The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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37 Transconjunctival Blepharoplasty
Foad Nahai
Abstract
The transconjunctival approach to blepharoplasty has continued
to gain in popularity. The reasons include the minimal risk
of lid retraction, the ability to combine fat management with
skin pinch or resurfacing, and the addition of fat grafting. It has
evolved from simple fat excision to fat preservation, fat redrap-
ing, and gateway to the midface.
Keywords
fat excision, fat redraping. fat grafts canthopexy, skin pinch
37.1 Evolution of Technique
In an effort to minimize the risks associated with the open or
transcutaneous skin–muscle approach to blepharoplasty, there
has been renewed interest in the transconjunctival approach.
Originally described by Bourguet in 1928, the transconjunctival
approach was reintroduced in 1973 by Tessier for removal of fat
from the lower eyelid and treatment of congenital deformities
and trauma. This approach was later popularized for the removal
of lower lid fat by Baylis et al and by McCord and Moses in the
oculoplastic literature in the 1980s, and by =arem and Resnick in
the plastic surgery literature in the early 1990s. These surgeons
emphasized the safety of this technique and the significant
reduction in complications it offered, with almost complete
elimination of lid retraction and its consequences. My personal
experience, reported in 1995 and again in 2010, confirmed the
safety and efficacy of this approach for removal of fat from the
lower eyelid. Over time, interest in transconjunctival blepharo-
plasty waned as the focus shifted to amelioration of aging of the
lid–cheek junction with an emphasis on fat redraping and the
transpalpebral approach to midface elevation. Today, however,
the transconjunctival approach is again attracting attention
and gaining in popularity, not only for fat removal from the
lower eyelid but also for fat redraping, fat redistribution, and a
transconjunctival gateway to the midface. In 1999 we described
the transconjunctival approach to the medial or nasal fat pocket
of the upper eyelid.
37.1.1 Advantages
In addition to the obvious benefit of significantly decreasing
complications, the other advantage to this technique is that there
is no visible scar. Lid retraction and its consequences³exposure,
round eye, scleral show, and ectropion³have all but been elimi-
nated with this approach. Baylis et al reported no lid retraction,
as did =arem and Resnick. A personal review of 300 consecutive
blepharoplasties between March 1992 and March 1996 (portions
of which were published in 1995) included 120 transconjunctival
blepharoplasties and 180 transcutaneous blepharoplasties. As
shown in Table 37.1, the overall complication rate was 5 for the
transconjunctival group but 13 for the transcutaneous group.
In the transconjunctival group there was no lid retraction, but
in the transcutaneous group 3.3 had lid retraction. The revi-
sion rate for the transcutaneous group was 2.2, while for the
transconjunctival group it was 1.6. The complication rates were
similar in primary and secondary blepharoplasties.
37.1.2 Disadvantages
Although the addition of a skin pinch allows removal of skin
excess, orbicularis muscle trimming and redraping is not possible
through this approach. Access for redraping and redistribution of
periorbital fat and access to the midface are possible through this
approach, but it is not as straightforward as the open approach.
In the upper eyelid, only the nasal fat pocket can be approached
through the conjunctiva, which limits its role to removal of fat
from that pocket only.
37.2 Management of Fat in
the Eyelids
Over the years there has been considerable change in our man-
agement of periorbital fat. Gone are the days of the skin–muscle–
fat excision blepharoplasty. It was through this evolution of fat
management around the eye in the late 1990s that transcon-
junctival fat removal became less popular in general and I chose
Table 37.1 Series of 300 transconjunctival and transcutaneous
blepharoplasties (March 1992–March 1996)
7rDnVFRnMunFWiYDO
(N = 120)
Transcutaneous
(N = 180)
Primary
blepharoplasty
101 (84%)
145 (80%)
Secondary
blepharoplasty
19 (16%)
35 (20%)
Mean follow-up
3 yr
3 yr
Range
2–4 yr
2–4 yr
Surgical revision
2 (1.6%)
4 (2.2%)
Exposure
0
8 (4.4%)
Subconjunctival
hematoma
2 (1.6%)
4 (2.2%)
Infection
0
2 (1.1%)
Granuloma
2 (1.6%)
0
Scleral show/
ectropion
0
6 (3.3%)
Overall
6 (5%)
24 (13%)

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it with significantly less frequency in my practice. My current
management of lower lid fat includes the following:
• Redraping
• Preservation
• Excision
• Augmentation
In selected patients lower lid fat grafting with skin resurfacing
or skin pinch produces excellent results and obviates the need for
a skin–muscle flap.
Even in the upper eyelid, I am preserving fat rather than resect-
ing, especially in the lateral pocket.
37.3 Indications
Fat management, especially in the lower eyelid, is now custom-
ized to each individual. I base my options for fat management
on the amount of fat present and an evaluation of the lid–cheek
junction. If the patient has little if any aging of the lid–cheek
junction with true excess fat, I prefer resection of fat. If the
patient has no excess fat, the fat pocket is not opened. If the
patient has aging of the lid–cheek junction and sufficient fat
for redraping, then redraping or redistribution of that fat is the
procedure of choice. In patients who require improvement of
the lid–cheek junction and do not have an adequate volume of
lower lid fat, augmentation with autologous fat or a dermis graft
is necessary. Autologous fat grafting is far more popular, simpler,
and less invasive than dermis fat grafts (Fig. 37.1).
For individuals with excess lower lid fat and little or no lid–
cheek junction change, the postseptal transconjunctival approach
is an ideal operation with safe, easy fat removal from all com-
partments. It is also a good operation for patients with excess fat
and fine skin wrinkling and in those with apparent excess skin in
whom fat removal will result in redraping of the excess skin into
an acceptable contour with elimination of the skin laxity. Laser
resurfacing and peels have been advocated for skin tightening
after transconjunctival fat removal to deal with the excess skin;
however, I have found that skin excision is best for handling the
excess skin. The combination of transconjunctival fat removal
and skin excision through skin-pinch blepharoplasty is a suitable
alternative to the transcutaneous skin-muscle flap blepharoplasty
in selected patients. For candidates for redraping or redistribution
or augmentation of the periorbital fat, the preseptal transconjunc-
tival approach allows access to the periorbital fat, sub–orbicularis
oculi fat (SOOF), and midface. This approach does not afford
the same easy access and visualization as the transcutaneous
approach.
37.4 Preoperative Assessment
A complete medical history is taken. :e ask about hypertension
and medications that affect bleeding. A careful ophthalmologic
history is then obtained. The patient is asked about any history
of eye problems or operations, specifically inquiring about
glaucoma and laser in situ keratomileusis (LASI.) procedures,
symptoms of dry-eye syndrome or irritation, whether the
patient wears glasses or contact lenses, and any family history of
eye problems, especially glaucoma.
The examination includes an evaluation of the lower lid skin,
muscle, fat, and lid–cheek junction. Lid tone should be assessed
with the pinch and traction tests. Schirmer’s test is done on a
selective basis, as indicated. Although I routinely measure every
patient’s eyes with the Hertel ophthalmometer, it may not be as vital
to do so for patients undergoing transconjunctival procedures.
37.5 Upper Eyelid
37.5.1 Pertinent Anatomy
The only fat compartment to herniate in the upper eyelid is the
medial compartment. The other compartment is retained ana-
tomically, does not herniate, and cannot be exposed through the
conjunctiva (Fig. 37.2).
Fig. 37.1 Lower lid fat management.

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:e consider the upper eyelid to be divided into tarsal and
orbital portions at the level of the supratarsal fold, which is
located 3 to 5 mm above the upper border of the tarsal plate in
Caucasians and much lower in Asians. It is formed by the fusion
of the levator palpebrae superioris aponeurosis, orbital septum,
and fascia on the deep surface of the orbicularis oculi muscle.
This fused layer acts as a sling and holds up the periorbital fat
so that the excess fat drapes over the fold rather than herniating
below it (Fig. 37.3).
This sling is lower laterally and much higher nasally, thus allow-
ing herniation of the nasal fat pocket below it. The other structure
of importance here is the levator aponeurosis. The lateral horn of
the levator is much lower than its medial horn. These two factors
combined allow transconjunctival access to the nasal or medial fat
pocket without risk of injuring or involving the levator aponeuro-
sis (Fig. 37.4).
The medial or nasal fat lies medial to the levator aponeurosis
and below its medial horn. The lateral temporal or central upper
eyelid fat pocket lies anterior to the levator aponeurosis and is
inaccessible through the transconjunctival approach. The medial
or nasal fat is usually pale yellow or white. It contains more sen-
sory filaments, branches of the supratrochlear nerve, and more
blood vessels, branches of the superior ophthalmic artery. The
fat of the lateral central or temple compartment is much more
yellow in color and has sensory fibers and vascular branches of
the supraorbital nerve and artery (Fig. 37.5).
37.5.2 Transconjunctival Approaches
Only the nasal fat pocket can be approached through the medial
conjunctiva below the medial horn of the levator aponeurosis
through the so-called bare area described by Guerra et al.
Fig. 37.2 Illustration that the only fat compartment to herniate in the
upper eyelid is the medial compartment.
Fig. 37.3 Anatomical relationships of the upper eyelid fat
compartments.
Fig. 37.4 The levator muscle, (a) its aponeurosis, and (b) the sling allowing herniation of the medial or nasal pocket only.
a
b

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VI Eyelid Surgery
37.5.3 Preoperative Planning
Patient Protection
The transconjunctival approach is suitable for a primary or sec-
ondary procedure for removal of excess medial upper eyelid fat.
The best candidates for this procedure have excess fat limited to
the nasal pocket, with little or no true skin excess. In my experi-
ence, most of these patients have undergone previous blepharo-
plasties, with remaining excess fat in the medial or nasal pocket.
Markings
:ith gentle pressure on the globe, I look for the maximum bulg-
ing of the medial fat pocket and place a small mark on the skin.
37.5.4 Operative Technique
Anesthesia
Local anesthesia is my choice if fat removal is the only procedure
to be performed. If it is combined with other facial rejuvenation
procedures, I prefer general anesthesia. Before injection of the
local anesthetic, 1 to 2 drops of topical tetracaine anesthetic are
placed on the eye. The local anesthetic, 0.5 lidocaine with epi-
nephrine 1:200,000, is infiltrated transcutaneously and through
the conjunctiva. If the patient is under general anesthesia, the
lidocaine–epinephrine mixture is injected for its vasoconstrictor
effect, but the tetracaine is not necessary.
Incision
A corneal protector is placed over the eye. The medialmost part of
the upper eyelid is retracted; I prefer to use a Blair retractor. The
´bare areaµ is immediately exposed and an incision made in the
conjunctiva with Colorado tip needle electrocautery. This incision
is kept in the medialmost part of the upper eyelid and should not
extend laterally beyond the bare area, where it may injure the
levator aponeurosis and risk postoperative ptosis. Once the inci-
sion is made, I take a pair of fine blunt-tipped scissors and spread
the blades. The nasal fat pocket immediately comes into view.
Fat Excision
The medial fat pocket is then easily teased and delivered through
the incision, where it is trimmed with the electrocautery. The
endpoint is reached when there is no bulging medially in the
upper eyelid with gentle pressure on the globe (Fig. 37.6).
Closure
The conjunctival incision is always left open.
Fig. 37.5 The relationship of the sling with the fat pockets.
Fig. 37.6 Transconjunctival blepharoplasty: fat excision.

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Postoperative Care
The patient’s head is elevated, and ice packs are placed on the
eyelids.
37.5.5 Results
The transconjunctival approach for removal of fat in the upper
eyelid has been free of complications in our hands, specifically
free of eyelid ptosis. There have been no revisions, and patients
have been consistently pleased.
The middle-aged woman shown in Fig. 37.7 underwent an
endoscopic brow lift, transconjunctival removal of fat from the
upper eyelids, a lower lid blepharoplasty with transpalpebral
midface lift and neck lift, and laser resurfacing of the forehead.
She is seen 12 months postoperatively. 1o skin was removed
from the upper eyelids; the improvement seen in the upper lids
resulted from the endoscopic brow lift and excision of fat from
the medial fat pocket.
The 50-year-old woman shown in Fig. 37.8 underwent an
endoscopic brow lift, transconjunctival removal of fat from the
upper eyelids, lower lid blepharoplasty, and a face and neck lift.
She is shown 3 years after surgery. 1o skin was removed from the
upper eyelids. The medial upper lid improvement that resulted
from transconjunctival fat removal is most evident in the split-
face view.
The woman in her early fifties shown in Fig. 37.9 had had a
previous coronal brow lift. She underwent an endoscopic brow
lift with transconjunctival removal of fat from the nasal pocket of
the upper eyelids. The upper eyelids were improved as a result of
the transconjunctival removal of fat from the nasal pocket and the
endoscopic brow lift. There was no skin excision from the upper
eyelids.
37.6 Lower Eyelids
37.6.1 Pertinent Anatomy
An understanding of the anatomic relationships between the
fat pockets and other lid structures is the key to this approach.
It should be remembered that the outer lamella of the lower
eyelid is composed of the skin and orbicularis muscle. The
middle lamella is the orbital septum, and deep to it is the
periorbital fat; the posterior lamella behind the orbital fat is
made up of the lower lid retractors (capsulopalpebral fascia)
and conjunctiva.
Orbital Fat Pads
The orbital fat pads are bounded anteriorly by the orbital septum.
The septum is attached inferiorly to the arcus marginalis and
fuses superiorly with the lower lid retractors. The orbicularis
Fig. 37.9 Woman in her early 50s who had had a previous coronal brow lift and underwent an endoscopic brow lift with transconjunctival removal of
fat from the nasal pocket of the upper eyelids.
Fig. 37.7 Middle-aged woman (a) pre- and (b) 12
months post an endoscopic brow lift, transconjunctival
removal of fat from the upper eyelids, a lower lid bleph-
aroplasty with transpalpebral midface lift and neck lift,
and laser resurfacing of the forehead.
a
b
Fig. 37.8 Woman aged 50 at presentation (a) pre- and (b) 3 years post an endoscopic
brow lift, transconjunctival removal of fat from the upper eyelids, lower lid blepha-
roplasty, and a face and neck lift. (c) The medial upper lid improvement that resulted
from transconjunctival fat removal is most evident in the split-face view.
a
b
c

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VI Eyelid Surgery
muscle and skin are anterior to the septum. The orbital fat pads
are bounded superiorly and posteriorly by the lower lid retrac-
tors. The lower lid retractors arise from the terminal muscle
fibers and tendons of the inferior rectus muscle. They fuse with
the orbital septum 5 mm below the inferior tarsus and insert on
the tarsal plate. The posterior lower lid retractors are applied
very close, in fact quite adherently, to the lower lid conjunctiva
(Fig. 37.10).
The inferior oblique muscle lies within the orbital fat and is the
only eye muscle at risk during blepharoplasty. The muscle origi-
nates along the anterior medial orbital floor, passing posteriorly
and laterally beneath the globe separating the medial and central
fat pockets (Fig. 37.11).
The Compartments
The central compartment is separated from the lateral com-
partment by the arcuate expansion of the inferior oblique
muscle, which inserts into the orbital rim anterolaterally. The
inferior oblique muscle separates the central and medial fat
compartments.
37.6.2 Transconjunctival Approaches
Transconjunctival approaches to the lower eyelid are either
preseptal or postseptal. Each approach has its own advantages
and limitations. The postseptal approach allows only fat
removal. The preseptal approach allows access for fat removal
and redistribution, along with access to the midface and orbital
rim (Fig. 37.12).
Transconjunctival Approaches
The preseptal approach allows the following:
• Fat removal
• Fat redistribution
• Access to midface
The postseptal approach allows the following:
• Fat removal only
The preseptal incision is placed in the following places:
• Below the tarsal border
• At the level of the upper arcade
The postseptal incision is placed in the following places:
• In the fornix 4 to 5 mm below the tarsal border
• At the level of the lower arcade
Fig. 37.10 Orbital fat pads.
Fig. 37.11 Anatomy of the lower lid fat compartments.

