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For a number of years, the two accepted methods used to treat the aging eyelid surgically have been the skin flap technique, with excision of excess skin and removal of herniated fat pads [2, 7, 8], and the skin-muscle flap technique, with excision of herniated fat pads and excess skin and muscle [1]. Although both procedures have produced excellent results in selected patients, the disadvantages associated with each are numerous (Tables I and 2).

The combined skin and skin-muscle flap technique described in this article is a very conservative approach to lower blepharoplasty that involves minimal anatomical disturbance and that effectively corrects anatomical derangement associated with aging. The intention in devising this variation in lower blepharoplasty was to create a skin flap over the pretarsal segment of the orbicularis oculi muscle, preserving the intimate anatomical relationship between the muscle and the tarsal plate (Fig 1).

	Fig 1. (A) Basic concept of skin and skin-muscle flap technique. (Dashes indicate lines of dissection.) (B) Dissection of skin flap over pretarsal portion of the orbicularis muscle and skin-muscle flap over the septum orbitale. (C) Excess muscle excised or (D) excess muscle overlapped (see text). (E) Front view showing the pretarsal part of the orbicularis muscle intact and preseptal muscle raised together with the skin, over the septum orbitale.
Table 1. Lower Blepharoplasty Skin Flap Tecbnique Advantages Disadvantages 1. Maintains the anatomical relationslup of the tarsus to the orbicularis muscle. 2. Necessary amount of skin may be excised independently of muscle. 3. Decreases tendency to produce pretarsal flatness. 1. Involves difficult and tedious dissection. 2. Irregularities, bumps, and muscle bulges may be visible under the thin skin flap. 3. No muscle toning can be done. 4. Results in hyperpigmentation.
Table 2. Lower Blepharoplasty Skin Flap Tecbnique Advantages Disadvantages 1. Provides for easy and fast dissection (except for pretarsal portion) and less bleeding during dissection. 2. Decreases chance of skin slough, hyperpigmentation, and subcutaneous hematoma. 1. Destroys anatomical relationship of tarsus to orbicularis muscle. 2. May produce pretarsal flatness. 3. Causes ectopion if required amount of skin is removed (too much muscle is removed). 4. Creates possibility of epiphora because of orbicularis muscle pump disturbances.

Fig. 2. Operative technique. (A) Horizontal incision at the lateral canthal area. (B) Elevation of skin flap over pretarsal part of the orbiculazis muscle with tenotomy scissors. (C) Subciliary incision completed, (D) Skin flap completed. (E) Muscle incised and skin muscle flap raised (F) Excess orbital fat removed. (G), (H) Excess muscle excised laterally and superiorly; lateral toning of the preseptal orbicularis muscle done. (I) if the operation has been done correctly, opening the mouth, pressing the orbit, and similar maneuvers will not change the position of the skin flap appreciably. (J) Excess skin removed along the margin of the lower eyelid (not at the incision line). (K) Lateral excision. Usually more skin is removed laterally than at the infraciliary area. (L) Repain completed with 6-0 continuous nylon sutures.

Operative Technique

A lateral canthal incision is made, with dissection of the skin overlying the pretarsal portion of the orbicularis muscle to a width of approximately 6 mm (Fig 2A). Elevation of the skin flap is completed with an incision directly beneath the eyelashes, usually with a pair of small tenotomy scissors (Fig 2A-D). At the level of the inferior edge of the tarsus, this skin flap is converted to a skin-muscle flap (Fig 2E), leaving intact the part of the orbicularis muscle corresponding to the tarsus. The pretarsal portion of the muscle is separated from the preseptal portion of the muscle, and the skin flap becomes a skin and skin-muscle flap. Dissection under the muscle is done quickly; herniated fat pads become accessible, and are removed as in conventional blepharoplasty (Fig 2F). In the lateral canthal area, the portion of the orbicularis muscle corresponding to pretarsal muscle fibers is not cut. However, the portions corresponding to the septal portion are cut to facilitate excision of the fat pads (see Fig 2E, F).

Repair begins with draping of the entire flap upward and laterally over the eye and upper eyelid (Fig 2I, J). This flap usually rests at an appropriate level without traction. The laterally cut edge of the preseptal portion of the orbicularis muscle is lifted with forceps and moved laterally and superiorly. Toning and tightening of the preseptal portion of the orbicularis muscle are accomplished by removing part of the muscle laterally and suspending it from the lateral canthal area with deep sutures (5.0 Vicryl; Ethicon Co., Somerville, NJ) to the periosteum and stump of the muscle (Fig 2H). This suturing should be done very carefully to avoid excessive tension on the muscle; however, there should be sufficient toning to achieve a youthful concavity in the preseptal area. At this point, maneuvers such as opening the mouth or putting pressure on the orbit will not pull the flap downward if the amount of the lateral traction is correct (see Fig 2I). The pretarsal portion of the muscle and the frame of the eye are left intact with no cuts. If, in an older person, tarsorrhaphy shortening or a similar procedure appears necessary, it is done at this time.

