Lower blepharoplasty; advanced techniques and adjunctive procedures

ABSTRACTIntroduction There are two main techniques of lower blepharoplasty: transcutaneous and transconjunctival approaches. Most patients seeking lower eyelid rejuvenation have concomitant involutional changes in the lower eyelid and midface, which would better be addressed concurrently with the lower blepharoplasty procedure to yield better aesthetic and functional outcomes.Areas covered This study aims to review common aging-related changes in the lower eyelid as well as important preoperative considerations, surgical techniques, and various modifications of lower blepharoplasty. A literature search was performed in the PubMed database of English-language journals without restriction on the publication date using selected keywords. The relevant articles were selected by reviewing the titles and abstracts.Expert opinion The lower eyelid and midface should be perceived as a continuum. Currently the fat preservation approach is the mainstream in lower blepharoplasty to prevent postoperative skeletonization of the eye. Fat transposition, via either pedicled fat flaps or free fat grafts, is used to efface tear trough deformity and the eyelid-cheek junction as a primary aim inaesthetic lower eyelid surgeries. Lower blepharoplasty can also be combined with adjuvant procedures to address festoon and droopy midface in selected individuals.KEYWORDS: Lower blepharoplastylower eyelidtear troughtransconjunctival blepharoplastytransconjunctival blepharoplastyorbital fat Article highlights The composite morphology of lower eyelid and mid-face aging is commonly designated as the double convexity deformity.The concept of lower blepharoplasty has shifted from a pure subtractive surgery to fat reposition, conservative skin excision and blending of the eyelid-cheek junction.Releasing the orbicularis retaining ligament is a crucial step in lower blepharoplasty, specifically for patients with an untoward infraorbital hollow.Although pedicled fat flap transposition can effectively efface the infraorbital hollow, this technique has some downsides.Recently it has been demonstrated that the aims of fat redistribution in lower blepharoplasty can be safely achievable by the minced fat graft technique.Most, if not all, cases of lower blepharoplasty would better be complemented with prophylactic canthal anchoring techniques to prevent lower eyelid malposition.Suborbicularis oculi fat elevation is an alternative to lower eyelid fat repositioning, particularly for subjects with negative vectors or hypoplastic malar prominences.Declaration of interestsJD Clark is a professional speaker for Horizon therapeutics. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.Reviewer disclosuresPeer reviewers on this manuscript have no relevant financial or other relationships to disclose.Additional informationFundingThis paper was not funded.