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Postseptal Approach
Transconjunctival blepharoplasty by the postseptal approach
permits access to the orbital fat through an incision in the con-
junctiva and lid retractors/capsulopalpebral fascia without any
disruption or involvement of the skin, muscle, or orbital septum.
The incision is usually made in the conjunctiva of the inferior
fornix, 4 or 5 mm below the tarsal border at the level of the lower
conjunctival vascular arcade (Fig. 37.13).
Preseptal Approach
The preseptal approach permits access to the fat pads through
the orbital septum and allows access to the orbital rim, SOOF,
and the midface without any involvement of the orbicularis
muscle or skin. The incision is made along the lower tarsal
border, 1 or 2 mm below the lid margin. This incision extends
through the conjunctival lid retractors and capsulopalpebral
fascia. The space behind the orbicularis is then entered, and the
dissection is continued deep to the orbicularis but anterior to the
orbital septum. This dissection is continued down to the orbital
rim, and the arcus marginalis is easily released, affording access
to the midface. Access to the fat requires resection or incision of
the orbital septum (Fig. 37.14).
37.6.3 Preoperative Planning
Patient Selection
The best candidates for transconjunctival fat removal or redrap-
ing are those with excess fat and little if any real skin excess.
The combination of transconjunctival fat removal and skin-pinch
excision is a suitable procedure in some patients. Fat redraping
is appropriate for patients with aging of the lid–cheek junction
with little or no real skin excess.
Markings
:ith gentle pressure on the globe, the skin is marked directly
over each bulging compartment. If fat redraping is planned, the
nasojugal groove and lid–cheek junction are marked.
Fig. 37.12 Preseptal and postseptal transconjunctival approaches to the lower eyelid.
Fig. 37.13 Transconjunctival blepharoplasty by the postseptal approach.
Fig. 37.14 Transconjunctival blepharoplasty by the
preseptal approach.

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VI Eyelid Surgery
37.6.4 Operative Technique
The ideal candidate for the postseptal approach is a patient with
bulging lower lid fat compartments with no real excess skin. The
ideal candidate for the preseptal approach has aging of the lid-
cheek junction with no real skin excess.
Anesthesia
The choice of local versus general anesthetic is the same as
described previously for the upper eyelid.
Postseptal Approach
Incisions
The globe is protected with a corneal protector. Stay sutures
of 5–0 Prolene are placed medially and laterally through the
conjunctiva of the inferior fornix. These two sutures are then
pulled upward, facilitating the dissection and also affording
extra protection to the globe. A Blair retractor or traction sutures
are then placed in the lower lid margin (Fig. 37.15).
/RZer ArFDde
The incisions are made with the electrocautery, 4 to 5 mm below
the lid margin at the level of the lower arcade (Fig. 37.16).
I prefer to make two separate conjunctival incisions: one medi-
ally over the medial fat compartment and the second laterally over
the central and lateral compartments. These two incisions leave
an intervening bridge of conjunctiva over the inferior oblique
muscle in an effort to minimize the risk of injury to the muscle
during fat removal (Fig. 37.17). A single continuous incision, by
contrast, affords better exposure without significantly increasing
the risk of muscle injury.
Once the conjunctiva and the adherent lower lid retractors and
capsulopalpebral fascia have been incised, the fat compartments
may not always be readily visible (Fig. 37.18).
If the fat is not readily visible, gentle spreading with fine, blunt-
tipped scissors will easily expose it. The central and lateral fat
compartments are more easily identified than the medial fat com-
partment. I have found that resection of the central fat facilitates
identification of the medial fat. It should be kept in mind that the
inferior oblique muscle separates the central and medial fat pock-
ets, whereas the arcuate expansion of the inferior oblique muscle
Fig. 37.17 Use of two separate conjunctival incisions leaves an
intervening bridge of conjunctiva over the inferior oblique muscle in an
effort to minimize the risk of injury to the muscle during fat removal.
Fig. 37.16 Lower vascular arcade.
Fig. 37.15 Transconjunctival blepharoplasty by the postseptal approach: incisions.

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separates the central and lateral compartments (Fig. 37.19). Once
the fat is exposed, I like to deliver the fat through the incisions to
assess the amount to be resected (Fig. 37.20).
The exposed fat is then removed in a careful, graded fashion
with the coagulator and Colorado tip needle. The endpoint is
reached when the remaining fat is flush with the infraorbital rim
when gentle pressure is applied on the globe (Fig. 37.21).
Closure
1o closure is required if two separate incisions are made. If a single
continuous incision is made, the wound is sutured (Fig. 37.22).
Preseptal Approach
Incisions
One continuous, long incision is made just below the tarsal
border. This is facilitated by retracting the tarsal plate upward
and inferiorly with Blair retractors or through the placement
of stay sutures in the lid margin. The incision is made with the
electrocautery and a Colorado tip needle (Fig. 37.23).
Once the incision has been made, stay sutures are placed along
the inferior margin to facilitate exposure. The dissection is con-
tinued through the conjunctiva and lower lid retractors, exposing
the orbital septum on the deep surface and the orbicularis on
the superficial side of the incision. A Desmarres retractor is then
placed deep to the orbicularis and pulled downward (Fig. 37.24).
([SRVure Dnd 5ediVWriEuWiRn RI )DW
Dissection is continued deep to the orbicularis but superficial to
the orbital septum, downward toward the orbital rim. The arcus
marginalis is released, and dissection may continue into the
midface as needed. The orbital septum is then opened, the fat
Fig. 37.18 When the conjunctiva and the adherent lower lid retractors
and capsulopalpebral fascia have been incised, the fat compartments
may not always be readily visible.
Fig. 37.19 If the fat is not readily visible, gentle spreading with fine,
blunt-tipped scissors will easily expose the fat. The central and lateral
fat compartments are more easily identified than the medial fat
compartment.
Fig. 37.21 The exposed fat is removed in a careful, graded fashion
with the coagulator and Colorado tip needle. The endpoint is reached
when the remaining fat is flush with the infraorbital rim when gentle
pressure is applied on the globe.
Fig. 37.20 Once the fat is exposed, the fat is delivered through the
incisions to assess the amount to be resected.
Fig. 37.22 No closure is required if two separate incisions are made. If
a single, continuous incision is made, the wound is sutured.
Fig. 37.23 Transconjunctival blepharoplasty by the preseptal
approach: incision.

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VI Eyelid Surgery
compartments are exposed and trimmed if necessary, and then
the fat is mobilized over the orbital rim (Fig. 37.25).
This fat is retained over the rim by transcutaneous sutures. My
preference is 6–0 catgut, tied over a small pledget of petrolatum
gauze if needed. The suture is introduced through the lower lid
skin at the lid–cheek junction according to the preoperative mark-
ings (Fig. 37.26). The suture traverses the skin and orbicularis
oculi muscle (Fig. 37.27). It is then placed through the mobilized
periorbital fat below and then back through the orbicularis and
skin (Fig. 37.28).
Several sutures are placed and tied over the pledgets if needed.
Once the last such suture has been placed, the conjunctival incision
is then closed with an intraconjunctival suture so that there will be
no exposed sutures that could irritate the cornea (Fig. 37.29).
Postoperative Care
The patient’s head is elevated, and ice packs are placed on the
eyelids.
37.6.5 Results
The woman in her early 30s shown in Fig. 37.30 underwent
transconjunctival removal of fat from the lower eyelids. The dark
circles were ameliorated by the application of hydroxyquinone
skin bleach. Her postoperative result is shown several months
after the procedure.
Transconjunctival fat removal with erbium laser resurfacing
was performed on the lower eyelids of the woman in her forties
shown in Fig. 37.31. One year and 3 years postoperatively, she
Fig. 37.24 Transconjunctival blepharoplasty by the preseptal approach: placement of stay sutures and Desmarres retractor.
Fig. 37.25 Exposure and redistribution of fat.
Fig. 37.26 Retention of fat over the rim by transcutaneous sutures.
Fig. 37.27 Suture traverses the skin and orbicularis oculi muscle.

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demonstrated an average to below-average result because the
aging of the lid–cheek junction was not addressed through
the transconjunctival removal of fat from the lower eyelid. An
alternative approach would have been preseptal conjunctival fat
redraping over the lower lid–cheek junction.
The 70-year-old man shown in Fig. 37.32 requested improve-
ment of the fat bags in the lower eyelid. He wanted a simple
procedure with minimal recovery. Transconjunctival postseptal
removal of fat from the lower lid was done. The result shown
several months later demonstrates satisfactory reduction of the
fat bags, although the aging of the lower lid–cheek junction and
aging skin were not addressed.
37.7 Outcomes
The transconjunctival approach to upper and lower eyelid bleph-
aroplasty has been relatively trouble free. Complications involv-
ing exposure and lid retraction are extremely rare. Recovery
is rapid with little risk of chemosis. Postoperative swelling is
minimal compared to transcutaneous approaches.
Injuries to the levator aponeurosis in the upper eyelid resulting
in ptosis have not been reported. Although injury to the inferior
oblique muscle during transconjunctival lower lid blepharoplasty
has been reported, it is very rare, and I have not personally
encountered it. Although the muscle is always at risk when resect-
ing fat from the central and medial pockets, I do not think that this
risk increases with the transconjunctival approach.
37.8 Concluding Thoughts
The transconjunctival approach remains a safe and effective
method for eyelid recontouring, lid–cheek blending, and peri-
orbital rejuvenation. The approach offers little in the way of
orbicularis muscle reshaping, skin removal, or lid anchoring.
Modifications such as the skin pinch and approaching the orbicu-
laris and canthus through the upper eyelid have been described,
thus extending the indications for this approach.
Fig. 37.29 Once the last retaining suture has been placed, the
conjunctival incision is then closed with an intraconjunctival suture.
Fig. 37.28 The retaining suture is then placed through the mobilized periorbital fat below and then back through the orbicularis and skin.

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VI Eyelid Surgery
Fig. 37.30 (a,c) Woman in her early 30s pre and (b,c) several months post transconjunctival removal of fat from the lower eyelids and application of
hydroxyquinone skin bleach to the dark circles.
a
b
c
Fig. 37.31 (a,c) Woman in her 40s shown pre and (b,d) 1 year and (e) 3 years post transconjunctival fat removal with erbium laser resurfacing on her
lower eyelids. Procedure did not address the aging of the lid–cheek junction.
a
c
e
b
d

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Clinical Caveats
Upper lid:
• Only the nasal fat pocket can be approached through the
conjunctiva.
• Lateral extension of the conjunctival incision should be
avoided, because it may damage the levator aponeurosis.
• Ideal candidates are individuals with fat herniation of the
nasal fat pocket with no real skin excess.
Lower lid:
• The preseptal approach allows fat excision, fat redistribution,
and access to the midface.
• A postseptal approach allows fat removal only.
• The inferior oblique muscle separates the medial and central
fat compartments.
• A preseptal approach with fat redistribution is technically
challenging.
• Ideal candidates have excess fat with no real excess skin.
Suggested Reading
Upper Lid
>1@ Guerra AB, Berger A III, Black EB III, 1guyen AH, Metzinger RC, Metzinger SE. The
bare area of the upper conjunctiva: a closer look at the anatomy of transconjunc-
tival upper blepharoplasty. Plast Reconstr Surg 2003;111(5):1717–1722
>2@ Guerra AB, Metzinger SE, Black EB III. Transconjunctival upper blepharoplasty:
a safe and effective addition to facial rejuvenation techniques. Ann Plast Surg
2002;48(5):528–533
>3@ -anuszkiewicz -S, 1ahai F. Transconjunctival upper blepharoplasty. Plast Reconstr
Surg 1999;103(3):1015–1018, discussion 1019
>4@ .amer FM, Mingrone MD. Experiences with transconjunctival upper blepharo-
plasty. Arch Facial Plast Surg 2000;2(3):213–216
>5@ 1ahai F. Transconjunctival upper blepharoplasty: a safe and effective addition to
facial rejuvenation techniques. Ann Plast Surg 2002;49(2):215
>6@ Pacella S-, 1ahai FR, 1ahai F. Transconjunctival blepharoplasty for upper and
lower eyelids. Plast Reconstr Surg 2010;125(1):384–392
Fig. 37.32 (a,c,d) Man aged 70 pre- and (b,c,e) several months post transconjunctival postseptal removal of fat from the lower lids.
a
d
b
e
c

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Lower Lid
>7@ Baylis HI, Long -A, Groth M-. Transconjunctival lower eyelid blepharoplasty.
Technique and complications. Ophthalmology 1989;96(7):1027–1032
>8@ Bourguet -. 1otre traitement chirurgical de ´pochesµ sous le yeux sans cicatrice.
Arch Franco-Belges Chir 1928;31:133
>9@ de la Plaza R, Arroyo -M. A new technique for the treatment of palpebral bags.
Plast Reconstr Surg 1988;81(5):677–687
>10@ Goldberg RA, repositioning. Plast Reconstr Surg 2002;110(1):302–305, discussion 306–308
>11@ Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital
fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000;105(2):743–
748, discussion 749–751
>12@ Hidalgo DA. An integrated approach to lower blepharoplasty. Plast Reconstr Surg
2011;127(1):386–395
>13@ -ones GE, Trimble-Bried -, 1ahai F. Transconjunctival blepharoplasty: a clinical
experience. Perspect Plast Surg 1995;9(2):72–82
>14@ .awamoto H., Bradley -P. The tear ´TROUFµ procedure: transconjunctival repo-
sitioning of orbital unipedicled fat. Plast Reconstr Surg 2003;112(7):1903–1907,
discussion 1908–1909
>15@ McCord CD -r, Moses -L. Exposure of the inferior orbit with fornix incision and
lateral canthotomy. Ophthalmic Surg 1979;10(6):53–63
>16@ McCord CD -r, Shore -:. Avoidance of complications in lower lid blepharoplasty.
Ophthalmology 1983;90(9):1039–1046
>17@ Pacella S-, 1ahai FR, 1ahai F. Transconjunctival blepharoplasty for upper and
lower eyelids. Plast Reconstr Surg 2010;125(1):384–392
>18@ Sadove RC. Transconjunctival septal suture repair for lower lid blepharoplasty.
Plast Reconstr Surg 2007;120(2):521–529
>19@ Tessier P. The conjunctival approach to the orbital floor and maxilla in congenital
malformation and trauma. J Maxillofac Surg 1973;1(1):3–8
>20@ Tonnard PL, Verpaele AM, =eltzer AA. Augmentation blepharoplasty: a review of
500 consecutive patients. Aesthet Surg J 2013;33(3):341–352
>21@ =arem HA, Resnick -I. Expanded applications for transconjunctival lower lid
blepharoplasty. Plast Reconstr Surg 1991;88(2):215–220, discussion 221

