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Plast Reconstr Surg. 2017 Jan;139(1):139e-150e. doi: 10.1097/PRS.0000000000002849.

Evidence-Based Medicine: A Graded Approach to Lower Lid Blepharoplasty.

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Cleveland, Ohio; and Cairo, Egypt From the Departments of Plastic Surgery and Anatomy, Cleveland Clinic; and the Department of Plastic Surgery, Cairo University.



After studying this article, the participant should be able to: 1. Define the anatomy of the lower eyelid tarsoligamentous framework and the related periorbital retaining ligaments, and cite their surgical relevance. 2. Perform a systematic functional and aesthetic evaluation of the lower eyelid focusing on the lid-cheek junction, and clinical tests that predict the need for lateral canthal tightening. 3. Enumerate the different approaches to lower eyelid rejuvenation and discuss their merits/limitations. 4. Describe surgical strategies to blend the lid-cheek junction and tighten the lateral canthal retinaculum.


Modern lower lid blepharoplasty requires a thorough understanding of periorbital anatomy, age-related changes of the lid-cheek junction, and the variables controlling lower lid tone and position. The surgical strategies are best used in a graded fashion. The patient with isolated lower lid bags may be treated by transconjunctival fat resection alone. Additional mild skin laxity can be improved with skin pinch or skin-only undermining. Skin resurfacing using chemical peeling or laser can further address fine lines. In these patients with an abnormality of the lid-cheek junction, release of the medial orbicularis oculi muscle and variable amounts of the orbicularis retaining ligament is essential. This is combined with orbital fat resection or repositioning through a transconjunctival or transcutaneous skin-muscle flap. The transcutaneous approach most often necessitates lateral canthal tightening to optimize lid margin control. Generally, the degree of laxity dictates whether a canthopexy or a canthoplasty is most appropriate. Lateral canthal procedures can be applied to patients displaying clinical signs predictive of lid malposition and to those presenting with varying degrees of established lid descent.

[Indexed for MEDLINE]

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