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Special Communication |

Biplanar Contour-Oriented Approach to Lower Eyelid and Midface Rejuvenation

Tanuj Nakra, MD1
[+] Author Affiliations
1TOC Eye and Face, Austin, Texas
JAMA Facial Plast Surg. 2015;17(5):374-381. doi:10.1001/jamafacial.2015.0860.
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Importance  Cosmetic rejuvenation of the lower eyelid-midface complex has evolved as our understanding of 3-dimensional midfacial aging and anatomy has become more sophisticated. Treating the lower eyelid and the midface as a single aesthetic unit leads to a more effective and natural-appearing rejuvenation.

Observations  This is a review of midfacial anatomy and a 5-step approach to lower blepharoplasty and midface rejuvenation: (1) midfacial autologous fat transfer, (2) canthoplasty, (3) transconjunctival orbicularis-retaining ligament release and orbital fat manipulation, (4) transcutaneous midface–superficial muscular aponeurotic system elevation and orbicularis contouring, and (5) skin treatment. In addition, long-term aesthetic outcomes and complications are reviewed for 43 patients (86 eyelids) who underwent the 5-step biplanar approach lower blepharoplasty and midfacial rejuvenation (40 women and 3 men, with a mean age of 60 years). Follow-up averaged 10.8 months. Forty-one patients rated their outcome as “excellent,” and 3 patients rated their outcome as “good.” No patients rated their outcome as “fair,” “no improvement,” or “worsening.” Seven patients (7 eyelids) had unilateral complications requiring postoperative intervention.

Conclusions and Relevance  The biplanar contour-oriented approach to lower blepharoplasty and midfacial rejuvenation is an option for treatment for aging of the lower eyelid-midface complex. The aesthetic outcomes appear natural owing to the synergy of reconstructing the aging changes of multiple lower eyelid and midface structures.

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Figure 1.
Multiple Causes of Midfacial Aging

There are multiple causes of facial aging: bone, soft tissue, muscle, skin, and ligament rigidity. For every patient, each aspect must be analyzed to create a customized lower eyelid–midface rejuvenation plan.

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Figure 2.
Biplanar Approach

The biplanar approach allows robust midface reconstruction. The transconjunctival incision allows subperiosteal orbital fat repositioning, and the transcutaneous incision allows for ligament release, midface elevation and orbicularis contouring.

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Figure 3.
End-to-End Fat Pedicle Positioning

Fat pedicles transposed over the orbital rim to the preperiosteal midface drape create a smoother final contour when they are sutured end-to-end, and there is concerted effort to flatten the pedicles into a continuous consistently thick layer.

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Figure 4.
Orbicularis Contouring

When the midface is pulled up vertically in the transcutaneous approach, the orbicularis muscle tends to roll forward into an aesthetically displeasing roll. The multiple micromattresses with 6-0 chromic gut suture plicate the orbicularis muscle in multiple places to flatten the contour roll.

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Figure 5.
Skin Excision Vectors and Beveled Lateral Incision

Once lateral canthal stabilization and midface/orbicularis elevation is secure, the skin excision can be performed along graded vectors. Centrally, vertical elevation and excision is performed. Primary sutures are placed at the lateral canthus. At the medial aspect of the incision, the vectors are directed laterally, and at the lateral aspect of the incision, the vectors are directed medially. The incision is beveled at the lateral aspect to allow a smooth contour between the thinner lateral canthal skin and the thicker elevated malar skin.

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Figure 6.
Representative Patient Examples

All 4 patients underwent transconjunctival lower blepharoplasty with orbicularis-retaining ligament (ORL) release, midface fat transfer, canthoplasty, transcutaneous superficial muscular aponeurotic system–orbicularis elevation with midfacial ligament release, and orbicularis contouring. During the lower blepharoplasty, patients 1 and 4) (A and D) underwent inferior orbit fat transposition, and patients 2 and 3 (B and C) underwent orbit fat resection and/or contouring. A, Patient 1 is a 64-year-old woman shown 8 month postoperatively who also underwent concurrent upper blepharoplasty and brow-lifting. With midface flattening, she benefited from inferior orbit fat transposition. Four months after blepharoplasty, she underwent full-face fractionated laser resurfacing. B, Patient 2 is a 60-year-old woman shown 5 months postoperatively who also underwent endoscopic brow elevation and upper blepharoplasty. C, Patient 3 is a 61-year-old woman shown 5 months postoperatively. Without substantial ORL tethering or midfacial deprojection, she did not require orbital fat transposition, and underwent conservative orbital fat resection instead. Note excellent eyelid-cheek contour with camouflage of the malar mound. D, Patient 4 is a 60-year-old woman shown 18 months postoperatively who also underwent concurrent upper blepharoplasty and brow-lifting. With a tight ORL and midface flattening, she benefited from inferior orbit fat transposition, and to optimize her symmetry, some central and medial fat was trimmed on the left side. Six months after blepharoplasty, she underwent full-face fractionated laser resurfacing.

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