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38 The Lower Eyelid Pinch Blepharoplasty
Lorne King RosenÀeld
Abstract
This chapter focuses on the surgical rejuvenation of the lower
eyelid by using an operative approach that at once delivers a more
aesthetic result with less complication compared with the tradi-
tional skin–muscle flap. Called the pinch lower blepharoplasty, it
can accomplish these better outcomes by enabling the surgeon to
take greater control of the lower eyelid. The pinch blepharoplasty
does so by offering three integral advantages: First, by preserv-
ing the eyelid’s structural middle lamella, it reduces the risk of
surgically induced dry eye or scleral show and promotes a faster
recovery. Second, the consistent integration of the stitch cantho-
pexy promises efficacious control of the tone and posture of the
eyelid and position of the canthus. Third, girded by this reliable
support, the crepiness, wrinkling, and even festooning can be
confidently recruited and treated and the orbital grooving effec-
tively effaced with a malleably robust, strategically positioned
pinch, without the need for release of the orbicularis retaining
ligament, adjuvant skin resurfacing, or grafting/filler treatments.
Effectively, this maneuver allows for a real-time, accurate assess-
ment and tailored adjustment of both the location and extent of
the pinch. And in doing so, the surgeon can remain confident that
this same pinch does not adversely impact but reliably preserves
the posture of the eyelid above. Ultimately, the pinch blepharo-
plasty abolishes the need for both early postoperative maneuvers
of taping and massage to address eyelid malposition and late
secondary interventions to clean up residual deformities.
Keywords
eyelid aging, eyelid rejuvenation, complications, scleral show,
dry eye, malposition, pinch blepharoplasty, stitch canthopexy,
eyelid posture, eyelid wrinkling, eyelid festooning, periorbital
grooving
38.1 Introduction
The lower eyelid blepharoplasty embodies a classic surgical para-
dox: the more one performs a complex surgery, the more respect
it ultimately commands. But that will happen only if the surgeon
critically assesses results. And when it comes to the skin–muscle
flap technique for the lower blepharoplasty, ignorance may be
bliss, but knowledge can be quite motivating
So, when I examined my own outcomes, I observed, not as
infrequently as I would have liked, two particular stigmata of a
less than perfect result at the lower eyelid. First, lingering crepey
skin was noted, most often in those with prodigious fat herniation
or skin wrinkling. And this scenario makes cogent sense when one
honestly considers how much skin is prudently not excised from
the truly bulky, relatively denervated, hard-fought skin–muscle
flap (Fig. 38.1).
Second, albeit mild but enduring scleral show was evident, often
preceded by weeks of overly optimistic eyelid taping and the like.
This outcome can equally be truthfully predicted if one concedes
all of the same unintended consequences of the skin–muscle flap
just described (Fig. 38.2).
I was compelled by these discomfiting observations to seek
an effective solution³a modified procedure that would at once
ensure optimal correction of the eyelid deformities and yet secure
normal eyelid posture. And so was born the pinch blepharoplasty.
My personal experience, now approaching 1500 cases, began in
2001 and was originally reported in 2005, confirmed the sound
safety and efficacy of this approach.
Although the true incidence of eyelid malposition after a
traditional muscle flap blepharoplasty is not well defined, the
plethora of articles on the subject attests to its persistence.
Scleral show has been ascribed to multiple causes: excess skin
removal, untreated eyelid laxity, denervation of the orbicularis
oculi muscle, and scarring of the outer or middle lid lamellae.
Fig. 38.1 This 48-year-old woman, (a) shown preoperatively and (b) 1 year after a traditional blepharoplasty, showing neglected redundancy of skin.
(Reproduced with permission from Rosenfield LK. The pinch blepharoplasty revisited. Plast Reconstr Surg. 2005; 115:1405-1412.)
a
b

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VI Eyelid Surgery
This postoperative problem may be considered subtle and indeed
is often not even acknowledged. But it is an undeniable, glaring
example of the ´operatedµ look that we should all strive to avoid.
And there is an equally prevailing blind spot within our literature
to the frequently incomplete removal of lower eyelid skin excess.
38.2 Birth of the Technique
There have been many valiant efforts to reduce the incidence
of eyelid malposition following traditional blepharoplasty. As
documented by =arem and Resnick, one approach has been to
forgo the skin incision entirely and approach the eyelid instead
through the conjunctiva only, thus definitively preserving the
integrity of the outer and middle eyelid lamellae. Although the
incidence of scleral show with this technique may be less, except
for the very young patient with nominal fat herniation and skin
wrinkling, even with natural shrinkage, redundant eyelid skin
will otherwise be left untreated, if not worsened by the proce-
dure’s inevitable eyelid ´deflation.µ
In an effort to mitigate this outcome, the addition of skin resur-
facing with a chemical peel or laser has been suggested. However,
unless the skin redundancy is quite modest, even this strategy may
not adequately treat the skin redundancy. Also, should the entire
face not be properly treated,, distracting lines of demarcation are
always possible. Additionally, if either of these therapies penetrates
too deeply, undesirable changes in eyelid posture may still occur.
:ith a skin–muscle flap, a relatively conservative resection
of the skin has always been advocated, regardless of the extent
of redundancy. Indeed, it is often impressive how little skin is
actually removed despite such an aggressive flap dissection. And
of course, in a patient with more significant excess skin, this con-
servatism has surely led to inadequate treatment.
Another adjunctive technique, particularly in the patient with
a lax eyelid, is to enhance canthal support by an iteration of can-
thoplasty or canthopexy. In principle, this strategy should ame-
liorate the incidence of lid malposition, but the results have been
frustratingly inconsistent: we have all seen scleral show after a
traditional blepharoplasty despite the addition of this attempted
canthal fortification. An inadequate canthopexy, overaggressive
skin resection, unavoidable muscle denervation, and middle
lamellar scarring can conspire to explain this unpredictability. The
deliberate placement of the skin–muscle incision more inferiorly
to preserve a wider remaining orbicularis strip of muscle may be
salutary but has not proven to be a dependable tactic.
Like so many of our ´advances,µ the aforementioned panoply
of frustrations with our traditional techniques simply led me to
resurrect a better idea. The pinching of the excess skin from the
lower eyelid is not a new concept: Parkes et al were actually the
first to suggest the technique, in 1973. However, their description,
which predated the transconjunctival approach, attenuated its
potential benefits with their division of the underlying orbicularis
muscle to retrieve the excess fat.
Then, in 1992, Dinner et al published a single case report on the
ultimate combination of the skin pinch with the transconjunctival
approach in what they called a ´no flapµ technique. Ristow included
a variation of the concept in Mimis Cohen’s 1994 textbook with a
direct, rather than ´pinchedµ skin resection, guided by a measured
and marked technique akin to traditional upper eyelid.
Ultimately, my actual impetus to revisit and refine the concept of
a pinch blepharoplasty did not arise from an exhaustive literature
search. Instead, primed with the aforementioned concerns, it
began with the serendipitous observation of one single slide within
a comprehensive presentation by Glenn -elks in 2000. The solution
became even more lucid considering our decades-old standard
approach to the upper eyelid blepharoplasty: we already measure
the extent of eyelid excess with a temporary skin ´pinchµ while
observing the effect on the eyelash and brow posture. :hy not
apply the same simple metric to the lower eyelid but with an actual
skin pinch" Thus was born the ´pinch blepharoplastyµ series.
38.3 Evolution of the Technique
First, the most important ´evolutionµ was that the pinch tech-
nique eventually fully displaced the skin–muscle flap approach
in my practice. From there, three additional seminal technical
tweaks were made.
1. Initially, as I reported, I did not invoke the stitch canthopexy in
patients who did not demonstrate obvious laxity or show. How-
Fig. 38.2 This 55-year-old woman, (a) shown preoperatively and (b) 1 year after a traditional skin–muscle lower blepharoplasty, exhibits scleral
show, a telltale postoperative residuum. (Reproduced with permission from Rosenfield LK. The pinch blepharoplasty revisited. Plast Reconstr
Surg. 2005; 115:1405-1412.)
a
b

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ever, before long I once again began to witness, even in these
patients, albeit not as severe or often, scleral show. Accordingly,
I have since integrated the canthopexy in all blepharoplasty pa-
tients with an incidence now of even mild show that approaches
zero. This strategy actually makes cogent sense when one con-
siders that any patient who presents with aging changes will per
force have laxity of their tarso-ligamentous sling.
2. Early in my experience, I found a subset of patients, particularly
the most wrinkled, who, despite the pinch excision, were still
left with some residual skin. Thus was born the planned, sec-
ond-stage ´re-pinch.µ
3. Despite its efficacy, this strategy did mandate a second inter-
vention, usually appended by a repeat stitch canthopexy. So, a
new tack was taken to endeavor to remove more if not all of the
redundant skin initially by gradually moving lower onto the eye-
lid and closer to the excess. This advance has indeed essentially
displaced the second-stage pinch while still delivering as incon-
spicuous a scar as before.
At this point in the evolution, I am now fully armed with a
maximally secured stitch canthopexy that in turn facilitates a
maximally confident pinch skin plasty, for not only the most
wrinkled but even the properly festooned.
38.4 Principles of the Technique
From its birth and evolution, this technique is girded by three
principles:
1. The first guiding premise is that one need not widely under-
mine tissue in order to recruit, excise, and otherwise treat its
excess. Instead, this excess is most efficiently removed by either
drawing the tissue in the same vector of its excess and/or ex-
cising it through an incision perpendicular to the excess. In the
case of lower eyelid wrinkling and the pinch skin plasty, both of
these maneuvers are employed: the vertical excess is effectively
captured by its naturally facile recruitment vertically and ex-
cised through a conveniently well-hidden incision horizontally
(Fig. 38.3).
This same principle is inherent in the powerful lateral
recruitment of neck skin in the pinch rhytidoplasty and in the
effective discontinuous dissection and advancement of skin in
the high tension abdominoplasty, as originally described by
Lockwood. In effect, the smoothing of lower eyelid wrinkling
may be analogized to the making of a rumpled bed (Fig. 38.4).
2. The second fundamental precept is that the inherent sup-
port within a structure must be strengthened before a load
should strain it. So, in the instance of the lower eyelid, before
the ´weightµ of any surgery should test this retinacular sling, it
should first be tightened: hence, the efficacy of the stitch can-
thopexy girding the eyelid prior to the pinch skin plasty. Effec-
tively, this maneuver is analogous to tightening a clothesline
before placing a load of wet garments on it (Fig. 38.5, Fig. 38.6).
Fig. 38.4 (a,b) Demonstration of the pinch skin plasty effectively
“making the bed” at the lower eyelid.
a
b
Fig. 38.3 Demonstration of the principle that vertical skin excess
is most effectively removed by its vertical recruitment through a
horizontally oriented skin pinch.

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VI Eyelid Surgery
3. The third motivating tenet is that to achieve maximal eyelid cor-
rection, the most effi cacious tactic is to gravitate inferiorly and
pinch more of where the excess skin actually lives. This strategy
is akin to most eff ectively pulling a roll out of a living room car-
pet by doing so at the end nearest the excess.
38.5 Advantages
The true measure of success of any aesthetic surgical procedure
should be its ability to balance two goals at the same time: to
deliver better aesthetic results consistently whilst ensuring
maximal safety. My personal experience, now approaching 1500
pinch blepharoplasties, confi rms that this approach is indeed
capable of simultaneously honoring those lofty goals as com-
pared with the traditional skin–muscle fl ap technique. This vari-
ation off ers two distinctive advantages: more crepey skin can be
safely removed while an aesthetic eyelid posture is secured.
This rewarding marriage of these outcomes is primarily the
result of the inherent precision and power of the pinch technique.
The approach enables the surgeon to defi ne more accurately and
execute, in real time, the maximal prospective skin resection
possible without aff ecting eyelid posture. The pinch technique
protects the eyelid and its posture on several fronts: it avoids the
creation of the bulky skin–muscle fl ap, which encourages both
excess swelling and attendant vertical traction, and it eschews the
violation of the orbicularis muscle and orbital septum, which can
lead to lid denervation and scarring.
Another reason for the improved aesthetic results is the often
seen amelioration of the eyelid–cheek groove with a more youth-
ful vertical shortening of the eyelid, secondary to the ´eff acingµ
Fig. 38.5 Illustrating how the stitch canthopexy girds the eyelid before the pinch plasty, akin to the tightening of the “clothes line.”
Fig. 38.6 Illustrating the third pinch principle.

