While cosmetic eyelid surgery is very common, there are major differences between the upper and lower blepharoplasty procedure. This is primarily due to the much more static but suspensory nature of the lower eyelid. This makes it much more unforgiving than the upper eyelid and even slight disruptions of support or scar contracture creates lid malposition. This challenge is magnified in the thick-skinned lower eyelid patient.
In the February 2018 issue of the journal Facial Plastic Surgery a paper entitled ‘Managing the Lower Eyelid Complex in the Thick-Skinned Patient’. In this paper the authors address the differences in lower eyelid anatomy and surgical technique in performing lower bepharoplasties in skin color of Fitzpatrick III or higher. Such patients will have thicker skin and more pigment which predisposes them to pigmentary dyschromia and hypertrophic scarring particularly if peels and laser treatments are simultaneously done. Conversely the thicker skin develops fewer wrinkles and hides irregularities better with fat grafting or fat transposition. Because of the weight of the lower eyelid complex, canthopexies and canthoplasties should be liberally used to prevent postoperative lid malposition. Short-term postoperative lubrication should be aggressively used as they are predisposed to a higher incidence of temporary lagothalmos. Other highlights of this paper include:
The use of a transconjunctival approach for herniated fat removal or transposition when there is no significant skin redundancy. A preseptal approach is preferred over the post septal approach.
In the transcutaneous skin-muscle flap technique, conservative skin trimming should be done. Various maneuvers can be done to mimic the natural stretch that will occur on the lower eyelid to help avoid over resection. Orbicularis muscle resuspension to the lateral orbital rim should always be done.
Patients with positive preoperative snap and distraction lower eyelid tests should have either canthopexy or a canthoplasty. When mild support is needed a canthopexy using the inner edge of the lateral orbital rim periosteum. When more support through a horizontal lid shortening is needed a tarsal strip technique is used.
When lower lid skin resurfacing is indicated a medium depth peel of either 35% TCSA or 88% phenol is used.
The use of Botox injections, either before or after lower blepharoplasty, for crow’s feet is unchanged from thin skinned patients.
While the management of the thick-skinned lower eyelid patients has some unique considerations, successful outcomes with a low incidence of manageable complications can result.
Dr. Barry Eppley
Indianapolis, Indiana