Reverse lower blepharoplasty: An eclectic procedure without cutaneous undermining

Abstract

There are several abnormalities on the lower lid that cannot be adequately treated through conventional blepharoplasty. Patients presenting excess subcutaneous adiposity, redundancy of skin, unaesthetic projection of cutaneous fold on the malar eminence, severe depression above the malar rim as well as many other situations are a constant challenge for their treatment. Adequate treatment cannot be achieved when standard methods are employed through cutaneous incision close to the ciliary border of the lower eyelid. Ever since I described reverse lower blepharoplasty (Rev Soc Bras Cir Plast 3(2):152-154; Aesth Plast Surg 12:45-50), which is a useful procedure for treatment multiples abnormalities on lower lid, I founded similar surgical principles with my new concepts for lipoabdominoplasty which are employed for treatment of flank lipoplasty, inner thigh lipoplasty, aesthetic surgery of the axilla, and further applications. In fact, when lipoabdominoplasty is performed, liposuction is done in order to remove the excess of localized adiposity creating an accentuated depression similar to that on lower lids with unaesthetic appearance. Surgical demarcation must be done carefully, with the patient in the operating room under intravenous sedation. The first reference line is the palpebromalar line from the nasojugal fold to the lateral end of the malar margin. The demarcation of this line is the key for further steps before surgery. It should be done on the proper limit, since if it is drawn out of it, the final scar will not be so good. The width of the cutaneous resection depends on the abnormality of each patient, but the amount of skin excised is much larger than that of conventional lower blepharoplasty. When patients present complex deformities on lower lids, it is mandatory to identify them during demarcation. The remaining skin above the area where skin resection will be done must be wide enough to cover the entire lower lid. The operation is performed under local anesthesia combined with intravenous sedation. Local infiltration is done subcutaneously using 0.40 mg xylocaine with epinephrine (1/200,000)] to separate the skin from the orbicularis muscle. Cutaneous incisions follow the drawn lines, and the skin is resected so that the subcutaneous adiposity or skin depression when it is present is included. A raw area is created after skin resection is performed where each patient presents local abnormalities. The orbicularis muscle is opened with scissors to expose the orbital septum which is also incised. The excess fat bag is resected, and careful hemostasis is done. The necessity to remove some amount of orbicularis oculi muscle is very rare, since it lies smoothly over the bag fat underneath. It is not necessary to suture either the orbital septum or the orbicularis oculi muscle. Cauterization is done only when the excess of bag fat is removed. The skin incision is stitched with a subcuticular running suture with 60 mononylon and covered with adhesive tapes. The running suture is removed 4 or 5 days after surgery when another tape covers the wound during the next 10 days.