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effect of this deficiency by the overlying redraping with the more
complete skin resection.
These benefits translate into a more adaptable and consistent
blepharoplasty. And in so doing, the surgeon can forgo the need
for additional, more invasive procedures, such as fat grafting and/
or ORL release. This advantage is seen most gratifyingly in many
of our most both challenging and deserving patients: the morpho-
logically challenging with a negative vector and poor lid posture;
older patients with poor lid tone; those with extensive skin or fes-
toons; and younger patients with primary skin redundancy and
nominal excess fat. If there is asymmetric excess skin between
eyelids, or even within one eyelid itself, the pinch can be tailored
accordingly. Empowered with this versatile tool, the surgeon can
now treat, for example, the medial eyelid skin, a zone that was
traditionally neglected, for an even more complete result (often
including improvement of the nasojugal grooving). In addition,
because the skin excess is more thoroughly treated, the surgeon
can avoid the need for regional laser or other resurfacing of the
eyelid, with its added risks and period of healing and attendant,
often distracting lines of demarcation.
Moreover, in patients with an ample excess of skin and or even
proper festooning, the advantages of the pinch blepharoplasty
can be maximized with a more inferiorly placed eyelid pinch of
skin, to excise even more skin. This ´mid-eyelidµ pinch simply gets
closer to the excess, amplifying the pinch’s efficacy. Additionally, if
indicated, one can invoke a staged reapplication of the pinch. This
repinch can be accomplished quite simply, with a local anesthetic.
Thus, it is feasible to remove all crepey skin at the lower eyelid
safely.
38.6 Indications and
Contraindications
The pinch lower blepharoplasty can comfortably replace the
standard skin–muscle flap technique and be offered to the same
group of patients. In contrast to the standard technique, there
is a productive breadth of application, depending on the extent
of the patient’s problem. That is, all patients are candidates, but
some are better candidates than others. Although results will
be superior in all patients, defining the best and worst patient
candidates for the pinch most effectively illustrates the nuances
of the technique.
The ideal patient presents with abundant thin, crepey skin,
minimal excess fat, and morphologically advantageous anatomy
(such as high cheekbones and almond-shaped eyes). :ith the
application of the pinch, the improvement achieved in these
patients can be dramatic, simply because the surgeon is able to
treat the eyelid more fully (Fig. 38.7).
At the opposing end of the spectrum, the imperfect patient is
one with thicker, sun-damaged skin, which clearly will not ´pinchµ
well (but is as equally a poor candidate for any surgical technique).
In these patients, it is best to plan the surgery so that the skin will
have the least distortion from local anesthetic so one may apply
the pinch most effectively (Fig. 38.8).
Because such a dramatic skin resection can be wielded with
this approach, the surgeon must be cautious when applying the
pinch to a patient with equally significant redundant fat, because
enough of this skin must remain to redrape the now less convex
lower eyelid.
38.7 Pertinent Anatomy
The essence of the pinch technique embodies a key anatomic
principle: to violate the eyelid anatomy as little as possible and,
if it is compromised by age and/or genetics, to rehabilitate it as
much as possible. Between the transconjunctival approach and
the pinch technique, this approach touches and takes only what
it needs to³the skin³leaving behind the critical neuromechan-
ical support: the orbital septum, the orbicularis muscle, and its
attendant nerves.
As for the canthopexy, the key anatomic principle is to keep
it simple. Because the lateral canthus truly comprises several
components and is not easily identified as a distinct structure,
the canthopexy has to become a kind of maneuver ´on faithµ: you
can only really ´feelµ its presence. That is, rather than trying to
painstakingly dissect and actually visualize the canthal tissues
themselves, the surgeon need only grasp and draw whatever
tissue is present in the area to know that the ´right stuffµ has been
Fig. 38.7 This 58-year-old woman demonstrates the “ideal” patient:
minimal fat, good morphology, and thin, crepey skin. (Reproduced
with permission from Rosenfield LK. The pinch blepharoplasty
revisited. Plast Reconstr Surg. 2005; 115:1405-1412.)
Fig. 38.8 This 57-year-old woman exhibits the leathery, sun-damaged
skin that can resist the usual satisfying skin pinch.

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VI Eyelid Surgery
captured. Then the strategy simply becomes a matter of manip-
ulating this anchor thoughtfully to perform an individualized
canthopexy.
38.8 Preoperative Assessment
38.8.1 History
The key to a better history in this and any aesthetic patient is to
glean all relevant information beyond the problem at hand, fiUVW.
This becomes particularly pivotal since blepharoplasty patients,
by definition, are often more elderly and thus carry more his-
tory: such as other systemic diseases, skin cancers, smoking
or other drug addictions, or anesthetic and anesthesia issues.
Then there are several critical, site-specific historical points to
be gleaned, including a history of eye dryness, tearing, or the
need for drops; allergies; Graves disease; prior eyelid surgery;
and previous filler injections (hyaluronic acid >HA@, etc.) or
autologous fat grafts.
38.8.2 Physical Examination
The preoperative physical examination should include the same
component analysis as for any blepharoplasty. However, with
this approach the pinch allows one to modify the surgery to
match the patient’s problem, so the value of a detailed analysis is
even more rewarding.
The critical elements to evaluate are listed in the box.
Critical Factors to Assess in the Physical
Examination
• The extent of the redundant skin: If necessary, either a lower
pinch at the time and/or a staged second pinch procedure
is planned. This is particularly relevant in the patient with
significant “active” skin: exaggerated wrinkling on animation
or frank festooning.
• The extent of the redundant fat: Depending on the volume
of excess, more or less skin should be pinched to ensure that
enough skin is left behind.
• The degree of lid laxity and attendant scleral show (as eval-
uated by a snap/distraction test et al): This can be treated
efficiently with a stitch canthopexy.
• The level of the lateral canthus (canthal tilt): The canthal
position can be adjusted relatively precisely with the stitch
canthopexy.
• The vector angle of the globe to the malar (positive/neutral/
negative): This aids the surgeon in the design of the best
application of the pinch and canthopexy components of the
surgery.
38.8.3 Photography
There are several tenets to be followed for photographic evalua-
tion of the eyelids and documentation of the results.
Prevent Parallax Error
Parallax error refers to the distorting difference in the apparent
position of an object when viewed along two different lines of
sight. Thus, in order to avoid parallax error, photographs must
be taken with the patient and surgeon seeing ´eye to eyeµ; that
is, there should be no height discrepancy that could potentially
distort the appearance of the posture of the lower eyelid in
relation to the globe.
This problem can be manifested when either the patient is not
level or the camera is not level. These effects can either mask or
exaggerate the actual eyelid position (Fig. 38.9).
%eZDre RI WKe ´0RrR 5eÁe[µ
:hen a tighter photo of just the eyelids is taken, some patients,
responding to the flash’s effect, may widen their eyes dramati-
cally. If this is noted, pulling the camera back to include a full-
face picture should correct this distortion (Fig. 38.10).
Follow the Dermatologist’s Credo
To document the salutary effects of the pinch procedure accu-
rately, progressively closer pictures of the face should be taken,
from full face to true close-ups of the wrinkles at the lower eyelid
(Fig. 38.11).
Control the Patient’s Emotions
There is a place for both active and passive photographs of a
patient’s lower eyelid. Photos should be taken of the patient smil-
ing to define the extent of muscle–skin excess. Often orbicularis
wrinkling is the patient’s primary concern, and any correction
of this problem is a true measure of the technique’s efficacy.
However, a smile can camouflage an eyelid posture or scleral
show problem (Fig. 38.12).
Compare the Present with the Past
The patient should be asked to bring photographs from the
past (such as college or wedding photos or well-focused candid
photos). The insight gained from reviewing such historic images
is invaluable not only for observing changes in the characteris-
tics of the periorbital area but also in our attempt to recapture
the patient’s characteristic expression or persona.
38.8.4 Patient Education
A patient with significant wrinkling must be informed that
either a more inferior and/or a second pinch blepharoplasty may
be necessary. The goals and actions of a canthopexy should be
explained, because in some instances the palpebral fissure will
purposely become more almond-shaped.

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Fig. 38.10 Photographs demonstrating the obvious infl uence of the camera fl ash on eyelid posture depending upon its distance from the subject.
Fig. 38.9 Patient poses (above) and camera positions (below) that can aff ect the evaluation of eyelid posture, whether pre- or postoperatively.

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VI Eyelid Surgery
38.9 The Procedure
38.9.1 Sequencing of Procedure
Following a proper sequence of steps in the pinch blepharoplasty
is critical if both predictable and maximal results are to be
realized:
1. Mark an eyelid ´pinch line,µ running horizontally from medial to
lateral, as close as possible to the preponderance of excess skin/
wrinkles.
2. Place no local anesthetic, if patient is under general or deep
anesthesia, or do so early (e.g., before the facial prep) to allow
the skin to return to a ´naturalµ state in order to ensure maximal
control at the time of its pinch.
3. Conduct the upper eyelid blepharoplasty next, leaving the
wound open in anticipation of the canthopexy.
4. Complete the transconjunctival portion of the lower blepharo-
plasty, before the pexy, to ensure facile distraction of the eyelid.
5. Perform the stitch canthopexy through the upper eyelid wound
(or a 1-cm or so lateral upper eyelid counterincision), before the
pinch, since some measure of lower eyelid skin may be ´treatedµ
with this maneuver.
6. Close the upper eyelid wound, before the pinch, as once again,
lower eyelid excess skin will be drawn by this step.
7. Perform the lower eyelid pinch procedure, as proximate to the
excess as possible and close the wound.
38.9.2 Details of Procedure
Protection
Corneal shields are placed at every facial case, whether or not an
eyelid surgery is conducted. It is prudent to utilize evaginated
shields, sporting an expanded cupula that promotes better
oxygenation of the cornea, particularly for more lengthy cases.
Fig. 38.12 Demonstration of how a smile can at once prove the significant improvement of orbicularis muscle effect with the pinch procedure and
deceive with the “correction” of a subtle scleral show.
Fig. 38.11 Deliberately macro (a) pre and (b) post photo-documentation to more clearly demonstrate the effect of the pinch plasty on skin wrinkling,
with minimal scarring.
a
b

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Markings
Mark a guiding ´pinch lineµ along the lower eyelid, representing
the uppermost margin of the future excision. Medially, this line is
usually placed several millimeters from the ciliary margin, con-
tinuing in a straight line laterally, deliberately leaving a progres-
sively enlarging triangular island of intact skin reaching 5 mm in
minimum height below the lateral eyelid margin. This maneuver
further discourages scleral show by lessening the purse-string-
like scar contracture that may occur with a curvilinear incision
hugging the ciliary margin (Fig. 38.13).
However, the latitude of this line should be modified depending
on the location and quality of the excess skin. That is, the pinch
line could and should be moved progressively lower on the eyelid
when there is more excess skin, to chase the excess and facilitate
maximal skin removal. ´I go lower on the eyelid because that’s
where the excess skin isµ (to paraphrase :illie Sutton). As long
as the final closure rests within the eyelid tissue proper, the scar
will remain as reliably imperceptible as all scars in this anatomic
zone (Fig. 38.14). In addition, by doing so, the nasojugal-orbital
grooves can often be simply and gratifyingly treated as well.
Local Anesthesia
After the markings, the surgeon applies local anesthetic every-
where but at the lower eyelid skin. Otherwise, it should be placed
early and judiciously to both minimize the amount of local
swelling and maximize its resolution.
Upper Blepharoplasty
If the upper eyelid is to be rejuvenated simultaneously, that pro-
cedure should be performed first. 1ormally just the premarked
excess skin is resected, preserving more or less of the underlying
muscle, depending upon the ´heavinessµ of the eyelid. Then
the underlying orbital fat is usually conservatively treated by
´contractionµ with the electrocautery or, as indicated by direct
excision, most often just at the medial pocket. The upper eyelid
wound is purposely left open to allow access for the later can-
thopexy. If an upper blepharoplasty is not planned, then a lateral
1-cm counterincision is made within the outer portion of a
routine upper eyelid marking.
Transconjunctival Surgery
The transconjunctival portion of the procedure is best conducted
next, preceding the canthopexy, lest the surgeon have difficulty
distracting the tightened eyelid. :ith two double hooks for expo-
sure, the conjunctiva is broadly incised, at least 5 mm superior to
the sulcus, with a needle-tipped electrocautery. Once identified,
the excess fat, just as in the upper eyelid, is conservatively either
trimmed or electrocauterized and the wound reapproximated at
its midsection with a 6–0 fast-absorbing catgut suture.
Stitch Canthopexy
The canthopexy should be performed next, before the lower
eyelid pinch procedure, because the potential lateral lift of the
pexy can treat a measure of the lower eyelid excess.
I distinguish two kinds of canthopexy to consider and execute:
prophylactic and therapeutic. The choice is primarily determined
by two factors: the position of the lateral canthus and the posture
and tone of the lateral lower eyelid. If the lateral canthus is at or
above the horizon and/or the lower eyelid tone is mildly weak
without scleral show, a prophylactic pexy is in order. If, instead, the
lateral canthus is at or below the horizon and/or the lower lateral
eyelid tone is measurably weak with scleral show, a therapeutic
lateral canthopexy should be performed. :ithin the therapeutic
category, this repair can be functional, to correct a weaker eyelid,
and/or aesthetic, to create a more almond-shaped eye.
In either case, the procedure is conducted through the lateral
aspect of an upper blepharoplasty incision or, if an upper bleph-
aroplasty is not planned, through a counterincision: using the
Bovie, a segment of approximately 1 cm of the superolateral inner
orbital rim is exposed, with great care to preserve the integrity of
the periosteum, which will be relied upon for the ultimate pexy
stitch (Fig. 38.15).
Fig. 38.13 A purposeful straight line of marking is designed to leave
a margin of intact skin that is wider (at least 5 mm) laterally than
medially as an added antidote to the inherent effects of scarring and
potential outcome of scleral show. (Reproduced with permission
from Rosenfield LK. The pinch blepharoplasty revisited. Plast
Reconstr Surg. 2005; 115:1405-1412.)
Fig. 38.14 (a) This patient has significantly more wrinkling than the
patient shown in Fig. 38.12. (b) The marking and resultant pinch are
intentionally set almost twice as far inferiorly to chase and treat the
excess skin on the eyelid more effectively, in one stage.
a
b

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VI Eyelid Surgery
1ext, a subfascial/submuscular ´tunnelµ is created between the
orbital rim and the lateral canthus using round-tipped iris scissors
(Fig. 38.16).
:ith the index finger of the nondominant hand over the lateral
canthus, the lateral canthal tissue is then captured using a very
fine-tipped, curved mosquito clamp (Fig. 38.17).
Then, prior to committing the anchoring of the pexy, slight
traction is made on first the mosquito and then the suture to con-
firm the adequate, but not excessive, correction of eyelid posture
and canthal position as necessary (Fig. 38.18).
If a prophylactic canthopexy is planned, the mosquito clamp
tip is passed up to the orbital rim to determine the ideal pexy
location, which will at once effectively tighten the lower eyelid
and still maintain the canthal angle.
If a therapeutic pexy is desired, the mosquito clamp tip is
placed more superiorly on the orbital rim as needed to realize the
desired correction of the eyelid posture and/or canthal position. If
some resistance is felt when doing so, then the canthal tissues, still
within the grasp of the mosquito, can be gradually released with
a scissors or Bovie, essentially performing a gradated cantholysis.
This maneuver should be conducted with the mosquito on some
tension so that the surgeon can ´proprioceptivelyµ conduct a
controlled liberation of the canthus. At most, a partial release is
usually all that is necessary to treat the eyelid properly and still
thwart its overcorrection.
The canthopexy is sutured in place by taking a double bite of
the captured canthal tissue with a 5–0 clear nylon suture and
securing this tissue to the periosteum within the orbital rim. Of
technical note, if the surgeon is right-handed and standing fully at
the patient’s left side, the needle may erroneously be passed from
top down at the periosteum, resulting in the suture potentially
tearing out as it is tied. Thus, it is best, on this side, to deliberately
stand behind the head of the patient in order to pass the needle
more naturally from the bottom up along the orbital rim to ensure
a proper ´throwµ of the suture. Of course, this applies in reverse,
at the right eye, for a left-handed surgeon.
The canthopexy is shown here before and after it is secured.
Either opaque scleral protectors may be removed or transparent
scleral protectors employed to facilitate evaluation of the outcome
of the pexy stitch.
The surgeon can then evaluate the efficacy of the pexy on eyelid
tone by conducting an immediate distraction test. An intraoper-
ative distraction test is shown before and after the canthopexy
(Fig. 38.19). Based upon these assessments, the suture should be
reapplied if the desired lid tightening and/or canthal positioning
effect has either been unrealized or exaggerated.
38.9.3 Pinch Skin Plasty
If no local anesthesia was initially placed and the patient is not
under general anesthesia, a bolus of intravenous sedation medi-
cation is given in anticipation of the pinch procedure. Then, using
two fine Adson-Brown forceps, the eyelid skin is progressively
pinched along the strategically chosen premarked line to capture
the maximal amount of excess, creating a proportional standing
´wallµ of skin (Fig. 38.20). The endpoint should be the maximal
recruitment of wrinkled skin resting primarily below while still
preserving a normal posture of the eyelid margin above. That
said, in the less common instance of significant wrinkled skin
above the pinch marking, this tissue can certainly be included
in the pinch (Fig. 38.21). An additional goal and outcome of
the pinch can be the simultaneous salutary effacement of any
orbital/nasojugal grooving that may be present.
Fig. 38.15 Through the lateral upper eyelid wound, careful dissection
to expose intact the lateral orbital periosteum, which will be crucial for
anchoring of the canthopexy.
Fig. 38.17 The micro-tipped mosquito clamp is seen capturing the
canthal tissues in preparation for the pexy.
Fig. 38.16 The path for the future capture of the canthal tissues is
made.
Fig. 38.18 Visual confirmation of the potential effect of the cantho-
pexy before it is permanently anchored to the orbital rim.

