components related to both gravitational effects and
volume alterations encountered in aging. Transcutaneous
blepharoplasty is indicated to treat skin excess, orbicu­
laris oculi redundancy, and malar mounding, as well as
provide the unique capability of redraping the orbicularis
muscle. Transcutaneous blepharoplasty should be under­
taken thoughtfully for appropriately selected patients to
yield the best results.
References available online at expertconsult.com.
R E F E R E N C E S
4. Wong CH, Hsieh MK, Mendelson B. The tear trough ligament:
anatomical basis for the tear trough deformity. Plast Reconstr Surg
2012;129(6):1392–402.

13  Transcutaneous Lower Blepharoplasty 151.e1
R E F E R E N C E S
1. Duke-Elder SWK. The eyelids. System of Ophthalmology: The
Anatomy of the Visual System. St. Louis, MO, USA, 1961. Vol. 2.
2. Flowers RS. Tear trough implants for correction of tear trough
deformity. Clin Plast Surg 1993;20(2):403–15.
3. Stutman RL, Codner MA. Tear trough deformity: review of
anatomy and treatment options. Aesthet Surg J 2012;32(4):426–40.
4. Wong CH, Hsieh MK, Mendelson B. The tear trough ligament:
anatomical basis for the tear trough deformity. Plast Reconstr Surg
2012;129(6):1392–402.
5. Lambros V. Observations on periorbital and midface aging. Plast
Reconstr Surg 2007;120(5):1367–76, discussion 1377.
6. Haddock NT, Saadeh PB, Boutros S, Thorne CH. The tear trough
and lid/cheek junction: anatomy and implications for surgical
correction. Plast Reconstr Surg 2009;123(4):1332–40, discussion
1341–2.
7. Paul MD, Calvert JW, Evans GR. The evolution of the midface lift in
aesthetic plastic surgery. Plast Reconstr Surg 2006;117(6):1809–27.
8. Hirmand H. Anatomy and nonsurgical correction of the tear trough
deformity. Plast Reconstr Surg 2010;125(2):699–708.
9. Flowers RS, Flowers SS. Precision planning in blepharoplasty. The
importance of preoperative mapping. Clin Plast Surg 1993;20(2):
303–10.
10. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty
patient. Bypassing the pitfalls. Clin Plast Surg 1993;20(2):213–23,
discussion 224.
11. Griffin G, Azizzadeh B, Massry GG. New insights into physical
findings associated with postblepharoplasty lower eyelid retraction.
Aesthet Surg J 2014;34(7):995–1004.
12. Rohrich RJ, Ghavami A, Mojallal A. The five-step lower blepha­
roplasty: blending the eyelid-cheek junction. Plast Reconstr Surg
2011;128(3):775–83.
13. Schiller JD. Lysis of the orbicularis retaining ligament and orbicu­
laris oculi insertion: a powerful modality for lower eyelid and cheek
rejuvenation. Plast Reconstr Surg 2012;129(4):692e–700e.
14. Barton FE Jr, Ha R, Awada M. Fat extrusion and septal reset in
patients with the tear trough triad: a critical appraisal. Plast Recon­
str Surg 2004;113(7):2115–21, discussion 2122–3.
15. Baker SR. Orbital fat preservation in lower-lid blepharoplasty. Arch
Facial Plast Surg 1999;1(1):33–7.
16. McCord CD, Boswell CB, Hester TR. Lateral canthal anchoring.
Plast Reconstr Surg 2003;112(1):222–37, discussion 238–9.
17. Hester TR Jr, Codner MA, McCord CD, et al. Evolution of tech­
nique of the direct transblepharoplasty approach for the correction
of lower lid and midfacial aging: maximizing results and mini­
mizing complications in a 5-year experience. Plast Reconstr Surg
2000;105(1):393–406, discussion 407–8.

152
INTRODUCTION
Traditional lower blepharoplasty consists of an open
approach, transcutaneous procedure in which variable
amounts of skin, muscle, and fat are excised. Inherent
to this technique is a predilection for rounding of the
canthal angle and lower eyelid retraction [1–5], noted to
occur in 6% to 20% of such cases [4]. In the authors’
experience these are very difficult problems to address and
cause tremendous dissatisfaction in the aesthetic blepha­
roplasty population. Traditionally, postblepharoplasty
lower eyelid retraction has been thought to be primarily
related to unaddressed lower eyelid laxity, anterior lamel­
lar shortage, and the development of a middle lamellar
scar [2,6]. More recently, it has been shown that weak­
ness of the orbicularis oculi muscle and negative orbito­
facial vector eyelid configuration also play an important
role in postblepharoplasty eyelid malposition [7]. Irre­
spective of the primary cause, canthal suspension, as a
means of addressing preexistent lower eyelid laxity, has
become an integral part of lower blepharoplasty and
reduces the incidence of postoperative eyelid malposition
and aesthetic deficit [8–12]. In addition to maintaining
aesthetics, when canthal suspension is added to surgery,
eyelid function is preserved. Unaddressed eyelid laxity
can biomechanically weaken orbicularis oculi function
[13] and lead to an inadequate blink, ocular surface expo­
sure, altered tear clearance, foreign body sensation, and
tearing [13–16].
In 1969 Tenzel [17] was the first to suggest lateral
canthal suspension as a method to correct lower lid mal­
position. He described a lateral canthotomy (open pro­
cedure) and inferior cantholysis to gain access to the
lower tarsus for suspension to the lateral orbital rim
[17]. Webster then described canthal suspension as an
adjunct to blepharoplasty to prevent lid malposition [18].
As it became clear that the incidence of lower lid mal­
position could be reduced with adjunctive canthal sus­
pension during blepharoplasty, this addition to surgery
became commonplace [6,18]. In 1979, Anderson et al.
[19] described the lateral tarsal strip (LTS), which gained
favor as a standard canthal suspension technique. In this
procedure the lateral canthal tendon (LCT) is accessed
through a canthotomy, and horizontal eyelid shorten­
ing is a common step. While the LTS and its variations
[20–26] are a landmark development in the manage­
ment of reconstructive eyelid procedures, its invasiveness
and disruption of canthal architecture and anatomy have
limited its integration into contemporary aesthetic bleph­
aroplasty. Some of the limits of this procedure include the
potential development of horizontal eyelid length dispar­
ity between the upper and lower lid, alteration of the
canthal angle and commissure, lateral canthal dystopia,
and poor overall cosmesis [27–30]. In the setting of ectro­
pion or entropion, patients are often accepting of these
issues as their premorbid condition has been improved
significantly. The aesthetic patient is much less forgiv­
ing. As such, open canthopexy procedures [10,18,31–35],
in which the canthal tendon is plicated to the orbital
rim, gained favor as they better preserve lateral canthal
anatomy and are less disruptive. In an effort to further
preserve canthal integrity and maintain canthal aesthet­
ics, closed canthal suspension techniques have evolved
[30,36–39]. In this setting the canthus is accessed from
a distant site without a canthal incision (hence a closed
procedure). This better preserves native canthal anatomy
and avoids the aforementioned complications of the
LTS procedure, as well as the development of canthal
webs and scars, which can occur when canthal incisions
are made.
In this chapter the authors attempt to simplify canthal
suspension surgery by detailing a spectrum of procedures,
including: (1) traditional open canthoplasty [17,19–26]
and open canthopexy [10,18,31–35]; and (2) more
contemporary closed canthoplasty [30,36] and closed
canthopexy [38]. The authors will also review canthal
nomenclature, relevant canthal anatomy, discuss canthal
aging changes, highlight key preoperative examination
pearls, and review postoperative care and complications.
CANTHAL NOMENCLATURE
The description of canthal surgery in the literature can be
confusing for both the novice and/or experienced surgeon
as numerous procedures are reported, most being simple
modifications of one another. What makes this even more
complex is the naming of these surgical variations and the
anatomic structures modified during surgery. For simpli­
fication and clarity, the authors prefer the general term
“canthal suspension,” as all canthal procedures have a
common goal of “supporting or tightening” the lower
lid at the canthus. In addition, to develop a proper foun­
dation and framework for understanding and planning
these procedures, a mental flowchart of the options avail­
able is often helpful. To this vein, the authors subdivide
canthal suspension techniques into two broad categories:
C H A P T E R 14 
The Spectrum of Canthal Suspension
Techniques in Lower Blepharoplasty
Andrea Lora Kossler, MD and Guy G. Massry, MD

