Primary goal: Removal of excess skin, orbicularis muscle, and fat
Secondary goals: May be combined with adjunctive procedures described in subsequent chapters, particularly lateral canthal reinforcement and SOOF lift.
Anesthesia: Local anesthesia with oral or intravenous sedation
Operative technique: The skin is incised just below the eyelid margin along its full length and slightly beyond into the lateral canthus. The exposed orbicularis muscle is incised along its length in a similar fashion. A skin-muscle "flap" is lifted off of the underlying orbital septum using blunt dissection with cotton-tipped applicators and sharp dissection with scissors. The skin-muscle flap dissection extends downward over the entire lower eyelid to a level approximately even with the orbital bony rim. The orbital septum in incised to expose the three fat pockets of the lower eyelid. The excess fat is teased free and clamped. The fat is removed with scissors, and each "stump" is cauterized before allowing it to retract back into the orbit. The patient is asked to open his or her mouth and look upward towards the forehead while the surgeon drapes the skin-muscle flap over the initial skin incision to determine the amount of "extra" tissue (generally, only a small amount). Any excess skin and muscle are trimmed. The skin edges are closed using sutures.
Variations: Many variations have been suggested, most of which have to do with placement of incisions or level of penetration from one tissue layer to the next. While all such adaptations are small attempts to overcome the basic insufficiency of this operation (extensive internal disruption of the eyelid, which is, in effect, filleted), none, in our opinion, make any sort of startling difference. If the orbicularis muscle is "hypertrophic" (and bunches into a "roll" just below the lashes when smiling), a thin strip of extra muscle may be removed. In patients with markedly excessive skin, only a skin flap may be dissected (rather than skin-muscle), and the orbicularis muscle then entered lower down near the bone (which later allows for more skin relative to muscle to be removed when the flap is trimmed).
Advantages: In addition to fat removal or repositioning, excess skin and orbicularis muscle may be removed (which is not possible in "pure" transconjunctival blepharoplasty).
Limitations: There are many problems with this operations, as discussed below. The "fatal" flaw of this operation is its highly invasive nature, wide dissection, and extensive violation of the orbital septum. In a modified form accompanied by extra "reinforcement" procedures, the operation has regained some of its lost luster with a small but vocal group of practitioners.
Risks and complications: The incidence of eyelid malposition following lower blepharoplasty undertaken from a skin approach is significantly higher than with transconjunctival surgery. More bruising, more swelling, and slower healing are to be expected. Uncommonly, eyelashes may be lost.
Comments: "Pure" transcutaneous lower blepharoplasty (that is, without adjunctive procedures such as lateral canthal reinforcement or midface resuspension) is a "dying" operation that has seen its day. While still employed by some surgeons, the procedure tends to create a harsher "surgical look" that is no longer in fashion (especially with younger patients and most men).
