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Surgical Pearls |

Extended Submuscular Blepharoplasty With Orbitomalar Ligament Release and Orbital Fat Repositioning ONLINE FIRST

Andrew A. Jacono, MD1,2,3; Melanie H. Malone, MD3
[+] Author Affiliations
1Facial Plastic and Reconstructive Surgery, North Shore University Hospital, Manhasset, New York
2Facial Plastic Surgery, New York Eye and Ear Infirmary and Albert Einstein College of Medicine, New York, New York
3New York Center for Facial Plastic and Laser Surgery, New York, New York
JAMA Facial Plast Surg. Published online September 08, 2016. doi:10.1001/jamafacial.2016.1047
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This Surgical Pearl presents a description and video illustrating the technique of extended submuscular blepharoplasty with orbitomalar ligament release and orbital fat repositioning.

The aging appearance of the lower eyelid involves a combination of degenerative changes including excess lower eyelid skin, “bags” from lower eyelid fat pseudoherniation, under-eye circles from devolumization of the soft tissues overlying the infraorbital rim, and upper midface ptosis from redundant orbicularis oculi muscle. Our lower blepharoplasty technique addresses all these changes while preserving a robust orbicularis oculi sling and maintaining lower eyelid position with periosteal fixation of the lateral canthus and skin-muscle flap (Figure 1A). This technique should be avoided in patients with negative vector lower eyelids and poor orbicularis muscle strength because they are at increased risk for lower eyelid malposition postoperatively.1 The technique can be viewed in the Video.

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Figure 1.
Extended Submuscular Blepharoplasty With Orbital-Malar Ligament Release and Orbital Fat Repositioning

A, Illustration depicting the critical elements of the procedure. SOOF indicates suborbicularis oculi fat pad. B, The skin flap is elevated inferiorly with a sharp iris scissors for approximately 1.5 cm, preserving an intact sling of functional pretarsal and preseptal orbicularis muscle. C, The composite skin muscle flap is elevated off the orbital septum to the orbital rim. The orbital retaining ligaments are released beyond the inferiormost aspect of the preoperatively marked tear trough superficial to the SOOF. D, The medial and central fat pads are rotated inferiorly over the orbital rim and fixated to the supraperiosteal plane. This technique fills the medial tear trough defect and blends the lower eyelid–cheek junction. The lateral fat pad has been conservatively excised. E, Submuscular flap is fixated to the periosteum of the orbital rim with a 6-0 nylon suture. The skin is redraped superolaterally so that most of the skin is removed lateral to the lateral canthus, and a minimal amount of skin is removed subciliarly.

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Figure 2.
Preoperative and Postoperative Photographs

Photographs depict a woman in her 60s who underwent extended submuscular blepharoplasty with orbital-malar ligament release and orbital fat repositioning. Note the preoperative lower eyelid excess skin, pseudoherniated eyelid fat, infraorbital hollowing, and upper midface ptosis. The preoperative lower eyelid position is maintained after surgery.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Extended Submuscular Blepharoplasty With Orbitomalar Ligament Release and Orbital Fat Repositioning

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