14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty
153
(1) open, and (2) closed, with each category further sub­
divided into either a canthoplasty or canthopexy variant.
An open canthal procedure involves a canthal incision,
or canthotomy, while a closed procedure does not. In
open surgery, as anatomy is obvious, precise placement
of the lower eyelid is enhanced. However, because the
canthus is disarticulated and reformed, canthal deformity
can occur. A closed canthal suspension, on the other
hand, accesses and suspends the canthal tendon or termi­
nal tarsus through a distant site (typically the upper lid
crease). In this technique, exposure is limited, anatomy is
better preserved, but placement of the canthus can be less
precise. Its main advantages are that it is less traumatic
and avoids lateral canthal deformity. A canthoplasty is
a procedure in which the LCT or temporal lower lid is
incised, plus/minus shortened, and secured to the lateral
orbital rim. Conversely, a canthopexy is a procedure in
which the lower eyelid is suspended to the lateral orbital
rim with a plication suture without modification of the
LCT or terminal tarsus.
Attaining clarity of anatomic terminology of the
canthus is also important to understanding canthal sus­
pension surgery. The connective tissue structure that
secures the terminal eyelid to the orbit is called the LCT.
It is derived/originates from distal fibers of the palpebral
orbicularis muscle and inserts onto the lateral orbital rim.
A synonymous name for the LCT is the lateral palpebral
ligament. This is actually a better description of the struc­
ture, as a tendon connects a muscle to bone to move the
bone, while a ligament attaches bones to bone to secure
their alignment, which is more descriptive of what is
occurring here. The lateral retinaculum is another name
used to describe the LCT. A retinaculum, by definition, is
a band around tendons to stabilize them and hold them
in place. As the LCT has contributions or connections
with many other structures (lateral horn of levator apo­
neurosis, check ligament of lateral rectus, orbital septum,
etc.), the confluence of these structures can be considered
a retinaculum. Finally, the lateral canthus is the general
area where the upper and lower lids meet, whereas the
commissure is the point of this union. The lateral raphe is
an area of fine fibrous bands where the terminal orbicu­
laris muscle of the upper and lower lids meet. Additional
nomenclature specific to lateral canthal surgery includes
the terms ab-interno (originating from the inside) and
ab-externo (originating from the outside). Refer to Table
14.1 for a simplified naming and description of relevant
canthal surgical concepts and anatomic structures.
CANTHAL ANATOMY
The lower eyelid is suspended medially and laterally at
the respective canthi by the medial canthal tendons and
LCTs. As stated, the LCT is a connective tissue structure
derived from the terminal pretarsal and preseptal orbi­
cularis fibers that inset onto the lateral orbital rim. It is
a three-dimensional structure anchored horizontally, but
with a vertical component, as the lateral canthus is typi­
cally 2 mm higher than its medial counterpart (normal
canthal tilt) [40,41]. In addition, it has an anterior and
TABLE 14.1  Canthal Nomenclature and Definitions
Nomenclature
Definition
Open canthal suspension
Requires a canthal incision (canthotomy) to access the LCT or terminal tarsus
Closed canthal suspension
Requires no canthotomy to access the LCT or terminal tarsus. These structures are accessed from a
distant site (i.e., upper lid crease)
Canthoplasty
The terminal tarsus or LCT is modified and secured to the lateral orbital rim
Canthopexy
The terminal tarsus, orbicularis muscle, or LCT are not modified, but are suspended to the lateral
orbital rim with a plication suture
Canthotomy
Lateral canthal incision
Cantholysis
Dynamic release of the LCT from the lateral orbital rim
Lateral canthus
The general area where the upper and lower lids meet laterally
Lateral commissure
The point of union of the upper and lower lids at the lateral canthus
LCT
Connective tissue structure that secures the upper and lower terminal eyelid to the lateral orbital rim
Lateral retinaculum
Another name used to describe the LCT. The confluence of several of the soft-tissue structures of the
lateral upper and lower eyelid that have connections with the LCT
LPL
Another synonymous name for the LCT
Lateral raphe
The area of fine fibrous bands where the terminal orbicularis muscle of the upper and lower lids meet
Orbitofacial vector
The relationship of globe projection to the lower lid and midface. When the globe and midface are
aligned in a horizontal plane the vector is neutral. When the globe projects more anterior than the
midface, the vector is negative; when the globe sits posterior to the midface the vector is positive
Ab-externo
Suture passage starts outside the wound (outside in) to secure the LCT to the lateral orbital rim
Ab-interno
Suture passage starts inside the wound (inside out) to secure the LCT to the lateral orbital rim
LCT, Lateral canthal tendon; LPL, lateral palpebral ligament.

154
MASTER TECHNIQUES IN FACIAL REJUVENATION
in the normal state moves laterally a few millimeters
with abduction. Finally, the orbicularis muscle (eyelid
protractor) is oriented circumferentially around the eye.
This normally would allow a circular contraction pattern
of the muscle. As the canthal tendons secure the orbicu­
laris laterally and medially, this biomechanically imparts
a vertical contraction pattern of the palpebral aperture.
When canthal integrity is lost with senescence or from
eyelid surgery, this contraction pattern becomes deficient,
leading to an altered blink, poor eyelid closure, and “fish­
mouthing” (Fig. 14.2) [13], or a medialization of the
lateral canthus with a shortened horizontal fissure and
impaired eyelid dynamics.
CANTHAL AGING CHANGES
With aging, tissue descent, deflation (bone and fat), and
cutaneous degeneration contribute to an alteration of
posterior component. The posterior portion attaches
3 mm posterior to the orbital rim at Whitnall’s tuber­
cle 10 mm below the frontozygomatic suture [40]. It is
important to recreate this attachment during canthal sus­
pension surgery, as it assures the lower lid’s appropriate
apposition to the globe (Fig. 14.1A). The anterior portion
of the tendon inserts at the anterior edge of the orbital
rim. This lends support to canthal integrity, but plays a
secondary role to the more critical posterior attachment.
Traditionally, the lateral canthus has been considered
a support structure only; however, it has other functions
and many moving parts. It is associated with the orbital
septum, the lateral horn of the levator aponeurosis, and
plays a role in native upper lid tension (Fig. 14.1B). For
this reason, on occasion, surgery has led to temporary
or permanent ptosis (when the upper limb of the tendon
is imbricated). The canthus is also intimately associated
with the check ligament of the lateral rectus muscle, and
Preseptal
orbicularis
Preseptal
orbicularis
Pretarsal
orbicularis
Lateral
canthal
tendon
Lockwood’s
ligament
Capsulopalpebral
fascia
Levator
aponeurosis
Levator,
lateral horn
Tarsus
Orbital
septum
Orbital
septum
Lacrimal gland
B
A
Pretarsal
orbicularis
Lateral canthal
tendon
(posterior part)
Lateral canthal tendon
(anterior part)
Whitnall’s
tubercle
Tarsus
Figure 14.1  (A) Axial section of the lateral canthus and lateral orbital rim demonstrating the anterior and posterior components of the lateral
canthal tendon (lateral palpebral ligament), with the posterior portion (deep head) attaching to Whitnall’s tubercle. (B) Lateral canthal anatomy,
and association with other eyelid structures.
B
A
Figure 14.2  (A) Laxity and dehiscence of the LCT can result in a (B) “fishmouthing” phenomenon with medialization of the lateral canthus and
deficient and weakened eyelid closure (arrows show direction of closure as horizontal rather than vertical with resultant lagophthalmos). LCT,
Lateral canthal tendon.

14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty
155
The lower eyelid margin normally rests just above
the inferior limbus in neutral gaze. The margin reflex
distance-2 (MRD-2), which is the distance between the
corneal light reflex and the lower eyelid margin with
the patient staring at a light in primary gaze, is used
to measure the lower lid position [44]. It is normally
6 mm and can increase in patients with lower lid laxity.
When lower lid retraction is present the lid rests below
the limbus, scleral show is manifest, and the MRD-2
increases. The horizontal palpebral fissure normally mea­
sures 30 mm and the canthus lies 2 mm higher tempo­
rally than nasally. Documenting these measurements is
important for assessment, surgical decision-making, and
photographic reference after surgery if needed.
The eyelid snap-back and distraction tests are per­
formed to evaluate the integrity of the lower eyelid canthal
complex. The snap-back test is performed by pulling the
lower eyelid down and away from the globe. The eyelid
should return to its normal resting position in less than 1
second without blink. If this is delayed the test is positive
and generally signifies orbicularis weakness (Fig. 14.3).
In the eyelid distraction test, the distance that the lower
eyelid can be pulled away from the globe is measured (Fig.
14.4). A distance of 8 mm or more is defined as a posi­
tive test and indicates clinically significant eyelid laxity.
In the setting of aesthetic blepharoplasty, the examination
modalities described may miss subtle degrees of eyelid
laxity that can still predispose to postoperative compli­
cations. Therefore, for the purposes of preserving eyelid
appearance and function after surgery, canthal suspen­
sion should be considered even when small deficiencies
of canthal tendon integrity are present.
Another critical factor on examination is the relation­
ship of globe projection to the lower lid and midface.
This relationship is referred to as the orbitofacial vector.
When the globe and midface are aligned in a vertical
plane the vector is neutral. When the globe projects more
anterior than the midface, the vector is negative; when
the globe sits posterior to the midface the vector is posi­
tive (Fig. 14.5). A negative vector configuration places
the eyelid at a mechanical disadvantage, as the lower
lid must work against a gradient to maintain normal
resting position. This is a delicate equilibrium that can
the dimensions of the palpebral aperture and the associ­
ated position, tone, and function of the lower eyelid. In
general, the eyelid aperture changes from one that is a
horizontal oval (longer in this dimension) to one that is
more vertical as the lateral canthus migrates medially
[42]. Canthal alterations resulting from tissue involution
is a multifactorial process that occurs in three dimen­
sions. It is very difficult to recreate a youthful appearance
and function when the sole intervention is tissue excision
and suspension in one plane. This is especially true of the
canthus, whose purpose is so much more than maintain­
ing appropriate lid position (i.e., blink, check ligament
to the lateral rectus, eyelid excursion, lacrimal pump
function, etc.). For this reason, the “belt and suspend­
ers” procedures we often employ in this setting can cause
havoc among the aesthetic patient population, even in the
presence of what appears to be a nice result [7,43]. This is
also why, in this particular patient population, less tissue
disruption is better and consideration should be given
to the more contemporary closed suspension techniques
elaborated on later.
PREOPERATIVE ASSESSMENT
A careful analysis of the lower lid position and func­
tion in patients undergoing blepharoplasty is essential
to determine the need for canthal suspension. In addi­
tion, identification of patients at high risk of postopera­
tive eyelid malposition is critical. For example, patients
with a history of thyroid disorder, facial nerve paresis,
previous blepharoplasty, or trauma require special atten­
tion on examination to assure surgical feasibility. The
physical examination should include both a static and
dynamic examination of the lower eyelid and canthus.
The clinical features evaluated include: eyelid position,
tone, and an assessment of laxity. Also, eyelid fissure
dimensions, lateral canthal angle configuration, direc­
tion of movement of the lateral commissure with blink,
adequacy of eyelid closure, and the morphologic relation­
ship of the globe to the cheek (orbitofacial vector) should
be assessed. In the following paragraphs the authors
will focus on the essential elements of the physical
assessment.
A
B
Figure 14.3  Snap-back test. (A) The lower eyelid is pulled inferiorly and away from the globe, (B) the lid returns without blink. Note that the
lower lid demonstrates decreased orbicularis tone as it does not return to normal position without blink (compared with opposite side). (Reprinted
with permission from Massry GG. Managing the lateral canthus in the aesthetic patient. Master techniques in blepharoplasty and periorbital reju­
venation. New York, NY: Springer New York; 2011. p. 187.)