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Fig. 38.21 (a–d) Demonstration of progressively more inferiorly situated pinch walls depending upon the location and extent of the deformity to be
corrected. (Reproduced with permission from Rosenfield LK. The pinch blepharoplasty revisited. Plast Reconstr Surg. 2005; 115:1405-1412.)
a
c
d
Fig. 38.19 Additional confirmation, after the fixation of the cantho-
pexy, of an effective correction of lid laxity.
Fig. 38.20 The two Adson-Brown forceps progressively and differen-
tially gather the excess to the other, to ultimately create a “skin wall.”
b

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VI Eyelid Surgery
Once the wall of skin is created, it is essential that its excision
take place in relatively rapid succession before it naturally recedes.
A fine forceps is used to deliver traction at an oblique angle and
then a straight pair of ´supercutµ type scissors is employed to
amputate the skin wall at its base, in the fashion of excising a skin
tag³that is, not so superficial that excess tissue is left behind, but
not so deep that adjacent skin is inadvertently excised (Fig. 38.22).
The appropriate amount of skin has been removed if the wound
edges are properly kissing or at least proximate (Fig. 38.23).
Otherwise, in the very occasional instance that there is obvious
remaining excess, the surgeon can return with the same scissors
to trim any obviously still pinched skin judiciously. In what should
be truly a rare predicament, should too much skin have been
excised, the extracted skin would probably best be replaced as a
skin graft.
Prior to closure, the wound is purposely splayed open, both to
electrocoagulate any small bleeding vessels as well as to infuse
some local anesthesia with epinephrine if none had been initially
(Fig. 38.24, Fig. 38.25). The incision is closed with a 7–0 running
nylon suture. 1o taping or other support of the eyelids is neces-
sary postoperatively.
38.10 Ancillary Procedures
Except for those with truly advanced states of excess, in the
vast majority of patients, since the pinch blepharoplasty treats
the wrinkled excess skin at the lower eyelids so much more
comprehensively, the usual adjunct modalities, such as resur-
facing or peeling, are essentially never necessary at the primary
surgery and still only very rarely at a second stage treatment.
In addition, even though the aggressive removal of excess skin
from both the upper and lower eyelids does indirectly soften the
expression of the crow’s feet, a regular regimen of neuromodula-
tors is still usually necessary postoperatively. Finally, as has been
mentioned, with the now more inferiorly placed and ambitiously
conducted lower eyelid pinch, the naso-jugal-orbital grooving
is often effectively corrected by the effacement of the overlying
skin. Otherwise, if particularly recalcitrant, this grooving is
treated, sometimes intraoperatively but usually postoperatively,
with an injected dose of diluted HA.
38.11 Postoperative Care
Patients are started on iced cotton eye soaks during the surgery
itself. If the eyes are iced early and often, there will be reliably
less swelling and bruising. The patient performs this same icing
routine continually for the first 48 hours, with intermittent
breaks and then more on and off for an additional 3 days. Then,
by the fifth day, the sutures are usually removed and intermittent
warm compresses are started for the next 5 days. Of note, with
this technique, a taping and/or massage protocol is unnecessary.
In addition, herbal products (Arnica montana and bromelain) to
reduce bruising and swelling are given for the first 2 weeks post-
operatively. At 2 weeks after surgery, the patient may gradually
return to routine exercise over the subsequent 4 weeks.
The definitively greater efficacy of a ´lower on the eyelidµ pinch
has essentially replaced the need for my originally recommended
staged ´repinch.µ If a repinch is still deemed necessary, however,
it is best to wait at least 6 months for definitive healing. This stage
can be performed under local anesthetic with diazepam (Valium)
as necessary. If there is more than a minor amount of residual
redundant skin, then a repeat canthopexy is advisable to facilitate
a confident reapplication of the pinch.
38.12 Problems and Complications
The pinch blepharoplasty is a re-engineering of the traditional
blepharoplasty’s ´D1Aµ in order to prevent its equally traditional
complications and shortcomings. Thus, scleral show, eyelid
malposition, dry eye, and residual eyelid wrinkling are now very
rare occurrences. Accordingly, postoperative taping and massage
need no longer be a ´usual and customaryµ step in the care of
the blepharoplasty patient. Concomitant resurfacing treatments
have also become unnecessary with this more complete treat-
ment of the eyelid redundancy.
However, some issues, albeit minor, are unique to the pinch
blepharoplasty and should be highlighted:
1. Visible knot: If a nonabsorbable nylon-type suture is used for
the canthopexy, care should be taken, particularly in the thinner
patient, to ensure that the knot rests on the inside of the orbital
rim and that the suture is cut close to the knot, to prevent its po-
tential visibility through the upper eyelid skin. If, despite these
efforts, the suture becomes visible, it has been clipped shorter
early in the postop course or even extracted with impunity after
3 months. I tried a braided fiber suture in an effort to avoid this
potential problem, but after two cases of stitch abscess mandat-
ing extraction, I returned to the clear nylon.
2. Reddened scar: :hen the pinch is purposely performed lower
on the eyelid to maximize wrinkled skin removal, a reddened
scar will initially, per force, be more visible. The patient should
be duly informed of this and the fact that these same scars do
uniformly mature inconspicuously. In fact, as I tell my patients,
in contrast to the upper eyelid, I have never had to revise a lower
blepharoplasty pinch scar.
3. Lateral chemosis: Although it is not necessarily specific to the
pinch blepharoplasty, a lateral chemosis may result postsurgery.
Its exact etiology remains annoyingly unknown, but it is my and
others’ impression that canthal manipulation of any time may
be one of its contributing factors. This problem is always self-
limiting within a few weeks, but its resolution should be facili-
tated with a postoperative regimen of a combination antibiotic
and steroid drop and ophthalmologic guidance if it unduly per-
sists. If it is seen intraoperatively, phenylephrine drops can be
started right away for potentially immediate relief. To obviate
this nuisance problem, it is best to strive to capture the canthal
tissue with your first and only bite.
4. Fat necrosis: Like lateral chemosis, this problem is not directly
due to the pinch procedure, it may occur after fat manipulation
through the lower eyelid transconjunctival portion of the proce-
dure. That is, if the electrocautery either following or instead of
excision of the fat is too enthusiastic, one or more firm nodules
can, albeit very rarely, present themselves either early or, less
commonly, late postoperatively. :atchful waiting over several
weeks has resulted in spontaneous resolution in the couple of
instances seen in my series.
5. Pexy variability: Finally, if performed too aggressively, the can-
thopexy can produce an overly corrected result. Usually this
effect will improve over the first few weeks postoperatively.
On the other hand, if the pexy is not harnessed adequately, the
patient may be left with a canthal or lid deformity mandating a

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second repair. The best preventive maneuver is to deliberately
pause and critically assess the pexy result at surgery and redo
the repair as needed until it is right.
38.13 Outcomes
The foundation of this modification of the lower blepharoplasty
is built on a triad of maneuvers:
1. The deliberate preservation of the eyelid’s integrity, with inher-
ently less invasion, through the use of the transconjunctival ap-
proach
2. The mindful alignment of the canthus and the lower eyelid with
respect to the orbit and globe respectively, with the application
of the stitch canthopexy
3. The proficient excision of the redundant skin, with a tailored
accuracy, by the robust harnessing of the pinch technique
These same strategies deliver three reliable outcomes:
1. Attenuation of postoperative swelling and bruising on account of
this technique’s inherently ´kinder, gentlerµ approach
2. Both prevention and treatment of eyelid malposition and can-
thal displacement with a discerning application of the malleable
stitch canthopexy
3. Reduction in residual excess skin secondary to the flexibility
and horsepower of the skin pinch approach while maintaining
inconspicuous scarring
Together these efforts consistently deliver a salutary removal of
redundant skin of the eyelid while still safeguarding its posture.
Fig. 38.22 Excision of the pinch wall with dedicated supercut scissors
angled slightly upwards to control the exact resection of only the skin
pinched and no more.
Fig. 38.24 Splaying the wound open, demonstrating both the minimal
bleeding post pinch and the primarily intact orbicularis muscle.
Fig. 38.23 Ideally, if there is no visible or only a nominal wound cre-
ated immediately following the pinch, this finding definitively confirms
that the proper amount of excess skin has been excised.
Fig. 38.25 Illustrating the usual extent of the wound post pinch
(10–15 mm).

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VI Eyelid Surgery
In fact, with greater comfort performing the stitch canthopexy,
the surgeon can often go one step further and create a subtle,
more aesthetic shape to the otherwise normal lower eyelid. On
the other hand, particularly in a morphologically challenging
patient, the canthopexy may definitively correct the attendant
canthal deformity. If the pinch is deliberately placed more infe-
riorly, closer to the excess, most if not all of the redundant skin
can be captured without the need for my originally described
second-stage ´repinch.µ
These examples demonstrate the following:
1. Decidedly less bruising and swelling and, thus, faster healing
with the less invasive pinch blepharoplasty (Fig. 38.26, Fig.
38.27)
2. The extent of skin excision possible with the pinch technique,
averaging from 5 to 20 mm, increasing in size when challenged
by greater degrees of excess skin and wrinkling, which in turn
navigates the pinch ever lower on the eyelid (Fig. 38.28)
3. The reliable production of nominal scarring even when the skin
pinch is conducted at a lower ´latitudeµ on the eyelid to capture
the excess skin more productively (Fig. 38.29)
38.14 Results
The following cases were chosen to demonstrate the flexible
power of the pinch procedure given various patient presenta-
tions³from the ideal candidate to the most challenging, from the
elderly to the youthful.
Fig. 38.27 Postoperative appearance at 2 weeks.
Fig. 38.26 The typical early appearance of a postoperative patient is
shown at (a) 5 days and (b) at 10 days.
a
b
Fig. 38.28 (a–c) Demonstrating typical pinch wounds resting higher
or lower on the eyelid depending upon the extent and location of the
excess skin.
a
b
c

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38.14.1 The Ideal Patient
The best patient to choose as an inaugural application of the
pinch blepharoplasty technique is an older patient who has thin,
fair skin, minimal fat herniation, moderate wrinkles, and good
eyelid tone and facial morphology.
38.14.2 The Festooned Patient
Patients with proper festooning, with cascading excess skin
encroaching the cheeks, have always represented a surgical
challenge. However, with the full-on application of the pinch
blepharoplasty, these cases can be corrected with both maximal
aesthetics and safety (Fig. 38.30).
38.14.3 The Elderly Patient
The key concern with the elderly patient is their inherent tarsoli-
gamentous laxity of the lower eyelid and its attendant risks when
strained by a lower blepharoplasty surgery: from distracting
scleral show to symptomatic ectropion. The goal, therefore, must
be to address this vulnerability proactively before attempting to
correct the aging changes. It is just this kind of scenario where
the pinch blepharoplasty shines.
38.14.4 The Aging Patient
The middle-aged patient who presents with the beginnings of
facial aging can be desirous of its complete correction but equally
fearful of its looking overdone. The pinch blepharoplasty, with its
protective but still comprehensive strategies, reliably addresses
both of these issues.
The 53-year-old woman shown in Fig. 38.31 with the classic
stigmata of aging would previously have undergone a routine
blepharoplasty with CO2 laser or chemical resurfacing. Instead, an
upper and lower pinch blepharoplasty was accomplished with a
conservative transconjunctival fat reduction, a therapeutic stitch
canthopexy to restore her albeit nascent senescent eyelid show,
and a confident pinch plasty to smooth out her lower eyelid. The
result hearkens back to her youthful aesthetics as seen in the
picture from her early 20s.
38.14.5 The Younger Patient
Patients between 35 and 45 years of age who present with nascent
but very real signs of aging and are often frustrated by the lack of
definitive results with nonsurgical treatments and still desirous
of both a proper correction and attenuated downtime can now
Fig. 38.30 (a) This 64-year-old patient underwent a comprehensive transconjunctival fat trimming and a notably robust pinch plasty (over 15 mm)
effectively performed with its placement at the mid-eyelid and confidently executed with the support of a secure stitch canthopexy. (b) The result
reveals a relatively “complete” repair not only of the skin but of the orbital groove as well. These lower pinch placements still consistently deliver, as
seen here, as an inconspicuous a scar as any other.
a
b
Fig. 38.29 (a,b) Inconspicuous scar, resting practically in the middle of the lower eyelid, is the vestige of a more robust treatment of the excess
skin—a particularly powerful strategy in men.
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VI Eyelid Surgery
be offered a solution that efficaciously marries the extent of the
solution to the extent of the problem: the pinch blepharoplasty.
38.14.6 The “ Orbitally-Grooved”/
“Dark-Circled” Patient
Orbital-nasojugal grooving can be either an earlier or a later
distracting sign of aging and fatigue. Again, there are as many
contested solutions to the problem as there are many suspected
causes. However, one can often avoid the direct treatment with
fillers or fat, with the attendant risks and inconsistencies, by
the effacing effect of the pinch skin plasty in combination with
the softening influence of a conservative excision of ´overhang-
ingµ fat.
Often in tandem with the grooved patient is the common
adjunct complaint of darkly colored lower eyelids, which falsely
project the appearance of tiredness. There are again as many
suspect sources of this problem, including hypervascularity,
thin skin, and true hyperpigmentation, as there are imperfect
solutions, such as laser treatment, medicinal depigmentation, and
camouflage makeup. A consistent additional factor, however, is
the excess shadowing caused by the peaks and valleys of crepey
skin. :ith the proper mobilization of the pinch technique, this
offending crepey skin can be essentially effaced, delivering a
satisfying reduction in this shadowing and dark circles (Fig. 38.32,
Fig. 38.33).
38.14.7 The Younger Congenital Scleral
Show Patient
The younger patient can present with ´congenitalµ scleral show
that would otherwise be ascribed to eyelid laxity later in life.
These patients should thus be afforded a ´therapeuticµ stitch
canthopexy to restore the more natural, aesthetic almond-
shaped eye with a pinch skin plasty as indicated (Fig. 38.34).
38.14.8
The Morphologically
Compromised Patient
Patients who present with all the attributes of ´poor designµ³a
lax eyelid with show, negative canthal cant, and a flat cheek with
a larger globe³are always at risk of suffering the full spectrum
of eyelid posture complications following the routine blepharo-
plasty, from detracting scleral show to debilitating ectropion.
However, a reliable antidote to this scenario is the proper har-
nessing of the pinch blepharoplasty with the stitch canthopexy
(Fig. 38.35).
Fig. 38.32 (a) Dark shadowing highlighted by the crepey skin and the grooving accentuated by the overhanging fat. (b) “Correction” of both by the
simulated pinch and pexy.
a
b
Fig. 38.31 (a) The patient is seen preoperatively at age 53, (b) in a historic photo at age 23, and (c) postoperatively at age 54, with an attractive,
youthful eyelid posture restored.
a
b
b

