AAPS, American Association of Plastic Surgeons
AAPS, American Association of Plastic Surgeons
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2009 Annual Meeting Abstracts

The Endoscopic Management of the Difficult Lower Eyelid: A Review of 300 Cases
Andrew P. Trussler, MD, Tim Schaub, MD, H Steve Byrd, MD.
The University of Texas Southwestern, Dallas, TX, USA.

Purpose: Periorbital rejuvenation requires an analytical approach in order identify the characteristics of the difficult lower eyelid. Scleral show, eyelid laxity, exorbitism, malar retrusion, and canthal malposition are common components to the difficult lower eyelid; though even if identified, an effective and safe treatment regimen remains elusive. The senior author has performed over 300 endoscopic brow and midface-lifts (EBMF), and has a series of suture fixation points to treat the lower eyelid. (Figure 1)
This study evaluates the efficacy of the endoscopic treatment of the difficult lower eyelid. The limitations and ancillary procedures were identified in order to define a treatment protocol for periorbital rejuvenation within the EBMF population.
Method: Patients who underwent 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. Post-operative photographs were objectively 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 one year. The majority of patients with a difficult lower eyelid were treated with endoscopic orbicularis repositioning combined with midface elevation. Additional suture points were used in 12% of the population. Pre-existing lower eyelid scleral show was the most common indication for additional endoscopic suture placement, with Point 2 suture placed. Excess lower eyelid skin and deep tear trough were effectively treated with complimentary procedures to the EBMF. There were no cases of post-operative lower eyelid malposition or middle lamellar retraction. Skin resurfacing and volumetric filling were the most common revision procedures in this population.
Conclusion: The difficult lower eyelid can be treated via an endoscopic approach with orbicularis repositioning and midface elevation. This technique preserves the innervation and continuity of the lower eyelid orbicularis oculi muscle, eliminating middle lamellar scarring and risk of post-operative malposition. Additional suture application is needed in only a minority of patients and ancillary lower eyelid procedures can be safely performed in the same operative setting.
Figure 1. Midface Points of Suture Fixation
Point 1: Malar Retaining Ligament Suture used always for midface elevation
Point 2: Pre-septal Orbicularis Oculi used for scleral show and lid laxity
Point 3: Pre-orbital Orbicularis Oculi used for exorbitism
Point 4: Deep Head of Lateral Canthal Tendon used for canthal malposition


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