156
MASTER TECHNIQUES IN FACIAL REJUVENATION
patient population, the LTS is less commonly used in this
setting. However, in patients (typically older) who mani­
fest profound eyelid laxity in which horizontal eyelid
shortening is a necessary step, it is an excellent option.
The procedure begins with an 8-mm lateral canthot­
omy (Fig. 14.6A). The terminal lower lid is elevated,
putting the LCT on stretch. The tendon is released (infe­
rior cantholysis; Fig. 14.6B), allowing dynamic release of
the eyelid from the orbital rim (Fig. 14.6C). The inferior
border of the tarsus is released from its underlying attach­
ments to the conjunctiva and lower eyelid retractors (Fig.
14.6D). The anterior and posterior lamella are divided
(Fig. 14.7A), the mucocutaneous junction is trimmed
(Fig. 14.7B), and the excess skin is excised (Fig. 14.7C).
The lateral edge of the tarsus is drawn to its normal
anatomic insertion at the lateral orbital rim with a slight
overcorrection. Special attention is placed on assuring a
normal lower lid relation to the limbus and avoidance
of bowstringing of the eye by the lower lid (clothesline
effect). When an appropriate lid length is identified, the
terminal tarsus is shortened conservatively (Fig. 14.8A).
The posterior tarsus is deepithelialized, and a double-
armed 4-0 Mersilene or other such suture (Vicryl) on a
half-circle needle is passed through the terminal tarsus
(newly formed tarsal strip; Fig. 14.8B). The suture enters
the suborbicularis side of the tarsus and exists the epi­
thelial side (anterior to posterior). The suture engages
the periosteum, approximately 3 mm posterior to the
lateral orbital rim, so as to attain appropriate apposi­
tion of the lid to the globe, at the level of Whitnall’s
tubercle (Fig. 14.8C). The suture is tied, securing the
tarsus to the lateral rim (Fig. 14.8D). The commissure is
reformed with a 6-0 plain gut (or other) gray-line suture
from upper to lower lid (Fig. 14.9A and B). This suture
can also be passed through the underlying periosteum
between the lids to further secure the commissure to the
rim. The incision is closed (Fig. 14.9C).
be negatively impacted by even a small manipulation of
the lower lid/canthal complex. In fact, it has recently
been shown that negative vector globe/lid topography can
be a significant contributor to postblepharoplasty eyelid
retraction [7]. Special care and attention must be given
to patients presenting with negative vector topography,
which is typically seen in the setting of shallow orbits,
long eyes (myopia), proptosis, or a hypoplastic midface.
Finally, as with any aesthetic evaluation, it is impor­
tant to discuss the postoperative goals and expectations
of the lateral canthal surgery. The position of the lateral
canthus, and how patients perceive this, has significant
psychological impact. Careful attention should be paid
to discussing the suggested procedure at length so as to
avoid an unexpected change in appearance that may be
bothersome to the patient.
SURGERY
Open Canthal Suspension
Lateral Tarsal Strip
The workhorse of open canthoplasty has been the LTS
procedure. The LTS [19], and its variants [20–26], remains
one of the most common reconstructive canthal suspen­
sions performed today. It would be remiss not to describe
it, as it requires undoing and redoing all aspects of the
canthus. Once this is mastered, clarity is developed with
all forms of canthal suspension, and surgery becomes
easier to perform. As mentioned previously, disadvan­
tages of the technique can include any combination of
(1) shortening of the horizontal palpebral fissure; (2) lid
length disparity between the upper and lower lids, with
or without symptoms of eyelid imbrication; (3) misalign­
ment, distortion, or dystopia of the lateral canthal angle;
(4) prolonged chemosis; and (5) lateral canthal scarring,
webbing, or unacceptable aesthetic appearance [27–30].
As a result of these potential issues, and the fact that there
are now less invasive options available for the aesthetic
Figure 14.4  Eyelid distraction test. The lower eyelid is pulled away
from the globe and the distance is measured. Eight mm or more signifies
eyelid laxity. (Reprinted with permission from Massry GG. Manag­
ing the lateral canthus in the aesthetic patient. Master techniques in
blepharoplasty and periorbital rejuvenation. New York, NY: Springer
New York; 2011. p. 187.)
Figure 14.5  A negative orbitofacial vector is diagnosed if a straight
line drawn from the cornea falls anterior to the inferior orbital rim in
the lateral view.

14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty
157
D
C
B
A
Figure 14.6  Lateral tarsal strip. (A) A canthotomy initiates the procedure. (B) The inferior crus of the LCT is lysed (inferior cantholysis).
(C) Dynamic release of the lower lid after cantholysis. (D) The inferior border of the tarsus is separated from the conjunctiva and lower eyelid
retractors. LCT, Lateral canthus tendon. (Reprinted with permission from Managing the lateral canthus in the aesthetic patient. Master techniques
in blepharoplasty and periorbital rejuvenation. New York, NY: Springer New York; 2011. p. 188.)
B
A
Figure 14.7  (A) The anterior and posterior lamellae are divided, (B) the lid margin (mucocutaneous junction) is trimmed, .

158
MASTER TECHNIQUES IN FACIAL REJUVENATION
(C) the excess skin is excised. (Managing the
lateral canthus in the aesthetic patient. Master techniques in blepha­
roplasty and periorbital rejuvenation. New York, NY: Springer New
York; 2011. p. 190.)
T
C
Figure 14.7, cont’d 
D
C
B
A
Figure 14.8  (A) The tarsus is shortened, (B) a single- or double-armed suture, passed anterior to posterior, engages the newly formed lateral tarsal
strip, (C) which is secured to the periosteum at the level of Whitnall’s tubercle, and (D) and is tied securing the tarsal strip to the lateral orbital rim.
(Managing the lateral canthus in the aesthetic patient. Master techniques in blepharoplasty and periorbital rejuvenation. New York, NY: Springer
New York; 2011. p. 190.)
Commissure-Sparing Open Canthal Suspension
There is a subset of aesthetic patients who need more
than the typical canthal suspension attained with an
open canthopexy or the closed procedures that will be
described, but do not require the invasiveness of an LTS
procedure. Also, some patients benefit from a degree
of positional change in the canthus, which is often not
predictably attained without total canthal reconstruction
(such as LTS). In these cases the authors have used what
they call a commissure-sparing open canthal suspension
(CSOCS). The results have been predictable, reliable, and
have resulted in less of the potential aesthetic deficits
mentioned for the more aggressive LTS procedure.
A canthotomy is performed starting 2 to 3 mm lateral
to the commissure (Fig. 14.10A). It is important to leave
this bridge of tissue from the commissure intact. The
lower lid or commissure is elevated, putting the canthal
tendon on stretch (Fig. 14.10B). The canthal tendon is
then internally lysed in a graded fashion (Fig. 14.10C).

14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty
159
accurate in canthal positioning than the closed proce­
dures described later.
Open Canthopexy
There is a subset of patients who require only mild lower
lid support during blepharoplasty. It is best to always
err on the side of caution when deciding on adding lid
support in these cases, so as to avoid the difficulties of
dealing with postoperative lower eyelid malposition. As
a general rule, if the thought of canthal suspension arises
during surgery, the surgeon should trust his/her instincts
and add the procedure. In cases that need mild support
with minimal canthal distortion, a canthopexy can be
added. In most of these scenarios, the authors prefer a
closed procedure (described later), as the canthus is less
disturbed. However, in cases when a skin pinch is added
(i.e., already an infraciliary incision), or in isolated lower
blepharoplasty when an upper lid crease incision is not
planned, an open canthal tendon plication (canthopexy)
is an option. A 4- to 5-mm canthal incision is also made
to or through the commissure (Fig. 14.12A). A suture
(4-0 Vicryl, PDS, or similar type on half-circle needle)
The canthus will dynamically release, allowing expo­
sure for periosteal suture placement (Fig. 14.10D). A
5-0 polydioxanone (PDS) suture is passed through the
open wound to engage the lateral orbital rim periosteum
(same location as with the LTS) and then fed internal to
external (ab-interno; Fig. 14.11A) and external to inter­
nal (ab-externo; Fig. 14.11B) through the same hole in
the commissure and again through the periosteum (Fig.
14.11C), before tying the suture and securing the canthus
(Fig. 14.11D). An alternative suture pass is to place both
ends of a double-armed similar suture through the same
entry point in the commissure (ab-externo only) and then
engage the periosteum internally with both ends of the
suture. In either scenario, the canthus can be raised with a
more aggressive cantholysis, and the direct view attained
for positioning. Also, if orbicularis plication is desired,
a subcutaneous dissection frees the terminal preseptal
orbicularis muscle for direct plication. The authors con­
sider this an intermediate canthal suspension procedure.
It avoids the disadvantages of a LTS and preserves the
commissure and canthal angle, yet in their experience
is more powerful than an open canthopexy and more
C
B
A
Figure 14.9  (A, B) The commissure is reformed with a gray-line suture from upper to lower lid. The underlying periosteum can be incorporated
in this pass to secure the commissure to the orbital rim. (C) The canthus is closed. (Courtesy Guy Massry, MD.)

