To understand why this is so, consider the anatomy of the lower eyelid. The lower eyelid is suspended from one edge of the orbital rim to the other. The eyelid functions as a windshield wiper to move tears over the corneal surface. This protects the eye surface as well. To function properly, there is a layer of muscle just under the skin called the orbicularis oculi muscle that is responsible for supporting and moving the eyelid.
At the eyelid margin, this muscle is thicker and functions to hold the eyelid margin against the eye surface. This is important because the lower eyelid has to fight the effects of gravity. The relationship of the orbital rim to the lower eyelid is of critical importance. In faces where the orbital rim and cheekbone are not as strong, the muscular hammock of the lower eyelid is even more important for holding the eyelid against the eye surface so it can do its job. Behind this muscle is a thin layer of connective tissue called the orbital septum, which separates the orbit from the eyelid. The fat, which herniates into the lower eyelid to make a “bag” in some individuals, lives behind the orbital septum.
Now consider what happens when a surgeon performs a transcutaneous lower blepharoplasty, or cosmetic lower blepharoplasty through a skin incision, also called an infraciliary incision. To get to the herniated orbital fat, that incision is made through the lower eyelid skin just below the lower eyelid lashes. It is also made through the muscle and the septum sitting behind the lower eyelid skin. The surgeon then removes the herniated orbital fat or the fat can be transposed and moved into the top of the cheek to filler a tear trough hollow. Often “excess skin and muscle” are then trimmed from the lower eyelid to remove lower eyelid skin wrinkles and the incision is then sewn closed. This incision is highly disruptive to normal lower eyelid anatomy and function.
The roll of orbicularis oculi muscle that lives at the edge of the eyelid is responsible for making a muscular hammock that holds the margin of the eyelid against the eye and is profoundly weakened. The motor nerves that supply this muscle are severed by the infraciliary incision. This permanently weakens the lower eyelid and causes it to slump or slide blow its natural position. As the lower eyelid heals, scar tissue that develops in all layers of the eyelid also contributes to the downward pull on the lower eyelid. Of course, if too much “extra skin and muscle” are removed at the time of lower blepharoplasty, this also makes the situation worse.
In an effort to mitigate the risk of the lower eyelid being pulled down, many surgeons who perform transcutaneous lower blepharoplasty perform routine canthopexy at the time of the surgery. Canthopexy involves placing a deep stitch between the outer corner of the eyelid to the lateral orbital bone to support the eyelid. Unfortunately this stitch can distort the tissues further contributing to post-surgical changes.
Another problem with the transcutaneous lower blepharoplasty is the loss of the muscle roll at the lower eyelid margin when “excess skin and muscle” are removed. The dramatic and disturbing change in the appearance of Renee Zellweger is partially caused by the removal of this muscle roll. That roll of muscle is actually aesthetically important. The South Koreans have a name for this: the love band. They have surgeries for increasing the prominence of the love band. Certainly it is important to carefully consider surgery on this structure because of its aesthetic importance.
Dr. Steinsapir is a firm believer that the best way to get out of trouble is by staying out of trouble. The transconjunctival lower blepharoplasty does not have the level of complications associated with the transcutaneous lower blepharoplasty. Yes, the surgeon must be comfortable working near the eye but Dr. Steinsapir a board certified ophthalmologist and fellowship trained oculofacial surgeon so he has all the skills needed to comfortably and safely perform transconjunctival surgery. There are individuals who have excess lower eyelid skin and wrinkles. Something more is needed to address these eyelids other than just performing transconjunctival surgery. This can be a skin pinch, were the bulk of the work is performed behind the eyelid but only a pinch of skin is removed in the front of the eyelid.
Another alternative is what is known by surgeons as a biplanar lower eyelid surgery. This can be very helpful for addressing lower eyelid festoons at the time of the lower transconjunctival blepharoplasty. The approach here is to use the transconjunctival arcus marginalis surgery behind the eyelid to deal with herniated orbital fat and improve the lower eyelid hollow. An anterior, infraciliary incision is made just through the skin leaving the underlying muscle intact. A limited vertical midface lift procedure can be performed through this. Skill, experience, and wisdom are needed to get the best possible result with the lowest risk of potential complications.
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Combining transconjunctival lower blepharoplasty with a chemical peel is an excellent option for many individuals. Dr. Steinsapir is a master of chemical peel and he can design and tailor a chemical peel that will be right for you. This can be performed at the time of your lower eyelid surgery.
