Enhancing Safety and Aesthetics in Lower Blepharoplasty: Outcomes of a Transcutaneous Technique with Canthal Anchoring and Orbicularis Oculi Sling Support

Goals/Purpose: There have been numerous advancements in the understanding of facial anatomy that have helped improve the safety and reliability of lower blepharoplasty. However, there still exists major controversies related to the ideal approach to lower blepharoplasty. Recently, many surgeons have preferred a transconjunctival approach given the increased rates of lower lid malposition, chemosis, persistent scleral show, and scarring. Contrarily, a transconjunctival approach does not allow addressing excess skin laxity or redundancy in orbicularis oculi and is associated with inadequate removal of fat. This study presents a retrospective review of a single surgeon’s practice to highlight the reliable and durable outcomes for a transcutaneous lower blepharoplasty with a lateral canthal anchoring suturing technique and orbicularis oculi muscle sling.

Methods/Technique: A retrospective chart review of 287 patients who underwent blepharoplasty in the senior author’s practice was conducted between October 2021 and September 2023. The inclusion criteria were patients who underwent cosmetic transcutaneous lower blepharoplasty with lateral canthal anchoring and orbicularis oculi sling. All patients included in the study had a minimum of 12 months of follow-up. The primary outcomes of interest included rate of complications and rate of operative revision.

The lower blepharoplasty technique we describe begins with performing a transcutaneous incision with a lateral extension past the lateral canthus. After addressing the other components of the lower blepharoplasty procedure –release of the orbital retaining ligament, fat transposition, and micro fat grafting– lateral canthal anchoring is performed using a crossed horizontal mattress suture with a double-armed 4-0 Vicryl on an S2 needle. The lid is positioned to ensure opposition with the globe to reduce post-operative chemosis. An orbicularis sling is then created to support the newly anchored lateral canthus. The overlying skin is then repositioned in a superior and oblique vector, and the redundant skin is excised at rest.

Results/Complications: 148 patients met the inclusion criteria, each having undergone bilateral lower blepharoplasty, for a total of 296 lower blepharoplasty procedures performed in the study period. The mean age of the study group was 57.6 years old (range, 22 to 83 years), with 121 female patients. Most cases were primary, with four revision blepharoplasty cases. All patients who underwent lower eyelid blepharoplasty also underwent autologous fat grafting to the upper cheek to aid in orbitomalar region contouring. 30 patients (27%) also underwent concomitant rhytidectomy. The mean follow-up period was 23.2 months, with a minimum of 12 months of follow-up for each patient. The quality and durability of cosmetic improvement from this operation was determined from photographic analysis. The rate of revision surgery was found to be 3.8% (five patients). Among this group, two patients needed minor scar revision under local anesthetic and three patients had persistent asymmetry with minor lower eyelid fullness. There were no instances of asymmetry in eyelid shape or a need for revision canthopexy.

Conclusion: This case series of 148 patients undergoing lower eyelid blepharoplasty with at least 12 months of follow-up demonstrates a low revision rate for both primary and revision surgery, with no revision surgery required for eyelid shape change. In our experience, a transcutaneous lower blepharoplasty with lateral canthal anchoring allows for maximal control over all anatomic regions in the lower lid. In this way, we have produced satisfactory aesthetic results while providing superior control over lower eyelid shaping with minimal revision rates.