160
MASTER TECHNIQUES IN FACIAL REJUVENATION
D
C
B
A
Figure 14.10  Commissure-sparing open canthal suspension. (A) A canthotomy is performed 3 mm lateral to the commissure. (B) Elevation of
the lateral lid puts the canthal tendon on stretch. (C) Internal lysis of the lateral canthal tendon in a graded fashion. (D) The periosteum engaged
with forceps. (Courtesy Guy Massry, MD.)
B
A
Figure 14.11  (A) A 5-0 polydioxanone suture is passed through the lateral rim periosteum and then through the commissure (ab-interno internal
to external), and (B) the same suture returns through the same hole in the commissure (ab-externo external to internal), .

14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty
161
D
C
(C) again engages the periosteum, (D) secures the canthus to the lateral rim. (Courtesy Guy Massry, MD.)
A
Figure 14.11, cont’d 
D
C
B
A
Figure 14.12  Open canthopexy. (A) A canthal incision is made to or through the commissure. (B) A semi-circle needle engages the lateral canthal
tendon and is secured to the lateral orbital rim. (C, D) Optional terminal preseptal orbicularis suspension suture.

162
MASTER TECHNIQUES IN FACIAL REJUVENATION
the potential for eyelid imbrication, scars, webs, and the
other myriad of complications that can arise from tradi­
tional canthal surgery. This option is especially useful for
the typical aesthetic patient who requires only minimal
lower eyelid suspension. The senior author has found this
an invaluable tool in reducing complications and patient
complaints after lower blepharoplasty surgery.
A variety of such procedures have been described
[30,36–39]. The authors will focus on a temporal upper
lid crease as the entry location for surgery. An 8-mm
incision is made. The orbicularis muscle is divided and
a submuscular, preperiosteal dissection ensues to the
canthus (Fig. 14.13A). The canthus is tented up with
forceps and the LCT is strummed with scissors or other
cutting device from the temporal upper eyelid incision
(Fig. 14.13B). At this point surgical planning and intra­
operative findings dictate the next step. Depending on
the degree of laxity present (dictated by clinical experi­
ence), the tendon can be left undisturbed (canthopexy;
Fig. 14.14A), scored in a graded fashion, or lysed (can­
thoplasty; Fig. 14.14B). If the tendon is manipulated at
engages the LCT and is secured to the lateral orbital rim
periosteum as previously described (Fig. 14.12B). As an
aside, some surgeons prefer to only suspend the terminal
preseptal orbicularis with a similar suture bite, or to add
such suspension to the LCT plication (Fig. 14.12C). The
authors often add an orbicularis suture, but never in iso­
lation, as they feel this is a weak suspension at best. If the
commissure is preserved, an alternative suture placement
is the full-thickness commissure approach described in the
CSOCS technique. If the commissure has been divided, a
gray-line suture is placed to recreate an aesthetic canthal
angle. The canthus is closed with interrupted absorbable
or permanent suture.
Closed Canthal Suspension
What the authors refer to as closed canthal suspension is a
relatively contemporary means of providing lower eyelid
support and preserving canthal appearance and integ­
rity. As stated, in these procedures the canthal tendon
or terminal tarsus is accessed from a distant site as to
avoid canthal incisions, division of the commissure, and
B
A
Figure 14.13  Closed canthal suspension. (A) Temporal eyelid crease incision and dissection in a submuscular, preperiosteal plane to the lateral
canthus. (B) Forceps tent up the lateral canthus and the lateral canthal tendon is strummed from the temporal upper eyelid incision. (Courtesy
Guy Massry, MD.)
B
A
Figure 14.14  (A) The lateral canthal tendon (LCT) left undisturbed and plicated/suspended to lateral orbital rim (canthopexy). (B) The LCT is
lysed (canthoplasty) and the cut end is then secured to the lateral orbital rim.

14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty
163
canthus to the periosteum (Fig. 14.15C). The preference
for technique is surgeon dependent and all lead to similar
results. As an aside, if “pseudo-eyelid shortening” or
lower lid tension is desired, the canthal suspension suture
can engage the terminal tarsus in lieu of the LCT. As a
matter of caution, it is possible to imbricate the terminal
upper lid fibers of the LCT in this technique. This can
lead to temporary and rarely permanent postoperative
ptosis. This can be avoided by careful suture placement
and, when needed, a graded release of these upper LCT
fibers prior to tying the suspension suture. The temporal
wound can be closed in layers or skin only.
Hang-Back Canthal Suspension
Surgical modifications are necessary for negative vector
eyelids to prevent “bowstringing” of the globe by the
all, there will be a degree of release from its bony attach­
ments. The authors feel that even if only minimal lower
lid support is desired, the tendon should be scored as to
create a raw surface for readhesion. Once the appropriate
release is attained, the canthus is secured with various
suture options. The authors prefer a double-armed 5-0
PDS suture on an RB-1 needle. The canthal tendon can
be grasped internally through the wound (ab-interno)
and directly secured to the periosteum at the appropri­
ate location (Fig. 14.15A). Alternatively, after engaging
the canthal tendon, the suture can be passed internal to
external through the commissure and then back the other
direction (ab-interno/ab-externo) prior to securing the
periosteum (Fig. 14.15B). Finally, both ends of the suture
can be passed through the same location in the commis­
sure external to internal (ab-externo) prior to securing the
D
C
B
A
Figure 14.15  Suture techniques for lateral canthal suspension. (A, B) Ab-interno: the lateral canthal tendon (LCT) is grasped internally through
the wound and secured to the periosteum. (C, D) Ab-interno/ab-externo: the LCT is grasped internally, the suture exits the commissure (external)
then back through the commissure to engage the periosteum, .
Continued

164
MASTER TECHNIQUES IN FACIAL REJUVENATION
Suture allowed
to hang back
Hyperfixation
B
A
Fixation point
too low
Figure 14.16  Hang-back canthal suspension. (A) Bowstringing of a prominent eye with lid tightening. Note scleral show and lid retraction (arrow)
created by lid tightening. (B) Hang-back canthal suspension with supra-placement of periosteal fixation suture. Note elevation of lower lid and
reduction of scleral show. (Adapted from Managing the lateral canthus in the aesthetic patient. Master techniques in blepharoplasty and periorbital
rejuvenation. New York, NY: Springer New York; 2011. p. 194.)
F
E
(E, F) ab-externo both suture arms are passed through the commissure, external to internal, and are then secured to the
periosteum.
A
Figure 14.15, cont’d 
lid (Fig. 14.16A) [3]. In this setting there is a relative
deficiency of horizontal lower eyelid length in relation to
globe projection. A normal suspension of the lower lid
will cause it to retract inferiorly along the globe, leading
to both eyelid retraction and scleral show.
In this scenario, the authors recommend a hang-back
modification to canthal suspension. This modification can
be added using any of the techniques previously described;
closed or open approach with a canthopexy or cantho­
plasty. When the lateral canthal suture is secured to the
lateral orbital rim, the suture is left loose or allowed to
hang back. The amount of hang back is tailored to each
case depending on the amount of pseudo-lid lengthening
desired. This maneuver artificially lengthens the eyelid
and prevents bowstringing. Additionally, the suture can
be supraplaced along the orbital rim, providing a greater
elevating effect (Fig. 14.16B) [3].
POSTOPERATIVE CARE AND COMPLICATIONS
Postoperative care is identical to the management of
lower blepharoplasty. Ophthalmic antibiotic ointment is
used on the incision three times a day for 1 week. Ice
compresses are encouraged for the first 2 to 3 days for
10 to 15 minutes over every hour during the day. Patients
are instructed to avoid exercise or strenuous activity for
the first week after surgery and are typically seen 1 week
after surgery for the removal of skin sutures.