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38.14.9
The Male Patient with
Poor Morphology
Men can often be more challenging for blepharoplasty by virtue
of their inherently thicker, heavier skin, which together both
resists facile excision, resulting in potential undertreatment,
and attracts swelling, threatening eyelid posture deformities.
:ith the application of the pinch blepharoplasty technique, it is
possible to prevent these kinds of complications and still deliver
a successful aesthetic result.
38.14.10 The Thick-Skinned Patient
The opposite end of the patient candidate scale from the ideal
patient is the ´stifferµ skinned patient. Such patients are inher-
ently harder to treat with any blepharoplasty technique. :hen
performing the pinch technique on these kinds of patients, it
is doubly important that the eyelid be as ´virginalµ as possible
before pinching, so either no local anesthesia is placed or it is
placed long before the pinch to facilitate as much control as
possible. That said, the pinch approach still offers a safer tactic to
capture this excess skin and deliver an aesthetic result.
38.14.11 The Aging Herniated Patient
Patients who present primarily with herniated fat and little
excess skin must be treated with a more conservative pinch:
that is, most of this same skin must otherwise be preserved to
´repaperµ the future, more concave eyelid following the removal
of the prodigious volume of fat.
Fig. 38.35 (a,c) This 65-year-old patient underwent an upper bleph-
aroplasty in tandem with a therapeutic canthopexy and pinch lower
blepharoplasty that corrected both the depressed canthus and the
eyelid problem itself, as shown 18 months postoperatively (b,d).
a
c
b
d
Fig. 38.33 (a) Patient and (b) corroborative results at 1 year.
a
b
Fig. 38.34 (a) This 32-year-old woman presented with the complaint of an overly large globe accentuated by excessive scleral show. (b) An isolated
therapeutic stitch canthopexy was successfully conducted along with an upper blepharoplasty.
a
b

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VI Eyelid Surgery
38.14.12 The “2-Day Prime” Patient
Candidates, not unreasonably, often desire the delivery of the
quickest recovery as possible to allow for the earliest return to
work: the ´2-day Prime.µ Although the pinch blepharoplasty
clearly cannot deliver a full recovery in 2 days, it does shorten
the healing signifi cantly.
38.14.13 The “Repinch” Patient
Although the planned second stage repinch has essentially been
replaced now by the more inferiorly positioned fi rst pinch, this
approach remains a powerful cleanup tactic when implemented
(Fig. 38.36).
Fig. 38.36 (a,b) This 56-year-old patient presented with advanced sun-damaged skin for which a staged second pinch was planned at 6 months. (c) The
patient is seen in a historic photo at age 20 and 1 year after the repinch surgery, demonstrating reasonable success at recapturing her youthful look.
a
b
c

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38.15 Concluding Thoughts
The pinch blepharoplasty and stitch canthopexy modifications
together empower the surgeon to tame and command greater
control of the lower eyelid and ultimately deliver a better aes-
thetic result more safely. Personally, I have found the effects of
this technique quite gratifying: I have both a newfound serenity,
with its prevention of surgical stigmata, and a dependable satis-
faction with its promise of a more comprehensive correction. In
addition, because of its inherently kinder, gentler strategies, the
pinch lower blepharoplasty results in less bruising and swelling.
Thus, the patients enjoy a distinctly faster recovery. The pro-
verbial ´therapeuticµ postoperative taping and massage may be
abolished from routine practice.
The procedure’s advantages are particularly manifest whether
the surgeon is presented with the ideal, ber-wrinkled patient,
where one can offer a more complete correction, or the most mor-
phologically challenging patient. And now with the more inferi-
orly placed pinch, one can also realize improvements in patients
with proper festoons and orbital grooving. As an endorsement of
the efficacy of the pinch blepharoplasty, I have not performed a
skin–muscle flap for the lower blepharoplasty in over 20 years.
And the pinch blepharoplasty has eliminated the need for lower
eyelid resurfacing in most cases.
I now perform more canthopexies intelligently and excise more
skin confidently. The results of these efforts have included consis-
tently faster patient recovery, more accurate canthal and eyelid
positioning, and what is most important, significantly improved
aesthetic outcomes obtained more safely.
Clinical Caveats
• The surgeon should either infiltrate the local anesthetic after
the pinch or as early and minimally as possible.
• The less distortion of the tissues, the more accurate and facile
the pinch maneuver will be. This is particularly germane at
the start of a surgeon’s learning curve. To this end, it is often
helpful to sedate the patient more deeply just before the
pinch procedure.
• The stitch canthopexy should now be considered an integral
part of the surgery. Every patient presenting for a proper
blepharoplasty per force harbors laxity of the tarsoligamen-
tous sling. That said, the action of the canthopexy may be
classified as either prophylactic (elderly, prominent globe,
or malar hypoplasia) or therapeutic (measurable laxity, or
negative lateral canthal position scleral show). This stitch can-
thopexy, when judiciously harnessed, empowers the surgeon
to take full advantage of the pinch procedure and perform
the most complete removal of redundant skin.
• The pinch skin plasty should run horizontally and rest at least
5 mm from the ciliary margin to obviate cerclage-like and ver-
tical scarring, respectively. The pinch should be conducted as
low and close to the excess crepey skin as possible, taking
as much medially, if indicated, as one would traditionally
laterally. in order to recruit the skin maximally and correct
the orbital groove effectively. While creating the skin wall,
the surgeon endeavors to maximally “efface” the tissues
below the pinch while still preserving the posture of the ciliary
margin above. This same wall must be deliberately excised by
ensuring the ideal scissor angle while doing so.
• Both the pinch blepharoplasty and the stitch canthopexy
techniques have a notable learning curve. During this evo-
lution, the surgeon should be aware that it is deceivingly
easy to both “over- or underpinch” and “over or under pexy.”
So, when conducting either, the surgeon should have a low
threshold to both adjust the size of the pinch wall and replace
the pexy stitch if over- or undercorrection is perceived.
Suggested Reading
>1@ Dinner MI, Glassman H, Artz -S. The ´no flapµ technique for lower-lid blepharo-
plasty. Aesthetic Plast Surg 1992;16(2):155–158
>2@ -elks G:, -elks EB. 1o-touch lower blepharoplasty. In: Cardoso de Castro C,
Boehm .A, eds. Techniques in Aesthetic Plastic Surgery, Vol. 5. Midface Surgery.
Philadelphia, PA: Elsevier/Saunders; 2009:59–76
>3@ Lambros VS. Hyaluronic acid injections for correction of the tear trough deformi-
ty. Plast Reconstr Surg 2007; 120(6, Suppl):74S–80S
>4@ .im EM, Bucky LP. Power of the pinch: pinch lower lid blepharoplasty. Ann Plast
Surg 2008;60(5):532–537
>5@ Rosenfield L.. The pinch blepharoplasty revisited. Plast Reconstr Surg
2005;115(5):1405–1412; discussion 1413–1414
>6@ Parkes M, Fein :, Brennan HG. Pinch technique for repair of cosmetic eyelid
deformities. Arch Ophthalmol 1973;89(4):324–328
>7@ Ristow B. Transconjunctival blepharoplasty. In: Cohen M, ed. Mastery of Plastic
and Reconstructive Surgery, Vol. 3. Boston, MA: Little, Brown; 1994
>8@ Rosenfield L.. Pinch blepharoplasty: a safe technique with superior results.
Aesthet Surg J 2007;27(2):199–203
>9@ =arem HA, Resnick -I. Minimizing deformity in lower blepharoplasty. The
transconjunctival approach. Clin Plast Surg 1993;20(2):317–321

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VI Eyelid Surgery
39 Avoidance and Treatment of Complications of Aesthetic
Eyelid Surgery
Ted Wojno
Abstract
This chapter outlines the potential functional and aesthetic
complications of eyelid surgery. Diagnosis and management are
discussed.
Keywords
canthotomy, cantholysis, lagophthalmos, retraction, ectropion,
epiphora, dry eye, chemosis, eyelid crease
39.1 Introduction
Complications of aesthetic eyelid surgery range from tempo-
rary and mild to permanent and devastating (Table 39.1, Table
39.2). Although complications can never be completely avoided,
their frequency and severity can be minimized by a thorough
preoperative evaluation, judicious planning, and carefully
performed surgery. Listening to and understanding a patient’s
postoperative complaints is extremely helpful in avoiding
unhappiness.
39.2 Functional Problems
39.2.1 Infection
Given the robust blood supply to the periocular area, wound
infection is fortuitously rare. Patients commonly complain of
what they fear to be ´infection,µ but the vast majority of times,
their symptoms are simply the manifestations of the expected
postoperative edema and mucus discharge. The eyelid skin
is thin compared with the rest of the body and swells quite
remarkably. The eye will typically respond to any insult with
increased tear and mucus production, which patients fre-
quently mistake for bacterial infection, prompting a worried
phone call. I ask the patients to palpate the involved eyelid
and tell me whether it feels hot and firm to the touch, two
signs that would suggest infection. I tell them that the eyelid
swelling should ´have the consistency of bread dough,µ which
is greatest on the second or third postoperative day. Elevation
of the head and frequent application of cold compresses are
therapeutic.
Since most eyelid procedures involve opening the orbital
septum, infection, if it does occur, can spread into the orbit and
present as either a preseptal or orbital cellulitis or frank orbital
abscess. Given the increasing prevalence of methicillin-resistant
Staphylococcus aureus (MRSA) in the general population, any
suspicion of bacterial infection should prompt a culture of
the wound to guide appropriate oral or intravenous antibiotic
therapy.
39.2.2 Orbital Hemorrhage
and Hematoma
Postoperative orbital hemorrhage is a true emergency, since
it can lead to visual loss via compression of the central retinal
artery or optic nerve. Hemorrhage usually develops quickly
and often follows an episode of straining, coughing or Valsalva
maneuver. Patients complain of severe pain and firm swelling of
the eyelids and/or conjunctiva. Visual loss is often immediate but
may not be noticed by the patient if the upper eyelid is swollen
shut. Prompt treatment (ideally within the first hour) consists of
opening all the surgical incisions and, if necessary, canthotomy
and cantholysis of the superior and inferior crura of the lateral
canthal tendon (Fig. 39.1). If possible, explore the wound to see
whether a clot can be expressed and to see whether there are
any sites of active bleeding that can be cauterized. If available,
check the intraocular pressure and, if elevated or the globe is
firm, administer topical ophthalmic timolol maleate 0.5 drops,
oral acetazolamide 500 mg tablet (to decrease aqueous produc-
tion), and intravenous mannitol 20, 2 g/kg as an osmotic agent
to shrink the vitreous humor. Ophthalmologic consultation is
indicated.
39.2.3 Lagophthalmos and
Corneal Exposure
A small degree of lagophthalmos is normal immediately after
surgery due to the effects of local anesthesia. Eyelid edema can
also interfere with normal orbicularis oculi function, peaking on
Table 39.1 Functional problems that may be caused by eyelid surgery
Visual loss
Infection
Orbital hemorrhage and
hematoma
Lagophthalmos
Corneal exposure
Lid retraction
Lateral canthal rounding
Ectropion
Entropion
Trichiasis
Ptosis
Diplopia
Mydriasis
Paresthesias
Refractive change
Dry eye
Epiphora
Chemosis
Table 39.2 Aesthetic problems that may be caused by eyelid surgery
Eyelid shape
Asymmetry
Scar
Skin texture differences
Fat injection lumps
Loss of lashes
Underresection of fat
Overresection of fat

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the second to third postoperative days. This is easily managed
by frequent application of bland ophthalmic ointment and cool
compresses. Exposure that persists beyond the fi rst week is
usually due to overzealous skin excision or excessive tighten-
ing of the levator muscle in ptosis repair (Fig. 39.2). Massage
of the upper and/or lower eyelids may remedy mild cases, but
additional surgery is frequently needed. If due to ptosis repair,
the only solution is to release the levator muscle to the point
of closure of the eyelids. If due to excessive skin excision and
if the lagophthalmos is mild, it may be possible to open either
the upper or lower lid incisions and gently tease the wound
apart to alleviate the vertical skin shortage. The wound is then
allowed to heal by secondary intention and will usually provide
a surprisingly good cosmetic result. If severe, a skin graft will be
needed, much to the displeasure of the patient, since cosmesis
is rarely perfect.
For best cosmetic results in the upper eyelid, the skin graft
should be placed in the pretarsal portion of the eyelid immedi-
ately adjacent to the lid margin (Fig. 39.3). If, however, the upper
eyelid fold is still quite low, the lower edge of the skin graft can be
placed just superior to the eyelid crease, with the result that the
graft is nicely hidden in the fold (Fig. 39.4).
In the lower eyelid with overresection of skin, the graft
is generally best placed onto the surface of the tarsal plate
(Fig. 39.5). Lagophthalmos developing after several weeks is
uncommon but is usually due to scarring in the plane of the
lower eyelid retractors (so-called middle lamella scarring). This
can be remedied by cutting and recessing the capsulopalpebral
fascia and interposing a spacer graft (ear cartilage, hard palate,
or autologous or banked dermis) between the cut edge of the
Fig. 39.1 (a ) Canthotomy of the right lateral canthal tendon. (b) Another patient demonstrating cantholysis of the inferior crus of the right lateral
canthal tendon.
a
b
Fig. 39.3 A patient 1 month after skin grafts to both upper eyelids
placed onto the tarsal plates to treat lagophthalmos from previous
overresection of skin.
Fig. 39.2 (a) A patient with lagophthalmos due to excessive resection
of upper eyelid skin. (b) The same patient demonstrating the retrac-
tion of the upper eyelids on downgaze.
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b

