The Anterior/Posterior Lamellar Approach to Lower Eyelid Rejuvenation: "Anatomically Correct" Surgery
Richard H. Bensimon, MD.
Aesthetic Surgical Arts, Trumbull, CT, USA.
BACKGROUND: The lower eyelid is a structure with 3 distinct layers and different aging changes occur in each of them. The traditional trans-cutaneous blepharoplasty accesses the fat in the posterior lamella by transversing through the orbital septum, which by necessity causes scarring and contracture of this structure. When this is coupled with anterior skin resection in the vain attempt of improving wrinkles, there is vertical shortening and the all too often result is the operated look of a rounded outer canthus, or worse, frank ectropion.
METHODS: The first step in addressing rejuvenation of the lower eyelid to analyze the individual anatomical change in each lamella and deal with it appropriately while not invading the orbital septum. If pseudo-hernation of the orbital fat is present, this is corrected through a trans-conjunctival approach. If the orbicularis muscle is lax, it can be corrected with an orbicularis suspension or a lateral retinicular suspension. If textural aging changes of the skin are a significant factor, they can be effectively dealt with via resurfacing with a croton oil peel. If a true excess of skin is present, a simple excision is possible at the time of surgery, while a peel can be contemplated at a later date to improve the texture.
RESULTS: Utilizing these techniques, the lower eyelid looks natural without the telltale tightness and scleral show that denotes the "operated look". By idenitifying the structural and textural aspects of aging and correcting them, a more complete rejuvenation is attained.
CONCLUSIONS: The bi-lamellar approach deals with the specific anatomic issues of the aging lid, while avoiding the pitfalls of invading the orbital septum and injudicious skin resection which result in an unsightly change in shape of the eye.