14  The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty
165
open and closed canthal suspension procedures (cantho­
plasty and canthopexy) is essential to the aesthetic eyelid
surgeon. Traditional open canthal suspension techniques
are powerful and effective for correcting eyelid malposi­
tion. However, these techniques are less commonly used
in aesthetic blepharoplasty due to alterations in canthal
appearance. Closed canthal suspension techniques are
less invasive and disruptive to the canthus. While they are
less powerful than traditional canthal suspension proce­
dures, they may be appropriate for the typical aesthetic
patient who requires only minimal suspension.
References available online at expertconsult.com.
R E F E R E N C E S
3. Massry GG. Managing the lateral canthus in the aesthetic patient.
Master techniques in blepharoplasty and periorbital rejuvenation.
New York, NY: Springer New York; 2011. p. 185–97.
7. Griffin G, Azizzadeh B, Massry GG. New insights into physical
findings associated with postblepharoplasty lower eyelid retraction.
Aesthet Surg J 2014;34(7):995–1004.
12. Massry GG. Comprehensive lower eyelid rejuvenation. Facial Plast
Surg 2010;26(3):209–21.
13. McCord CD, Miotto GC. Dynamic diagnosis of “fishmouthing”
syndrome, an overlooked complication of blepharoplasty. Aesthet
Surg J 2013;33(4):497–504.
14. McCord CDJ. The correction of lower lid malposition following
lower lid blepharoplasty. Plast Reconstr Surg 1999;103(3):1036.
15. McCord CD, Boswell CB, Hester TR. Lateral canthal anchoring.
Plast Reconstr Surg 2003;112(1):222–37.
16. Tse DT. Color atlas of oculoplastic surgery. Lippincott Williams &
Wilkins; 2012. p. 76–81.
33. De Silva DJ, Prasad A. Aesthetic canthal suspension. Clin Plast Surg
2015;42(1):79–86.
38. Georgescu D, Anderson RL, McCann JD. Lateral canthal resuspen­
sion sine canthotomy. Ophthal Plast Reconstr Surg 2011;27(5):
371–5.
39. Massry G. An argument for “closed canthal suspension” in aesthetic
lower blepharoplasty. Ophthal Plast Reconstr Surg 2012;28(6):
474–5.
Early postoperative complications include: chemosis,
granuloma formation, epithelial lined cysts, suture abscess,
and wound infection. Chemosis typically resolves over a
few weeks with or without added topical or oral steroid
preparations. If persistent, superiorly directed eyelid
massage, a temporary tarsorrhaphy, or rarely conjunc­
tival cut down or cautery is needed. Cysts, granulomas,
and abscesses often require minor in-office surgical inter­
ventions and typically resolve without sequelae. Infec­
tion is treated with oral antibiotics and an incision and
drainage is added for localized abscess when appropriate.
Late postoperative complications, including alterations in
the canthal position (dystopia), lateral canthal scarring,
and web formation, are more troublesome. Relatively
minor changes in canthal appearance and position can
significantly alter the appearance of the eyes and result
in an unhappy patient. Asymmetries often resolve over 4
to 6 weeks but may require revision surgery if persistent.
Canthal scars and webs are especially problematic as revi­
sions are not predictable. Injectable wound modulators,
such as Kenalog 5 mg/mL or 5-fluorouracil 50 mg/mL,
can be helpful [45–47]. The authors inject 0.2 to 0.3 cc
of either medication, beginning as early as 2 weeks after
surgery. Injections can be repeated every 2 weeks until
no further improvement is noted (usually four injections
maximum). Two to four units of Botulinum toxin A can
also be given, and the authors have anecdotally noted an
improvement is scar or web flattening [46]. Finally, even
in the face of what appears as otherwise good surgery,
patients may complain of canthal pain, tight eyelids,
eyelids that “feel” different, and that they just don’t look
like themselves. These can be very difficult issues that
often never resolve. Reassurance, acknowledgment of the
problem, and time are the best medicines here.
CONCLUSION
Canthal suspension is an essential component of lower
eyelid surgery. Familiarization with the spectrum of both

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166
INTRODUCTION
Asia is the largest and most populous continent and
encompasses a myriad of cultures and ethnicities. As
such, “Asian aesthetics” also encompass diverse issues
and vary significantly throughout the continent. For the
purposes of this chapter, we will discuss aesthetics as it
relates to people of East and Southeast Asian heritage.
Although certain aesthetic concerns are nearly univer­
sal across ethnicities, patients of Asian ancestry seeking
cosmetic surgery often want enhancement of specific
features rather than complete transformation. Frequent
areas of focus on the face include the eyelids, the nose,
the cheek, and jawline. A recent survey showed that the
Asian country with the highest rate of surgical cosmetic
surgery procedures per capita is South Korea, second only
to Italy worldwide, followed in order by Taiwan, Japan,
Thailand, and China [1].
The eyelids are a prominent and distinctive feature of
an Asian face. The characteristic broad and arched brow,
flatter supraorbital bridge, and fullness of the eyelid along
with sharp canthal angles and accentuated almond shape
confer uniqueness to the Asian eye as an aesthetic unit
that is immediately recognizable and imparts its ethnic
identity (Fig. 15.1).
Of all surgical cosmetic procedures, blepharoplasty
is the most common facial procedure performed among
people of Asian ancestry [2]. Aesthetic eyelid surgery
often appeals to the younger Asian population that
requests the formation of a supratarsal eyelid crease,
or “double eyelid” [2]. In lay terms, a “double eyelid”
refers to an eyelid that has a visible eyelid crease, whereas
a “single eyelid” does not. Procedures that create or
accentuate an eyelid crease have been termed “double
eyelid procedures.” It is important to recognize that most
Asians do not seek a westernized look, but rather want
to accentuate their natural ethnic features [3].
ANATOMY
Face
The Asian face has inherent differences that distinguish
it from those of other geographic regions. On average,
many recognize the face to be wider with higher cheek­
bones. In one study, the bizygomatic and mandibular
widths were found to be greater, along with wider inter­
canthal and interpupillary distances [4]. The lower facial
contour is also unique, with a prominent mandibular
angle that is mostly attributed to the bony framework
and masseter hypertrophy. The Asian brow rests higher
than that of Caucasians and the brow fat pads tends to
descend with age, further contributing to the fullness of
the upper lids and the narrowed appearance of the eyelid
fissures [5].
Skin
There are major differences between ethnic groups that
translate into functional and aesthetic differences. Com­
pared with Caucasians, Asian skin is typically thicker,
has more melanin, and has more subcutaneous and sub­
muscular fat. Consequently, Asian faces have less solar
keratosis, fewer rhytids, and delayed age-related changes
(Fig. 15.2).
The same pigmentation that confers protection against
ultraviolet-mediated photodamage also makes Asian skin
more prone to solar lentigines and postinflammatory
hyperpigmentation, which can follow surgery, chemical
peels, laser procedures, or any form of cutaneous trauma.
Skin in people of Asian ancestry is also more prone to
developing hypertrophic scars as compared with Cauca­
sian skin (Fig. 15.3).
Eyelid
The eyelids in patients of Asian ancestry have a multitude
of anatomical differences that contribute to their unique­
ness. The presence of an epicanthal fold, lash ptosis due to
anterior lamella redundancy, a higher lateral canthal posi­
tion relative to medial canthal position, and an increased
prominence of eyelid and orbital fat all characterize the
Asian upper eyelid. Each of these will be addressed sepa­
rately (Fig. 15.4).
Eyelid Crease
Some studies have shown that up to half of the popula­
tion of Chinese origin has an eyelid crease [6]. The height
of the crease varies, but typically is around 5 to 7 mm in
females and 3 to 5 mm in males, whereas in Caucasians
it is on average 2 mm higher.
Various configurations of the crease have been
described. The crease can run parallel along the entire
eyelid length, or can taper nasally to blend into the epi­
canthal fold (Figs. 15.5 and 15.6). The eyelid crease is
mostly determined by distal interdigitations of the levator
palpebrae superioris (LPS) aponeurosis with pretarsal
C H A P T E R 15 
Aesthetic Rejuvenation in the Patient
of Asian Ancestry
Ramzi M. Alameddine, MD, Bradford W. Lee, MD, MSc, Wei Lu, MD, PhD,
Bobby S. Korn, MD, PhD, FACS, and Don O. Kikkawa, MD, FACS

15  Aesthetic Rejuvenation in the Patient of Asian Ancestry
167
Figure 15.1  Facial photograph of a 22-year-old female of Asian ances­
try. Note flatter supraorbital bridge, eyelid fullness, and sharp lateral
canthal angles.
Figure 15.2  Facial photograph of a 53-year-old female of Asian ances­
try. Note the increased pigmentation over the malar regions (black
arrow) and paucity of rhytids.
Figure 15.3  Right eye photograph of a 29-year-old female of Asian
ancestry who sustained a laceration in her right lateral canthal region.
Note hyperpigmented and hypertrophic scar.
Figure 15.4  Left eye photograph of a 23-year-old male of Asian ances­
try displaying typical lash ptosis. Note the epicanthal fold and higher
lateral canthal position relative to the medial canthus.
A
B
C
Figure 15.5  Varying configurations in the upper eyelid crease. (A) No discernible eyelid crease. (B) Eyelid crease medially blending with the epi­
canthal fold. (C) Eyelid crease running parallel to the epicanthal fold.

168
MASTER TECHNIQUES IN FACIAL REJUVENATION
the orbicularis and dermis, thus blunting formation of
a crease [11]. However, Kakizaki et al. [12] later dem­
onstrated that the LPS aponeurosis has a similar site of
attachment with respect to the superior tarsal border in
Asians and Caucasians, and believed that the supposed
lower level of fusion of the LPS aponeurosis and septum
was in fact explained by a shorter tarsal height in Asians.
The lower lid retractors are similarly thought to fuse
with the orbital septum at a position higher than that in
Caucasians. This explains the anterior and superior pro­
jection of orbital fat that confers the fuller appearance of
the lower eyelid [13].
Fat
Several aspects of the adipose tissue in Asian eyelids are
distinct. The brow fat pads contain a prominent layer of
fibro-adipose tissue that continues inferiorly in the pre­
septal, suborbicularis plane in a pretarsal layer towards
the lid margin [14,15]. In Caucasians this layer is under­
developed or mostly nonexistent. The Asian lower eyelid
is characterized by orbital fat pseudoherniation, where
the orbital fat is projected further more anteriorly with
respect to the orbital rim [13]. Due to its robust adipose
tissue and differing septal configuration, the lower eyelid
is more likely to have epiblepharon or entropion rather
than ectropion. The suborbicularis oculi fat seems to have
a similar configuration in Asians and Caucasians [13].
Epicanthus
The epicanthal fold is a medial canthal skin fold that is
a common and defining feature of the Asian eyelid. The
most common configuration is epicanthus tarsalis, where
the fold is most prominent in the upper eyelid (Fig. 15.8).
The formation of the epicanthal fold has been postu­
lated to occur during the embryonic stage of lid disjunc­
tion. Other theories suggest a differential skin growth rate,
a Z-shaped kink in the orbicularis muscle fibers, or an
abnormal medial attachment of the levator aponeurosis
orbicularis and the skin. The average tarsal height is
around 2 mm less in Asians than Caucasians, which may,
in part, contribute to the lower lid crease [7].
Many believe that a lack of interdigitations from the
LPS aponeurosis explains the absent crease in Asians
with single eyelids [8]. However, a recent cadaveric study
demonstrated their presence in both single and double
eyelids [9]. An alternative explanation for lid crease
formation may deal with anatomical differences in the
orbital septum and configuration of the eyelid fibroadi­
pose tissues. There may be a greater amount of preseptal,
submuscular, and subcutaneous fat in the patients who
lack a visible lid crease. The skin and orbicularis underly­
ing the crease were also found to be thinner in patients
with double rather than single eyelids [9].
Septum
The precise configuration of the orbital septum in Asians
is controversial. Doxanas [10] described the septum as
fusing with the levator aponeurosis at a lower position in
Asians compared with Caucasians, and suggested that this
allowed anterior and inferior displacement of preaponeu­
rotic fat, creating the classic full appearance of the Asian
eyelid (Fig. 15.7). The prolapsed fat may also prevent
LPS aponeurosis fibers from directly interdigitating with
Figure 15.6  Naturally occurring asymmetry of the eyelid creases
(black arrows) in relation to the epicanthal folds in a female of Asian
ancestry.
A
B
Figure 15.7  Cross-sectional diagrams of characteristic (A) Caucasian and (B) Asian eyelid anatomy. Note the anterior and inferior displacement
of preaponeurotic fat and shorter tarsal plate in the Asian eyelid.