460
VI Eyelid Surgery
retractors and the inferior border of the tarsal plate to lift the
lid vertically (Fig. 39.6).
Very rarely, lagophthalmos is due to damage to the branches of
the facial nerve innervating the eyelids. This may happen if there
has been extensive dissection in the periocular area for the eyelid
surgery or, more typically, from ancillary procedures such as rhyt-
idectomy or forehead lift. If permanent, procedures to improve
closure, such as placement of an upper eyelid weight or palpebral
spring, may be needed.
Also rare is presence of an adhesion between the levator muscle
and the superior orbital rim. This can occur if there has been
excessive resection of the preaponeurotic fat pockets (Fig. 39.7).
Release of the adhesion, accompanied by fat mobilization from
deeper in the orbit or fat grafting, may be necessary.
39.2.4 Lid Retraction and
Lateral Canthal Rounding
Upper eyelid retraction is due to excessive tightening of the
levator muscle in ptosis repair or excessive skin excision in upper
eyelid blepharoplasty. The treatment is as outlined in the pre-
ceding section on lagophthalmos and corneal exposure. Lower
lid retraction may be due to excessive skin excision or scar in
the plane of the lower eyelid retractors, as also discussed in the
preceding section. Lower lid retraction can also occur if an over-
zealous horizontal lid tightening procedure was performed on a
globe with physiologic exophthalmos (! 18 mm). In such cases,
the lower eyelid bowstrings under the prominent globe. The
classic analogy is that of the man with the pot belly tightening
his belt. The more he tightens the belt, the greater the overhang
of his belly. This is more frequently seen in patients with a fl at
malar eminence and heavy jowls. This may improve with time
and massage, but if it does not, it is best treated by recession of
the lower eyelid retractors with interposition of a spacer graft,
as discussed in the preceding section. If present, suspension of
a ptotic midface will also help. Lateral canthal rounding (round
eye deformity) is essentially a form of lower eyelid retraction
in which the retraction is more noticeable in the lateral eyelid
(Fig. 39.8).
39.2.5 Ectropion
Ectropion is present when the lower eyelid margin stands
away from the globe. It is differentiated from retraction,
wherein the lid margin is applied to the globe buts rests below
the inferior limbus. Lower eyelid retraction and ectropion may
coexist. A mild degree of ectropion may be noted in the hours
just after surgery. This is due to the effects of local anesthesia
on the orbicularis muscle and resolves when the anesthetic
wears off. This is more common when a horizontal shorten-
ing of the lid margin has not been performed at the time of
blepharoplasty. Persistent frank ectropion of the lower eyelid
generally has two causes. The first is overresection of the
anterior lamella, as is seen in lower eyelid retraction. In this
respect, ectropion is simply a more profound manifestation
of the same problem that causes lower eyelid retraction. The
second cause is failure to correct excess horizontal laxity of
Fig. 39.5 (a) A patient with bilateral lower eyelid skin overresection.
(b) The same patient one month after skin grafts to the anterior
surface of the tarsal plates.
a
b
Fig. 39.4 (a) A patient with lagophthalmos of the left upper eyelid
due to excessive skin excision. (b) The patient after placement of a
skin graft in the left upper eyelid just above the eyelid crease (arrow).
(c) The patient in primary gaze, demonstrating that the skin graft is
covered by her upper eyelid fold.
a
b
c

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the tarsoligamentous sling at the time of lower eyelid bleph-
aroplasty. The two causes are intrinsically related, because as
vertical excision of the lower eyelid anterior lamella increases,
so must the horizontal tension on the lid margin increase
in order to support the entire lid. This may occur more fre-
quently if the lower eyelid blepharoplasty has incorporated fat
repositioning into the cheek, which is done to soften the naso-
jugal fold. Fat repositioning involves cutting the orbitomalar
ligament to access the sub–orbicularis oculi fat (SOOF). Since
the orbitomalar ligament is one of the supporting ligaments of
the midface, lysing it essentially converts the cheek and lower
eyelid into a single unit, which can pull down the lower eyelid
margin.
As with lower eyelid retraction, a mild case of ectropion can
be treated by opening the subciliary portion of the incision and
teasing the edges apart to heal by secondary intention. If due to
uncorrected horizontal laxity, a lid shortening procedure will
usually suffi ce (Fig. 39.9). Severe cases will require the addition
of a skin graft and/or recruitment of skin from the midface
(Fig. 39.10).
It is often diffi cult to determine what steps are necessary to
correct lower lid malposition after blepharoplasty. If uncertain,
one can perform a ´two-fi nger testµ as outlined by Patipa to
determine the etiology of the problem. In the fi rst step of this
Fig. 39.8 Lateral canthal rounding is essentially a lower eyelid retrac-
tion more severe in the lateral part of the lower eyelid.
Fig. 39.7 (a) A patient who had adhesion of the upper eyelids to
the superior orbital rim after overresection of the preaponeurotic
fat (a prosthetic eye is present on the left). (b) The same patient in
downgaze.
a
b
Fig. 39.6 (a) A patient with middle lamellar scarring and retraction
of both lower eyelids. (b) The same patient 2 months after recession
of the lower eyelid retractors and interposition of ear cartilage grafts
between the retractors and the inferior border of the tarsal plates. (c)
Diagram of a spacer graft between the lower lid retractors and the
inferior border of the tarsal plate.
a
b
c

462
VI Eyelid Surgery
test, the examiner places the index fi nger against the lateral
lower eyelid and pushes it toward the lateral orbital rim (eff ec-
tively performing a horizontal tightening of the lower lid). If the
ectropion/retraction is corrected with this maneuver, horizontal
shortening of the lower eyelid is indicated (Fig. 39.11). It is
important to push the eyelid only laterally and not superiorly.
If the ectropion remains, the examiner then pushes superiorly
with the middle fi nger in the middle third of the eyelid. If the
ectropion/retraction is eliminated by this additional step, a
middle lamellar graft may be needed (Fig. 39.12). Some have
added an additional step with a ´three-fi nger testµ in which a
third fi nger is used to push skin up from the midface. Here, if the
ectropion/retraction is now reduced, a skin graft or midface lift
may additionally be required, indicating a relative skin shortage
in the eyelid.
39.2.6 Trichiasis and Entropion
Entropion is an inward deviation of the eyelid margin, result-
ing in the normally positioned eyelashes abrading the globe.
Trichiasis is a true misdirection of the lashes in a normally posi-
tioned lid margin. In fact, most of what is called ´trichiasisµ is
Fig. 39.11 (a) A patient with retraction of the right lower eyelid. (b) In the fi rst step of the “two-fi nger test,” the lateral lower eyelid is pushed against
the lateral orbital rim. In this case, the retraction is corrected by this maneuver, indicating the need for horizontal shortening of the lower eyelid.
(Reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A Repair Manual. New a
b
Fig. 39.9 (a) A patient who developed ectropion after lower eyelid
blepharoplasty due to failure to correct horizontal lid laxity. (b) The
same patient after horizontal lower eyelid shortening.
a
b
Fig. 39.10 (a) A patient with severe ectropion of the left lower eyelid
after lower eyelid blepharoplasty. (b) The same patient after horizontal
eyelid shortening and skin graft to the left lower eyelid.
a
b

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actually a focal cicatricial entropion of the lid margin. Entropion
and trichiasis may be present in the same eyelid. Cicatricial
entropion is due to contraction of the posterior lamella of the
upper or lower eyelid. It can occur after any surgery utilizing a
conjunctival approach including lower eyelid blepharoplasty.
Treatment consists of any of a number of procedures to rotate
the lid margin outward or expand the posterior lamella of the
eyelid with a graft, usually mucous membrane. In general, trichi-
asis and entropion are exceptionally uncommon problems after
blepharoplasty surgery.
True trichiasis or a very focal entropion can be treated with
electrolysis, cryotherapy, or surgical excision of the involved lid
margin.
39.2.7 Ptosis of the Upper Eyelid
Many cases of ptosis after blepharoplasty are undoubtedly due to
lack of recognition in the preoperative period. This may be seen
in cases where the patient is exerting significant frontalis muscle
action to compensate for the loss of field induced by the redun-
dant skin and eyelid position. Careful preoperative evaluation and
nullifying the action of the frontalis muscle with the examiner’s
finger are needed to detect this. Extreme postoperative swelling
of the upper eyelids can also lead to ptosis due to stretching of
the levator aponeurosis. :hen noted postoperatively, the only
solution is to perform a ptosis repair.
39.2.8 Diplopia
By far and away, the most common cause of this complaint
after surgery is the natural tendency of patients to use the term
´double visionµ for any disturbance in visual function. Swelling
from the surgery, blurred vision from lubricating ointments, and
tearing are the usual causes. The physician should ask patients
whether they frankly see two distinct objects side by side or one
on top of the other. Also inquire whether the problem is tempo-
rarily resolved by wiping the eyes or blinking. If so, the patient
can be reassured that this symptom is normal and temporary.
It is common for patients to note some diplopia in the hours
following eyelid surgery due to the effects of local anesthetic on
the extraocular muscles. This is quite frequent when hyaluro-
nidase has been added to the local anesthetic mixture, which
functions to spread the solution into the anterior orbit. This
will resolve within a few hours as the effect of the local wears
off. Orbital hemorrhage and edema also cause diplopia and are
accompanied by obvious signs of proptosis, eyelid swelling, and
ecchymosis. This will resolve after several days and is helped
by frequent cool compresses. Persistent diplopia is usually due
to damage to the inferior oblique muscle, which separates the
medial and middle fat pockets in the lower eyelid. The muscle
is relatively anterior in this location and can be easily harmed
by direct trauma from the surgical instrumentation (Fig. 39.13).
Given the primary and secondary action of this muscle, patients
may complain of a vertical deviation with a torsional component.
Ophthalmologic consultation is indicated. Strabismus surgery
may be needed and, if so, is usually only partially successful in
alleviating symptoms.
A less frequent cause of diplopia in the postoperative period
is decompensation of a previously existing phoria to a tropia. A
phoria is a latent deviation of the globe held in check by normal
fusional abilities and can become a manifest tropia after surgery
due to edema or sedation. This, too, usually resolves in a few
days.
39.2.9 Mydriasis
Pupillary dilation may be observed for a few hours after
lower eyelid surgery. This occurs if local anesthetic is used,
especially when combined with hyaluronidase. The local dif-
fuses into the anterior orbit and affects the inferior division
of the oculomotor nerve, which supplies the parasympathetic
fibers to the pupil. Since this nerve also supplies the inferior
rectus and inferior oblique muscles, a vertical deviation of
the globe may be observed and the patient complain of diplo-
pia. This resolves quickly as the effect of the local anesthetic
dissipates.
Fig. 39.12 (a) A patient with retraction of the right lower eyelid. (b) In the first step of the two-finger test, the lateral lower eyelid is pushed against
the lateral orbital rim. In this case, the retraction is not improved. (c) In the second step of the two-finger test, the examiner pushes up on the
middle of the lid margin with the middle finger. Now the retraction is improved, indicating the need for middle lamella support in the form of a graft.
(Reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A Repair Manual. New a
b
c

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VI Eyelid Surgery
39.2.10 Paresthesias of the Eyelid
Cutaneous incision performed in upper or lower eyelid blepharo-
plasty severs many of the fine sensory nerves to the lid margin
(Fig. 39.14). This results in numbness and paresthesias of the
lash line, most noticeable to women when applying eye makeup.
Some will complain that it makes application of makeup difficult
due to loss of tactile feedback from the makeup brush. This
resolves in 6 to 12 months.
39.2.11 Refractive Changes
The refractive state of the eye (myopia, hyperopia, and astig-
matism) is in part determined by the level and pressure of the
eyelids on the globe, which in turn determine corneal shape and
curvature. Any eyelid procedure leads to swelling and often a
difference in the lid level, which may cause significant changes
in the refractive error. Patients may quite suddenly notice that
vision is compromised, although the occasional patient may
actually report acuity improvement. Such changes are almost
universally temporary, with the refractive state of the eye
returning to baseline in 2 to 4 months. Patients should be advised
against changing their eyeglass or contact lens prescriptions
during this time.
39.2.12 Dry Eye and Epiphora
It is important to realize that any procedure on the eyelids
temporarily changes the mechanics of blinking, thus altering the
complex nature of the precorneal tear film (Fig. 39.15), leading
to a variety of symptoms. Fortunately, this is usually temporary
and patients return to baseline when edema resolves and normal
eyelid mechanics resume.
Dry eye and tearing are two of the commonest problems in
the ophthalmologist’s office and probably the most common
complaints after periocular surgery. Symptoms of ocular surface
problems are very bothersome to patients and cause significant
visual complaints. The etiology of such problems often confounds
those whose sole practice is ophthalmology. Adding to this prob-
lem is the unfortunate tendency of some providers of eye care to
label any complaint as ´dry eye,µ thus telling the patient to use
frequent artificial tears. Even worse is the almost reflex prescrip-
tion of an antibiotic–steroid combination eye drop or ointment
in the complete absence of infection or inflammation. 1umerous
ophthalmic disorders that present with symptoms of foreign body
sensation, ocular irritation, and inflammation are often misdiag-
nosed, leading patients to subsequently report that they have dry
eyes or blocked tear ducts. So what is a nonophthalmologist to do
when confronted with these complaints"
Most true dry eye disorders are due to a decreased production
of the aqueous component of the tear film (keratoconjunctivitis
sicca), which occurs with age and certain ocular disorders.
Symptoms of aqueous deficiency dry eye can be exacerbated by
any ocular or periocular surgery. The documentation of aqueous
tear deficiency is made by the Schirmer tear test (Fig. 39.16) per-
formed with application of a topical ophthalmic anesthetic (often
called the basic secretion tear test). Unfortunately, the test is not
completely reliable, having frequent false positives and negatives.
Fig. 39.13 (a) The inferior oblique muscle visible between the medial and middle fat pockets of the lower eyelid (forceps retracting the medial fat
pocket). (b) Diagrammatic representation of the inferior oblique muscle of the right lower eyelid separating the medial and middle fat pockets.
(Reproduced from Codner MA, McCord CD. Eyelid and Periorbital Surgery. New a
b