With appropriate caution, excess skin, muscle, or both may be excised from the infraciliary and lateral canthal areas. As a safety measure, excision of the excess tissue is performed at the level of the lower lid margin (not the incision line) to prevent excessive excision (Fig 2J, K). Although it may be tempting to remove all of what appears to be excess flap tissue to the incision line, 2 to 3 mm of skin should be left intact to account for the depression created under the lower eyelid. Skin repair is performed with no tension (Fig 2L). Closure is completed with 6-0 nylon sutures.

Results

The combined skin and skin-muscle flap technique has been used to perform bilateral inferior blepharoplasty in 350 patients ranging in age from 30 to 75 years. It is a safe, fast, and easy procedure that produces consistently satisfactory results with fewer complications than previously employed techniques. Table 3 lists the improvements achieved by this technique.

Discussion

The combined skin and skin-muscle flap technique is a conservative and anatomically sound approach to lower blepharoplasty. The pretarsal portion of the orbicularis muscle is responsible for blinking and for pumping to drain the lacrymal system. This technique demonstrates that adequate blepharoplasty may be accomplished without detaching the orbicularis muscle from the tarsus, while maintaining access to the preseptal portion of the orbicularis muscle. This is the portion of the muscle that becomes lax with aging and that usually needs toning (Fig 3). Leaving the pretarsal muscle intact not only preserves the anatomical function of the muscle but also saves time, because detaching the muscle from the tarsal plate is tedious and somewhat bloody. Another important aspect of this method is preservation of nerve supply to the pretarsal orbicularis muscle. (Nerve supply is lateral and will usually be preserved with the bridge of the intact muscle, laterally.)

This technique has some of the advantages of both previously reported methods of lower blepharoplasty [2-5]. The combined skin and skin-muscle flap technique permits independent treatment and reduction of muscle and skin. Because the redundancy of skin and muscle varies from one patient to another, the ability to handle and reduce each structure independently is self-evident.

In my experience, complete separation of the skin flap and muscle flap is unnecessary [6]. Complete skin and muscle flap separation has the inherent disadvantages of both skin flap and muscle flap techniques, violates pretarsal muscle anatomy, and involves unnecessary dissection between the preseptal muscle and skin.

The technique of skin and skin-muscle flap blepharoplasty also has some incidental advantages. Overlapping of the pretarsal and preseptal orbicularis muscle, if desired, could create infraciliary fullness more safely and easily than the method suggested by Sheen [9, 10]. This fullness could be considered desirable by patients in some ethnic groups, as well as patients with atrophic lid margin (see Fig 1D). Furthermore, because the lid margin becomes independent of the preseptal orbicularis muscle in the course of the procedure, satisfactory toning of the preseptal muscle laterally can be achieved (see Fig 3, Fig 4). Lateral suspension also lifts the ptotic cheek from the nasolabial fold to a varying degree. It should be emphasized that this effect on the cheeks is incidental, and overenthusiastic attempts to lift cheeks with this method should be avoided.

A	B
C	D
E	F
G	H
	Fig. 3. Preoperative (A, C, E, G) and postoperative (B, D, F, H) views of patient with atonic orbicularis muscle. Notice the marked improvement in the orbicularis muscle tone.

Since 1984, when the skin and skin-muscle flap technique was initially presented, a number of plastic surgeons around the United States have adopted the technique. Their comments have reiterated that this technique is easy to perform and teach. In fact, some consider it the safest method of lower blepharoplasty (Carraway JH: personal communication, 1989).

A	B
C	D
E	F
G	H
I	J
	Fig. 4. Preoperative (A, C, E, G, I) and postoperative (B, D, F, H, J) views of patient with herniated orbital fat and atomic orbicularis muscle and skin excess. Postoperative views show improved appearance and function. (Improvement in eyelid aperture is the result of blepharoplasty only.)

References

1. Beare R: Surgical treatment of senile changes in the eyelids: the Mclndoe-Beare technique. In Smith B, Converse JM (eds), Proceedings of the Second International Symposium on Plastic and Reconstructive Surgery of the Eye and Adnexia. St Louis, Mosby, 1967

2. Castenares S: Eyelid plasty. In Goldwyne RM (ed), The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. Boston, Little, Brown, 1982, p 267

3. Courtiss EH: Selection of alternatives in aesthetic blepharoplasty. In Rees TD (ed), Modern Trends in Blepharoplasty. Clin Plast Surg 8:739, 1967

4. Edgerton MT: Causes and prevention of lower lid ectropion following blepharoplasty. Plast Reconstr Surg 49: 367, 1972

5. Flowers RS: Blepharoplasty. In Courtiss EH (ed), Male Aesthetic Surgery. St Louis, Mosby, 1982, p 207

6. Klatsky SA, Manson PN: Separate skin and muscle flaps in lower lid blepharoplasty. Plast Reconstr Surg 67: 151,1981

7. Rees TD: Aesthetic Plastic Surgery. Philadelphia, Saunders, 1980

8. Rees TD (ed): Modern Trends in Blepharoplasty. Clin Plast Surg 8:643, 1967

9. Rees TD: The voice of polite dissent: comment on [10]. Plast Reconstr Surg 62:295, 1978

10. Sheen JH: Tarsal fixation in lower blepharoplasty. Plast Reconstr Surg 62:24, 1978

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