15  Aesthetic Rejuvenation in the Patient of Asian Ancestry
169
crease is desired, if absent. If a crease is desired, it is
important to discuss height as well as configuration.
Second, patients should be asked whether they would like
to alter the epicanthal fold. Finally, the extent of reduc­
tion of excessive tissue and volume should be clarified.
Many patients have distinct preconceived ideas of what
they desire. A natural-appearing low-set crease that runs
parallel to the lid margin and tapers nasally to blend with
an existing epicanthal fold is a commonly desired option.
Most patients prefer not to alter the natural appearance
of their epicanthal folds. Some patients may make use
of commercially available adhesive tapes to illustrate the
desired shape of the crease (Fig. 15.9), and physicians can
use this technique or a cotton-tipped applicator to simu­
late a crease. Photographs of prior surgical patients can
be used to show examples of reasonable postoperative
expectations. At the end of the discussion, the patient’s
preference with regards to the shape and height of a
crease and the extent of fat reduction should be clear.
During the patient evaluation, it is essential to record
the degree of dermatochalasis, fat prominence, position
of the brow, presence of lash ptosis or lacrimal gland
prolapse, and the configuration of the epicanthal fold.
Patients should be advised that the full healing process
and the final result may take several months, and that
asymmetry and crease height may change as the swelling
[16]. Recent histologic studies have shown obliquely ori­
ented orbicularis oculi fibers aligned in the same direction
as the fold, making the Z-shaped kink and medial levator
attachments hypotheses less likely [17]. A genetic basis
behind epicanthus development has not yet been identi­
fied. Furthermore, patients may have a well-formed epi­
canthal fold on one side but not on the other. Epicanthus
inversus, which is not typically characteristic of Asian
eyelids, may be associated with a multitude of congenital
syndromes, with genetic mutations in the FOXL2 gene
described in blepharophimosis syndrome [18].
PREOPERATIVE EVALUATION
Aesthetic surgeons who perform Asian eyelid surgery
should be knowledgeable about Asian facial anatomy
and understand that Asian patients may have different
aesthetic goals. Surgeons must be sensitive to variations
that also exist between different Asian ethnicities and that
all cultures do not necessarily share similar definitions
of beauty. It is important to recognize that the major­
ity of Asian patients wish to preserve and accentuate
natural features rather than transform to a “westernized”
appearance.
The preoperative discussion should focus on several
topics. First, the surgeon should elicit whether an eyelid
A
C
D
B
Figure 15.8  Varying configurations of epicanthal folds. (A) No epicanthal fold. (B) Epicanthal fold involving the upper eyelid (epicanthus tarsalis).
(C) Epicanthal fold involving the lower eyelid (epicanthus inversus). (D) Epicanthal fold involving both the upper and lower eyelids.

170
MASTER TECHNIQUES IN FACIAL REJUVENATION
everted, the superior tarsal border is identified, and three
double-armed sutures are passed from the conjunctiva to
the skin. The sutures are either externalized and tied, or
buried beneath stab incisions in the skin. Alternatively, a
nonabsorbable suture can be woven within the pretarsal
orbicularis along the superior tarsal border in a continu­
ous fashion, with the knot buried at the lateral aspect of
the intended crease. Potential limitations of the closed
techniques are longevity and inability to address derma­
tochalasis and fat prominence.
Our preferred procedure is the open technique [22,23]
(Figs. 15.10 and 15.11). This procedure involves a skin
incision that can address concomitant dermatochalasis or
fat prominence. This procedure yields a more dynamic
and physiologic crease that is not static and discernible
when the eyelid is closed. The incision is made at the level
resolves. The surgeon should discuss the possible need for
revisions and that this should only be considered after
healing is complete.
SURGICAL TECHNIQUES
Multiple surgical techniques have been described to create
a lid crease. Two broad categories are the open and closed
techniques. All techniques aim to create attachments or
adhesions between the LPS aponeurosis and the orbicu­
laris or skin at the level of the desired crease.
Closed suture techniques were first described by
Mikamo in 1896 [19–21]. These procedures are most
suitable for younger patients with minimal dermatocha­
lasis and fat prolapse. They are minimally invasive proce­
dures without extensive skin incisions. The upper eyelid is
A
B
C
Figure 15.9  Photographic series of a patient using adhesive eyelid tape to temporarily create an eyelid crease. (A) No discernible crease prior to
tape application. (B) Distinct crease simulated by placement of tape. (C) Adhesive tape is noticeable with eyelid closure (black arrows).
A
B
D
C
E
F
Figure 15.10  Surgical series of blepharoplasty with eyelid crease formation in an Asian patient. (A) Preoperative absence of eyelid crease.
(B) Skin marking made at the intended crease position, 5 mm above lid margin. (C) After skin incision, a small strip of orbicularis oculi is resected.
(D) The orbital septum is opened and a small amount of preaponeurotic fat is excised. (E) Placement of a nonabsorbable crease-fixating suture.
Note the suture pass through skin (black arrow)–levator aponeurosis (white arrow)–skin (black arrow). (F) Immediate postoperative appearance
with a distinctly visible eyelid crease.

15  Aesthetic Rejuvenation in the Patient of Asian Ancestry
171
nonabsorbable sutures that are removed in 1 week. We
prefer nonabsorbable sutures for skin closure to avoid
additional risk of postinflammatory hyperpigmentation
in Asian patients.
Although most Asians prefer to preserve the natural
appearance of their epicanthal folds, some do request
reduction or alteration of their folds. This can be achieved
with an epicanthoplasty. Our preference is either a
Z-plasty or a Root-Z procedure [24,25]. Patients should
be warned that hypertrophic or hyperpigmented scars can
occur as an undesirable sequelae of epicanthoplasty [26].
Postoperatively, patients are instructed to apply ice
compresses to the eyelids for the first 72 hours and to
limit physical exertion. Antibiotic-steroid ophthalmic
ointment is prescribed for topical use on the incisions.
Patients should be advised that edema and ecchymosis
may peak in the first week postoperatively, and that the
initial position of the eyelid crease tends to be high and
will descend as healing occurs. Sutures are removed in 5
to 7 days.
COMPLICATIONS
As with any surgical procedure, complications can occur
with Asian eyelid surgery but are fortunately rare and
can usually be managed effectively. Potential complica­
tions include excessive or insufficient fat removal, ptosis,
lagophthalmos, lid retraction, exposure keratopathy,
of the desired crease. Ideally, the incision tapers medially
but otherwise stays parallel to the lid margin. If desired
by the patient, it can flare laterally to a higher level
at the lateral canthus. In an older patient, the incision
can extend past the lateral canthus to encompass lateral
hooding. The amount of excess skin is determined using
the pinch technique. Even in younger patients 2 to 3 mm
of skin may be excised.
A skin incision is made with a No. 15 Bard-Parker
blade. Extra skin may be removed as discussed with
the patient. The orbicularis oculi muscle is typically pre­
served. The orbital septum is then opened across the
entire length of the eyelid. Conservative fat debulking is
performed as needed. If the lacrimal gland is prolapsed,
it should be reposited back into the lacrimal gland fossa
and sutured in position. A small 1- to 2-mm strip of
pretarsal orbicularis muscle is excised just beneath the
inferior aspect of the incision. The orbicularis excision
helps to create a more defined crease.
There are several ways to fixate a crease. One way is to
place “skin–levator–skin” sutures that are externally tied
(Fig. 15.10E). Alternatively, interrupted 7-0 polyglactin
sutures can also be used to create the crease. Each buried
subcutaneous suture is passed from one edge of the pre­
tarsal orbicularis just beneath the skin incision through
the LPS aponeurosis and tied off (Fig. 15.12). We have
not found it necessary to fixate the levator aponeurosis
directly to the tarsus. The overlying skin is closed with
A
B
Figure 15.11  Photograph of a patient of Asian ancestry (A) before and (B) after blepharoplasty.
A
B
C
Figure 15.12  Cross-sectional diagram showing different types of crease-forming suture placement. (A) Skin–levator–skin suture. (B) Skin–tarsus–
skin suture. (C) Buried orbicularis–levator–orbicularis suture.