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Examination of the corneal surface is easily done by instilling a
drop of fluorescein from a premoistened, sterile ophthalmic strip
(Fig. 39.17) into the eye and observing the ocular surface with a
cobalt blue light (Fig. 39.18).
Initial treatment of aqueous-deficiency dry eye consists of
supplementing the tear film with over-the-counter lubricating
drops or ointments. Lacrimal gland secretion may actually be
increased by using cyclosporine or lifitegrast drops. Regrettably,
these medicines take 2 to 3 months to be effective, and they work
on only a minority of patients. Dry eye can also be treated by
decreasing lacrimal outflow, thus keeping the naturally produced
tears in contact with the ocular surface for a longer period of time.
This is achieved by occluding the lacrimal puncta with dissolvable
plugs, silicone plugs, or even thermal cautery. In general, it is
legitimate to suggest to patients who complain of ocular irritation
after surgery to use liberal amounts of over-the-counter artificial
tears and/or ointments. Various preservative-free preparations
are less likely to cause long-term hypersensitivity issues, but for
short-term treatment there is no real reason to prefer one brand
over another.
Evaporative ´dry eyeµ occurs when despite normal aqueous tear
production, there is excessive exposure of the ocular surface. This
form of dry eye can also be seen in certain ocular surface disorders
that affect the outer, lipid-containing layer of the tear film, which
is responsible for preventing evaporation of the aqueous layer of
the precorneal tear film. Since the mechanics of normal blinking
constantly spread the lipid layer of tears over the aqueous layer,
surgically induced lid edema will temporarily interfere with this
process. Evaporative dry eye secondary to surgery will usually
Fig. 39.15 Diagram of the precorneal tear film. (Reproduced from
Nahai F, Wojno T. Problems in Periorbital Surgery: A Repair Manual. New
Fig. 39.14 One of the many vertically oriented sensory nerves that are
usually cut as part of an upper eyelid blepharoplasty.
Fig. 39.16 Schirmer tear test (basic secretion tear test) for dry eye.
(Reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A
Repair Manual. New Fig. 39.17 Moistening a fluorescein-impregnated ophthalmic strip
with tap water. (Reproduced from Nahai F, Wojno T. Problems in
Periorbital Surgery: A Repair Manual. New

466
VI Eyelid Surgery
normalize in few weeks as swelling diminishes and lid function
normalizes. This, too, is treated with liberal amounts of artificial
tears and ointments.
True epiphora is caused by increased tear production or
decreased lacrimal outflow. Increased tear production occurs
in any situation that causes ocular irritation, which, of course,
includes periocular surgery. Lacrimal outflow obstruction,
common with age and periocular injury, is also seen when con-
junctival edema (chemosis) from eyelid surgery blocks the egress
of tears from the eyes. Patients can be reassured that epiphora
secondary to eyelid surgery will resolve when edema subsides.
Epiphora can also result from a subciliary lower eyelid incision.
This incision may cut the fibers of the buccal branch of the facial
nerve that innervate the medial orbicularis, and thus weaken the
´lacrimal pumpµ function of this part of the muscle (Fig. 39.19).
This, too, usually resolves with time as reinnervation takes place.
39.2.13 Chemosis
This can be one of the more annoying complications of eyelid
surgery and is most commonly seen after lower eyelid blepha-
roplasty, especially if inferior crus cantholysis was performed.
The frequency is also increased in the presence of concomitant
upper lid surgery. It likely represents accumulation of lymphatic
fluid in the sub-Tenon’s space, exacerbated by inflammation (Fig.
39.20). Lymphatic drainage of the upper lid is to the preauricular
nodes, while the lower lid drains to the submandibular nodes.
Ancillary procedures performed in these areas can also increase
its incidence.
Patients may complain of seeing a ´bubble,µ ´blister,µ or ´tearµ
in the lateral part of the eye and comment that they feel a foreign
body sensation when blinking. :hile most chemosis resolves
spontaneously, there certainly are cases that can last up to a year.
The bothersome nature of the problem and its unpleasant appear-
ance prompt the patient to ask for treatment. 1umerous therapies
have been proposed, often with little evidence of effectiveness.
This perhaps leads to the conviction that the last intervention
tried was the right treatment, when what actually occurred was
spontaneous resolution.
Chemosis is sometimes seen developing even while lower
eyelid surgery is being performed. In this situation it may be
helpful to make a small 2-mm incision through the conjunctiva
and anterior Tenon’s capsule. This often results in a gratifying
immediate drainage of the fluid. The surgeon may also add a
temporary lateral tarsorrhaphy, which functions as a localized
pressure patch in the involved area.
Most of the time, the problem becomes apparent in the first
few weeks after surgery. If mild, it can be ignored and the patient
reassured. If symptomatic and unilateral, a pressure patch may
be placed for 24 to 48 hours. Topical ophthalmic steroid drops
(1 prednisolone) four times daily may help by decreasing
inflammation and edema. Topical ophthalmic nonsteroidal
anti-inflammatory drugs (1SAIDs), antihistamines, and decon-
gestants may also help. Severe chemosis may result in conjunc-
tival drying, and thus a bland ophthalmic ointment may provide
symptomatic relief.
Massage of the lower eyelid from medial to lateral (in the direc-
tion of the lymphatic drainage) may assist in resolution. A small
injection of hyaluronidase in the lateral conjunctiva may make
massage more effective. Conjunctival incision may also work for
chemosis that develops in the postoperative period. This is easily
done with only a topical ophthalmic anesthetic drop followed by
topical 1 to 4 lidocaine (Fig. 39.21).
39.3 Aesthetic Problems
39.3.1 Change in Eyelid Shape
Patients may complain about changes in the shape of the eyelids.
Some have the mistaken notion that surgery will restore their
youthful contours, which, of course, is rarely the case. This needs
Fig. 39.18 Illumination of the cornea with a cobalt blue pen light,
demonstrating keratitis of the inferior cornea, which is stained with
fluorescein. (Reproduced from Nahai F, Wojno T. Problems in Periorbital
Surgery: A Repair Manual. New Fig. 39.19 Diagram of the innervation of the lower eyelid by the buccal
branch of the facial nerve. A subciliary incision can cut the branches
to the medial lower eyelid orbicularis, weakening the lacrimal pump
mechanism.

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to be pointed out in the preoperative evaluation. Actual changes
in shape of the eyelids are common with upper eyelid ptosis
repair and lower eyelid horizontal shortening, both of which
aff ect the position of the eyelid margin. If objectionable, these
problems may require small surgical touchups in the months
following the original procedure. As with any other surgery, a
very small group of patients seem to be exceptionally dissatisfi ed
with their appearance despite what is in fact an excellent tech-
nical result. Such problems rarely have a satisfactory conclusion.
39.3.2 Eyelid Asymmetry
Even a 1-mm diff erence in eyelid or crease levels is easily noticed
by most patients. Eyelid asymmetry may be due to uneven skin
or orbicularis muscle excision in lids that were evenly matched
prior to surgery. This is most easily remedied by additional skin
or muscle excision on the side with excess. Eyelid asymmetry
also due to failure to sculpt the fat pockets evenly. Again, addi-
tional fat removal on the side with excess will be eff ective.
Crease and fold asymmetry will result if the inferior edge of the
upper eyelid incision was placed at diff erent levels on each side.
Careful preoperative measurement and marking will prevent this
problem. Most often, patients will complain that the eyelid with
the lower crease needs additional skin removal, when in fact, the
surgical removal of skin was symmetric. Correction is best accom-
plished by raising the lower crease, a procedure that is generally
more successful than attempting to lower a high lid crease (Fig.
39.22).
Crease elevation is accomplished by the following technique.
First, draw the proposed new crease on the upper eyelid above
the old, low crease. The new crease should be placed at the same
level as the crease on the opposite upper eyelid (Fig. 39.23a).
:ith a blade, incise through skin and muscle at the proposed
new crease. 1ext, undermine with scissors the skin and muscle
below the incision line across the eyelid and on the surface of
the tarsus (Fig. 39.23b). This will remove the old, lower crease
by severing the attachments of the old crease to the underlying
levator aponeurosis and/or tarsus. :ith a 5–0 or 6–0 polyester or
polyglactin suture, take a bite of the levator aponeurosis or tarsal
plate just deep to the lower edge of the incision (Fig. 39.23c). Then
take a bite of the orbicularis at the lower edge of the incision (Fig.
39.23d), and tie (Fig. 39.23e). Repeat in two other spots evenly
placed across the incision (Fig. 39.23f).
Upper eyelid asymmetry is also seen when pre-existing, unilat-
eral brow ptosis is not corrected at the initial surgery. Sometimes
however, brow asymmetry is not apparent until well after the
surgery, when frontalis relaxation occurs. A unilateral brow sus-
pension may be needed, while additional skin excision from the
upper eyelid may suffi ce in mild cases.
39.3.3 Unacceptable Scar
Scars in the upper and lower eyelid generally heal nicely by 6
months after surgery. Encouraging patients to avoid sun expo-
sure will be very helpful. Patients may, however, object to scars
that do not match on the left and right eyes in terms of length and
angulation. Careful marking at the time of the original surgery is
most important.
39.3.4 Complications of Fat Injection
Fat injections are increasingly incorporated into facial aes-
thetic surgery. Injection of fat into the subcutaneous plane
Fig. 39.20 Chemosis of the conjunctiva 2 months after a four-lid
blepharoplasty.
Fig. 39.21 (a) Chemosis of the conjunctiva 2 months after a four-lid
blepharoplasty. (b) Chemosis is improved immediately after lateral
incision of the conjunctiva.
a
b

468
VI Eyelid Surgery
of the eyelids can lead to a bumpy appearance in the skin.
This is a particularly diffi cult problem to cure and consists of
meticulous dissection and removal of the off ending fat. :hen
this problem occurs, treatment is rarely completely successful
(Fig. 39.24).
39.3.5 Skin Texture Problems
Patients with very thin skin who have a large resection of tissue
from the upper eyelid may complain that the skin above and
below the scar line ´does not match.µ This occurs when very
thin preseptal skin is sutured to thicker subbrow skin, creating
a sudden transition in the texture of skin at the scar line. 1o
treatment is possible, and fortunately, most patients seem to
adjust to this.
Some patients complain that the upper eyelid pretarsal skin,
especially just above the lash line, looks thicker than normal
after surgery. In some cases this is caused by persistent edema
and does normalize with time. In other cases, it seems that the
increased pretarsal show is simply perceived as thicker when in
fact it is normal. Again, patients seem to adjust eventually to the
appearance.
Fig. 39.22 (a) A patient who complained of excess skin of the left upper eyelid after upper blepharoplasty. (b) The patient in downgaze, demonstrat-
ing that the real problem is asymmetric placement of the upper eyelid incisions, with the left being lower than the right (arrows). (c) The patient after
elevation of the crease on the left upper eyelid, demonstrating improved symmetry of the lid folds. No skin was removed on the left upper eyelid.
a
b
c
Fig. 39.23 (a) For crease elevation, draw the proposed new crease (down arrow) above the old crease (up arrow) to match the crease level on the
opposite upper eyelid. (b) With scissors, remove the old crease by undermining it across its length on the anterior surface of the levator aponeurosis
and/or tarsus. (c) Take a bite of the levator aponeurosis or tarsal plate with a 5–0 or 6–0 polyester or polyglactin suture just deep to the lower edge
of the incision. (d) Next, take a bite of the orbicularis at the lower edge of the incision. (e) Diagrammatic parasagittal section of the crease suture. (f)
Diagram of the three sutures forming the new crease. (Parts b,c,d,f reproduced from Nahai F, Wojno T. Problems in Periorbital Surgery: A Repair Manual.
New a
d
b
e
c
f

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39.3.6 Loss of Eyelashes
Patients may comment that their eyelashes are thinner after
eyelid surgery. It is unclear whether this really occurs or is
simply a matter of perception. Lower eyelid lashes may have
indeed been cut with a subciliary incision, leading to the false
appearance of lash loss. As the lashes grow back out, this will
normalize. Alternatively, the density of the lower eyelid lashes
may have decreased if a large horizontal lower eyelid shortening
was incorporated into the repair. In this case, the overall number
of lashes per unit area will be decreased due to the stretching out
of the lid margin.
1either of the mechanisms just described explains the per-
ception of thinning of the lashes on the upper eyelid, however.
It is possible that blepharoplasty sometimes induces a degree of
ischemia of the lid margin, with subsequent loss of some of the
eyelashes. Be it real or imagined, there are a number of products
available for topical application that will improve lash growth.
These preparations can, however, cause contact dermatitis and
permanently change the color of a lightly pigmented iris to dark
brown.
Clinical Caveats
• Although most complications of periocular surgery are mild
and self-limited, visual loss and double vision can be severely
debilitating.
• Orbital hemorrhage is best treated within the fi rst hour of
occurrence. Knowledge of canthotomy and cantholysis is
essential.
• Lid retraction, canthal rounding, ectropion, and lagophthal-
mos share common etiologies and may coexist in the same
eyelid. When severe, spacer grafts into the middle lamella
may be needed for adequate treatment.
• Dry eye and tearing are the most commonly reported com-
plaints after eyelid surgery. These symptoms can be easily
managed by the surgeon in the vast majority of cases.
• Chemosis is common after lower eyelid surgery, especially
when canthotomy and cantholysis have been performed.
Although it is usually self-limited, some cases can be very
resistant to treatment.
• Even a 1-mm asymmetry of eyelid levels between left and
right is easily noticed by most patients and is a common
source of dissatisfaction.
Suggested Reading
>1@ Bernardino CR. Evaluating epiphora: nothing to cry about. Rev Ophthalmol
2011:-une 13.
ing-epiphora-nothing-to-cry-about
>2@ Hirmand H, Codner MA, McCord CD, Hester TR -r, 1ahai F. Prominent eye: oper-
ative management in lower lid and midfacial rejuvenation and the morphologic
classifi cation system. Plast Reconstr Surg 2002;110(2):620–628, discussion
629–634
>3@ Lelli G- -r, Lisman RD. Blepharoplasty complications. Plast Reconstr Surg
2010;125(3):1007–1017
>4@ McCord CD, Boswell CB, Hester TR. Lateral canthal anchoring. Plast Reconstr Surg
2003;112(1):222–237, discussion 238–239
>5@ McCord CD, .reymerman P, 1ahai F, :alrath -D. Management of postblepharo-
plasty chemosis. Aesthet Surg J 2013;33(5):654–661
>6@ McCord CD, :alrath -D, 1ahai F. Concepts in eyelid biomechanics with clinical
implications. Aesthet Surg J 2013;33(2):209–221
>7@ Mejia -D, Egro FM, 1ahai F. Visual loss after blepharoplasty: incidence, manage-
ment, and preventive measures. Aesthet Surg J 2011;31(1):21–29
>8@ 1ahai F, :ojno T. Problems in Periorbital Surgery: A Repair Manual. 1ew Thieme Publishers; 2018
>9@ Patel MP, Shapiro MD, Spinelli HM. Combined hard palate spacer graft, midface
suspension, and lateral canthoplasty for lower eyelid retraction: a tripartite
approach. Plast Reconstr Surg 2005;115(7):2105–2114, discussion 2115–2117
>10@ Putterman AM. Regarding comprehensive management of chemosis following
cosmetic lower blepharoplasty. Plast Reconstr Surg 2009;124(1):313–314
>11@ Symbas -, McCord C, 1ahai F. Acellular dermal matrix in eyelid surgery. Aesthet
Surg J 2011; 31(7, Suppl):101S–107S
>12@ :einfeld AB, Burke R, Codner MA. The comprehensive management of chemosis
following cosmetic lower blepharoplasty. Plast Reconstr Surg 2008;122(2):579–
586
Fig. 39.24 (a) A patient after upper eyelid blepharoplasty with fat grafting. She wanted the multiple eyelid folds corrected and some of the grafted
fat removed. (b) The patient 2 months after crease reformation and removal of some of the grafted fat.
a
b

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Part VII
Midfacial Rejuvenation
VII

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