PURPOSE

Periorbital rejuvenation requires a regimented pre-operative analysis in order to define characteristics of the difficult lower eyelid. Scleral show, eyelid laxity, exorbitism, malar retrusion, and canthal malposition should be identified pre-operatively, however an effective and safe operative regimen remains elusive. The senior author has performed over 300 endoscopic midface lifts and has devised a series of suture fixation points to treat the difficult lower eyelid.  This study defines factors that contribute to the difficult lower eyelid and describes an endoscopic treatment for them. The limitations and ancillary procedures were evaluated in order to devise an algorithm for periorbital rejuvenation.

METHOD Patients who underwent endoscopic midface and brow elevation (EBMF) by the senior author (HSB) were retrospectively evaluated. Preoperative patient photographs were analyzed by two blinded evaluators and then stratified into categories of lower eyelid morphologies. The categories included: lower eyelid malposition with scleral show, negative canthal tilt, negative vector orbit, exorbitism, and the deep tear trough. Intra-operative treatment and post-operative course were recorded, and post-operative photographs were evaluated. The data was analyzed to determine the pre-operative predictive patterns of endoscopic lower eyelid treatment.   

RESULTS

Three hundred patients (N=300) who underwent an EBMF between 1999 and 2007 were included in the study with the average follow-up of greater than one year. The majority of patients with a difficult lower eyelid were treated with endoscopic orbicularis repositioning combined with midface elevation. Suture 2, 3 and 4 were used in 14 % of the population with pre-existing lower eyelid scleral show being the most common indication for additional endoscopic suture placement. Excess lower eyelid skin necessitated removal with skin pinch, though if less than 3 mm of excess skin was present, resurfacing with chemical peeling or laser resurfacing was employed. A deep tear trough was treated with a transconjunctival septal reset as a complimentary procedure to the EBMF. Secondary post-operative skin resurfacing and volumetric filling was utilized in only a minority of patients. There were no cases of post-operative lower eyelid malposition or middle lamellar retraction.

CONCLUSION

The difficult lower eyelid can be treated via an endoscopic approach with orbicularis repositioning and midface elevation. Additional suture application is needed in only a minority of patients; however ancillary procedures can be safely performed in the same operative setting. An endoscopic lower eyelid algorithm will be presented.