172
MASTER TECHNIQUES IN FACIAL REJUVENATION
preaponeurotic fat pad or placement of a free fat graft
can be performed. The key is to prevent reformation of
prior attachments and the creation of multiple creases.
Satisfactory results can be achieved in this fashion, but
the surgeon should set limited patient expectations and
take care not to cause additional scarring, particularly
when the patient has already undergone multiple prior
revisions.
CONCLUSION
Patients of Asian ancestry are an increasingly prominent
segment of many aesthetic practices. Aesthetic surgeons
should be well versed in the anatomic differences, cul­
tural influences, aesthetic goals, and surgical procedures
unique to the Asian patient. Differing patient goals and
expectations provide a unique challenge; however, excel­
lent results and patient satisfaction can be achieved with
diligence and proper technique.
References available online at expertconsult.com.
R E F E R E N C E S
2. Hwang HS, Spiegel JH. The effect of “single” vs “double” eyelids
on the perceived attractiveness of Chinese women. Aesthet Surg J
2014;34:374–82.
7. Goold LA, Casson RJ, Selva D, Kakizaki H. Tarsal height. Oph­
thalmology 2009;116(9):1831.
9. Kakizaki H, Takahashi Y, Nakano T, et al. The causative factors
or characteristics of the Asian double eyelid: an anatomic study.
Ophthal Plast Reconstr Surg 2012;28:376–81.
12. Kakizaki H, Selva D, Asamoto K, et al. Orbital septum attachment
sites on the levator aponeurosis in Asians and whites. Ophthal Plast
Reconstr Surg 2010;26:265–8.
13. Carter SR, Seiff SR, Grant PE, Vigneron DB. The Asian lower eyelid:
a comparative anatomic study using high-resolution magnetic reso­
nance imaging. Ophthal Plast Reconstr Surg 1998;14:227–34.
14. Jeong S, Lemke BN, Dortzbach RK, et al. The Asian upper eyelid:
an anatomical study with comparison to the Caucasian eyelid. Arch
Ophthalmol 1999;117:907–12.
17. Kakizaki H, Ichinose A, Nakano T, et al. Anatomy of the epican­
thal fold. Plast Reconstr Surg 2012;130:494e–5e.
23. Kikkawa DO, Korn BS. Expert commentary. Blepharoplasty: special
considerations on the Asian eyelid. In: Mauriello JA. Techniques of
cosmetic eyelid surgery. A case based approach. Philadelphia, PA:
Lippincott, Williams and Wilkins; 2004. p. 229–35.
24. Yoo WM, Park SH, Kwag DR. Root z-epicanthoplasty in Asian
eyelids. Plast Reconstr Surg 2002;109:2067–71.
29. Choi HS, Whipple KM, Oh SR, et al. Modifying the upper eyelid
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epidermal inclusion cyst formation, lacrimal gland pro­
lapse or damage, infection, and the rare but devastating
retrobulbar hemorrhage and blindness [27]. Vision-
threatening retrobulbar hemorrhages require prompt
attention and evacuation.
The main adverse outcome pertinent to blepharoplasty
in the Asian patient is eyelid crease asymmetry. Small
amounts of asymmetry (0.5 mm) may be noticeable and
concerning to the patient. Fortunately, small amounts
of asymmetry often resolve over time. Greater degrees
of asymmetry (1 mm or more) may require intervention
(Fig. 15.13). The first step is to understand the cause of
the asymmetry. The crease might have abnormalities in its
height, shape, or longevity [28]. A high crease is undesir­
able because it appears unnatural. Causes of a high lid
crease include asymmetric height of incisions, excessive
fat removal, and inadequate or malpositioned suture fixa­
tion. Crease asymmetry secondary to volume loss may be
amenable to correction with soft tissue fillers. Hyaluronic
acid–based fillers can be injected into the deficient side
with good results [29]. For more permanence, autologous
fat grafting may also be used.
Surgical correction of crease asymmetry is more chal­
lenging. A discussion with the patient is essential to deter­
mine the surgical approach. The patient may prefer the
higher crease, in which case elliptical skin incision with
crease refixation on the side with lower crease can be
performed. If the patient prefers the lower crease, there
are several options to reduce crease height on the higher
side. A high crease can be lowered by excising an ellipse
of skin, where the superior border of the ellipse is at the
previous crease location, and the inferior border is at the
intended location of the new crease. To prevent readhe­
sion of the higher crease, inferior advancement of the
Figure 15.13  Photograph of a 25-year-old female of Asian ancestry
with asymmetric eyelid creases (black arrows) following blepharoplasty.

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15. Saonanon P. Update on Asian eyelid anatomy and clinical rel­
evance. Curr Opin Ophthalmol 2014;25:436–42.
16. Jordan DR, Anderson RL. Epicanthal folds. A deep tissue approach.
Arch Ophthalmol 1989;107:1532–5.
17. Kakizaki H, Ichinose A, Nakano T, et al. Anatomy of the epican­
thal fold. Plast Reconstr Surg 2012;130:494e–5e.
18. Jiang H, Huang X, Su Z, et al. Genetic analysis of the forkhead
transcriptional factor 2 gene in three Chinese families with blepha­
rophimosis syndrome. Mol Vis 2013;19:418–23.
19. Mikamo K. A technique in the double eyelid operation.
J Chugaishinpo 1896.
20. Uchida K. The Uchida method for the double-eyelid operation in
1,523 cases. Jpn J Ophthalmol 1926;30:593.
21. Maruo M. Plastic construction of a double-eyelid. Jpn Rev Clin
Ophthalmol 1929;24:393.
22. Kikkawa DO, Kim JW. Asian blepharoplasty. In Kikkawa DO (ed).
Int Ophthalmol Clin 1997;37(3):193–204.
23. Kikkawa DO, Korn BS. Expert commentary. Blepharoplasty: special
considerations on the Asian eyelid. In: Mauriello JA. Techniques of
cosmetic eyelid surgery. A case based approach. Philadelphia, PA:
Lippincott, Williams and Wilkins; 2004. p. 229–35.
24. Yoo WM, Park SH, Kwag DR. Root z-epicanthoplasty in Asian
eyelids. Plast Reconstr Surg 2002;109:2067–71.
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blepharoptosis correction in Asian patients. Plast Reconstr Surg
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rience and comparison among three kinds of epicanthoplasties.
J Plast Reconstr Aesthet Surg 2013;66:682–7.
27. Lowry JC, Bartley GB. Complications of blepharoplasty. Surv Oph­
thalmol 1994;38:327.
28. Chen L, Zhou Y, Zeng J, et al. Rejuvenation surgery through
blepharoplasty incision for mild to moderate upper eyelid sagging
in older Asian patients. J Craniofac Surg 2013;24:1731–3.
29. Choi HS, Whipple KM, Oh SR, et al. Modifying the upper eyelid
crease in Asian patients with hyaluronic acid fillers. Plast Reconstr
Surg 2011;127:844–9.
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1. International Society of Aesthetic Plastic Surgery (ISAPS). ISAPS
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-Results-Procedures-2011.pdf. [Last accessed April 2015].
2. Hwang HS, Spiegel JH. The effect of “single” vs “double” eyelids
on the perceived attractiveness of Chinese women. Aesthet Surg J
2014;34:374–82.
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ations. Singapore Med J 1991;32:316–18.
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metric study of facial morphology in various ethnic groups/races.
J Craniofac Surg 2005;16:615–46.
5. Ichinose A, Tahara S. Extended preseptal fat resection in Asian
blepharoplasty. Ann Plast Surg 2008;60:121–6.
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thalmology 2009;116(9):1831.
8. Morikawa K, Yamamoto H, Uchinuma E, et al. Scanning electron
microscopic study on double and single eyelids in Orientals. Aes­
thetic Plast Surg 2001;25:20–4.
9. Kakizaki H, Takahashi Y, Nakano T, et al. The causative factors
or characteristics of the Asian double eyelid: an anatomic study.
Ophthal Plast Reconstr Surg 2012;28:376–81.
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Arch Ophthalmol 1984;102:1232–5.
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and their relationship with single- and double-eyelid formation.
Aesthetic Plast Surg 1994;18:183–7.
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a comparative anatomic study using high-resolution magnetic reso­
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an anatomical study with comparison to the Caucasian eyelid. Arch
Ophthalmol 1999;117:907–12.

173
HISTORY
The signature operation of facial rejuvenation is the rhyt­
idectomy. Of all the procedures designed to remedy the
effects of aging, the rhytidectomy has the most profound
ability to improve the patient’s appearance. The first
recorded efforts to surgically rejuvenate the face appeared
early in the 20th century [1–3]. The first 50 years of the
20th century saw little advance; burdened by the risks of
anesthesia and the lack of medications, such as antibiot­
ics, surgeons were forced to move forward with great
trepidation. As technologic advances erupted in the latter
half of the 20th century, surgical advances soon followed.
In the last 30 years of the century, these technologic
advances enabled surgeons to provide excellent surgical
results to their patients and the popularity of facial reju­
venation has since exploded. Facial rejuvenation surgery
has never been more popular, as adjunctive modalities
such as dermal fillers and Botox have brought interest
in cosmetic improvements to an all-time high. Today, an
attractive outward appearance is a sign of strength and
health instead of vanity [4].
The original techniques employed short skin flaps
and minimal, if any, manipulation of the underlying soft
tissues for fear of damaging the facial nerve. With greater
anatomic understanding, the techniques progressed
deeper into the ptotic tissues of the aging face. The skin
flaps gradually became longer and the manipulations of
the underlying soft tissue, the superficial musculoapo­
neurotic system (SMAS), became more aggressive. With
these advances, new frontiers were crossed and new com­
plications arose. In addition, physicians working in this
field have now gained a much greater knowledge and
appreciation for other factors that historically had been
neglected, especially in regard to lifestyle choices, such as
smoking and alcohol intake, and in medications, such as
antiplatelet agents.
The field has undergone a fascinating 40-year evolu­
tion since the groundbreaking work of Dr. Skoog in the
1970s [5]. Skoog was the first to perform what can be
called the deep plane technique. Hamra advanced the
concept to include the soft tissues of the midface with his
deep plane and composite techniques [6–9]. Today, there
is great controversy as to the appropriate technique and
plane of dissection for optimal rejuvenation [4]. With
the advent of the deep plane facelift technique, rhytidec­
tomy took a quantum leap forward. For decades, rhyt­
idectomy provided the patient with a benefit that often
pleased the patient but left the surgeon wanting more.
This exciting technique enabled the surgeon to provide a
more lasting, natural result. We propose our techniques
described herein not as an answer to these dilemmas but
as a proven method to safe, excellent, reproducible results
in facial rejuvenation.
PERSONAL PHILOSOPHY
The evolution of our technique is based on several cri­
teria. First, the result with the deep plane technique was
superior to that of the SMAS lift plication and imbrica­
tion techniques. With a more thorough undermining of
the ptotic soft tissues of the face, a better postoperative
result soon followed, as would be expected. Although
the SMAS procedure is excellent for short-term gains
in reducing skin laxity and mild improvement of soft
tissue ptosis, the majority of the ptotic soft tissue remains
fallen. We agree with the previously published viewpoint
that “minilifts” or subcutaneous facelift procedures have
only dealt with laxity of the skin and do not completely
address the ptotic soft tissues of the face [6,7].
Second, once experience was gained with this tech­
nique, the long-term results became evident. In addi­
tion, the occurrence of the “pulled” or “operated look”
decreased rapidly with the increased use of this tech­
nique. We also believe that with the shorter skin flap and
superior blood supply of the deep plane technique, the
catastrophic issues of skin loss and poor scar appearance
are greatly diminished. With its strict adherence to physi­
ologically sound principles, the effect of the deep plane
technique is maintained for a longer period than that of
the skin flap techniques. This is due to the composite
flap maintaining the viscoelastic properties of the SMAS
[10]. Though others have not agreed with these opinions,
we maintain our results have improved greatly since the
transformation of techniques [11,12].
Much excitement has been generated over the
“weekend” or “mini-facelifts.” With the promise of
smaller incisions and less downtime, these procedures
have received significant attention over the last several
years as the popularity of plastic surgery has flourished.
These techniques are similar to standard SMAS facelifts
and thus are an option for certain patients.
Generally speaking, patients for whom these proce­
dures are devised suffer from lax skin, especially in the
lower face. When a patient considers facial cosmetic
surgery, we feel the first operation should be the definitive
procedure. If the patient has had a “less invasive” pro­
cedure in the past, the tissue planes are forever altered,
thus making further surgery, when the aging process has
come to fruition, much more difficult. This is obviously
C H A P T E R 16 
The Deep Plane Facelift
Calvin M. Johnson Jr., MD and Mark R. Murphy, MD

174
MASTER TECHNIQUES IN FACIAL REJUVENATION
a matter of personal preference, and some patients will
persist in having certain procedures performed regardless
of the surgeon’s preferences. This is a matter for each
individual practice. For ours, all primary facelifts are
done via the deep plane techniques.
A variety of midfacial approaches have been proposed
over the last 20 years. The point of origin for most of
these procedures is from the work of Tessier [13]. Several
variations of this approach have been proposed [14–26].
We favor the deep plane technique over the subperiosteal
midface approach for several reasons. The first is the
direct nature in which the deep plane technique addresses
the fallen tissue. The focus of midfacial rejuvenation is
the suspension of the soft tissues of the midface that
have fallen with time. In the deep plane technique, the
surgeon may directly manipulate this tissue to the desired
location. To state the issue directly, deep plane surgery
“works at the level at which mobility and aging laxity
are occurring” [27]. The tissue to be repositioned in
the midface is the cheek fat that rests on the zygomati­
cus musculature. With elevating the soft tissues off the
zygomatic musculature, the surgeon may now address
the nasolabial fold and the descent of the soft tissues
in a manner not possible before. A SMAS correction is
inherently more effective than a subperiosteal approach
in the midcheek because it is closer to the tissue to be
repositioned [28].
In addition, the nerves that innervate the facial mus­
culature enter from below. Thus, it stands to reason that
dissection techniques that leave the nervous structures
between the plane of dissection and the target tissue
leave the nerves at risk from either direct trauma through
inadvertent movements of the dissector or, more com­
monly, through traction neuropraxia. The subperiosteal
technique has been reported to have a high rate of facial
nerve injuries, implying a steep learning curve [14].
Edema from periosteal manipulations is significant,
and for it to persist for weeks, if not months, is not
uncommon [29–31]. To patients who are expecting
a “minimally invasive” procedure, this may prove to
be a difficult issue. In the subperiosteal approach, the
zygomaticus musculature is repositioned to a place it
never was before, the intermalar distance is necessar­
ily increased, and frequently manipulation of the lateral
canthus is required [32]. Not only is the lateral canthus
often altered, but the resetting of the zygomaticus mus­
culature may also lead to an unwanted alteration of
the patient’s appearance [33]. One must be concerned
about the potential for distortion of the palpebral fissure
with many of these procedures [34–38]. When an open
lower lid blepharoplasty approach is incorporated
into the subperiosteal midfacial techniques, the lower
lid malposition rate has been reported to be as high
as 50% [36].
An argument can be made for addressing the midfa­
cial region via volume rather than surgical manipula­
tion. Whether it be autologous fat injection or dermal
fillers, volume replenishment is almost always employed
as an adjunct to surgical elevation to create the optimized
outcome. The surgeon, to attain the desired result, must
be fully versed in not just surgical handling of ptotic
tissues but also in the key role that volume plays in facial
rejuvenation [39].
Our approach to facelifting, as with our overall prac­
tice approach, is the attainment of a natural, lasting result
via conservative means. We seek to provide the patient
with rejuvenation where the observer cannot detect that
an operation has occurred. The deep plane technique may
not be considered conservative in some quarters, but with
the technique performed as described herein, we feel it
to be exceedingly safe and well tolerated by the patient.
ANATOMY
The facelift surgeon must be fully versed in the complex
anatomy of the face. A complete discussion of the ana­
tomic relationships is beyond the scope of this chapter
and the reader is advised to refer to excellent published
reports on this challenging territory [40–42]. There are
several anatomic keys to the aging face, and specific areas
of concern are discussed. As we age, some of the most
profound effects are noted in the midface. A key to the
deep plane technique is the anatomy of the midcheek and
malar region.
The cheek mass descends with age and causes a deep­
ened nasolabial fold inferiorly while creating a depres­
sion at the infraorbital rim (Fig. 16.1) [43]. The malar
fat pad atrophies and descends with age, leading to a
cresent-shaped hollowness at the lid-cheek interface and
nasojugal groove, and lack of cheek prominence, giving a
sunken, tired appearance [44]. The effects of gravity are
more pronounced on superficial tissues [29,43].
Another feature of midfacial aging is the buccal fat
pad. It provides fullness to the cheek in youth and dimin­
ishes, relatively, in size as the patient ages [45]. This fat
pad has four major components, with the buccal being
the largest. On the lateral aspect of the masseter lies
this parotid-masseteric fascia, a key structure in the deep
plane technique. This fascia layer is found between the
overlying SMAS and the underlying branches of the facial
nerve (Figs. 16.2 and 16.3). Fortunately, this fascia binds
the branches of the facial nerve down, a key factor when
placing extreme traction on the SMAS to expose the deep
plane. As this fascia continues anteriorly, it shifts supe­
riorly to envelop the buccal fat pad, parotid duct, and
buccal branches of the facial nerve [45–47].
Another important area of the midface is the naso­
labial fold [48–50]. The nasolabial fold is a true anatomic
boundary between the fatty cheek above and the upper
lip below [48]. As the tissues of the midface become
ptotic with age, the nasolabial fold deepens and becomes
of greater concern to the patient.
The lower aspect of the face is dominated by jowling
and submental fat. The jowling that so troubles the aging
population results from the descent of the platysma
muscle in the neck and face with the associated fat and
skin along the mandibular line. The platysma has been
described as having a graded aging process [51,52]. The
history of submental fat resection is often attributed to
the work of Millard and others [53,54].
The SMAS merits specific discussion. First described
by Mitz and Peyronie, the SMAS layer and manipulations

16  The Deep Plane Facelift
175
the skin [62,63]. The SMAS is thicker in its lateral aspect
over the parotid and tapers as it travels medially [62,64].
Our experience concurs with these reports. There has also
been controversy over the relationship of the SMAS to
the parotid fascia as to whether they are separate layers
or one and the same [56–60,65,66]. Whether they are
one and the same or distinct layers means little to the
thereof have intrigued facial plastic surgeons for 40 years
[55]. This layer has been seen as an extension of the pla­
tysma into the face (see Figs. 16.2 and 16.3). The SMAS
is considered to be a fibromuscular structure that lies in
continuity with the platysma and has no bony attach­
ments [55–61]. The layer consists of connective tissue
and muscle. It has fibrous extensions that connect it to
Figure 16.1  The graduated stages of the aging face.