Lower Lid Subciliary Blepharoplasty Treatment & Management

Updated: May 03, 2019
  • Author: Scott J Rapp, MD; Chief Editor: James Neal Long, MD, FACS  more...
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Intraoperative Details

Patient preparation, marking, and incision

Anesthesia routes for the procedure should be carefully considered before the operation, balanced with the desires of the patient and the complexity of the operative plan. The procedure can be performed under local, monitored anesthesia care with local anesthesia or general anesthesia.

The face is prepared with povidone-iodine paint and a subciliary incision is designed approximately 2mm below the ciliary margin. If possible, a natural crease should be selected to aid in camouflaging the scar (see the image below). It is important that the extension of the lateral incision is not carried past the orbital rim to prevent surgical stigmata.

Subciliary incision design as reported by Rees and Subciliary incision design as reported by Rees and Dupuis.

After the administration of MAC or general anesthesia, a 30-gauge needle on a small-volume syringe is used to infiltrate along the designed incision in the subcutaneous, pre-muscular plane with 1% lidocaine with 1:200,000 epinephrine buffered with 8% sodium bicarbonate, mixed in a 1:5 ratio. The lateral and inferior orbital rim should also be infiltrated at the level of the periosteum if a canthopexy/canthoplasy or arcus marginalis release is planned. A period of 7-10 minutes is allowed to elapse to maximize the vasoconstrictive effects of the epinephrine. The contralateral side can be addressed after completion of the first side.

Flap elevation

The lateral portion of the incision is made along the predetermined marking, leaving the orbicularis oculi muscle beneath the skin intact. A curved iris scissor or tenotomy scissor is then employed to develop a subcutaneous plane along the subciliary marking and the skin is cut accordingly, avoiding the eyelashes.

A Frost suture (5-0 nylon or silk) may then be placed in the gray line lateral to the limbus, to protect of the globe and to facilitate retraction. In addition, a well-lubricated corneal shield may also be inserted.

Depending upon the anatomical correction required, a skin only or skin-muscle flap is then elevated. If a skin flap is chosen, it is elevated down to the level of the inferior orbital rim or the last skin wrinkle. Electrocautery under low power is used to achieve hemostasis throughout the course of dissection.

A skin-muscle flap may be elevated using the same incision. When this approach is utilized, a skin flap is elevated, preserving the most cephalad 4 mm of pretarsal orbicularis oculi muscle. Once completed, the orbicularis oculi muscle is then divided. The avascular retro-orbicularis plane is then developed down to the level of the inferior orbital rim, between the overlying muscle and the orbital septum. Special care should be taken not to perforate the septum (see the image below). Castro recommends a skin-muscle flap if there is orbicularis oculi muscle redundancy or flaccidity. [40]

Technique of skin-muscle flap elevation from Rees Technique of skin-muscle flap elevation from Rees and Dupuis.

Management of orbital fat

The management of orbital fat is best determined before entering the operating room. Preoperatively, the presence or absence of excess orbital fat is assessed while the patient is sitting erect. With this information, clinical decisions can be made regarding the volume and location of fat excision or whether retroseptal fat should be preserved. This is more difficult to do in a supine position, however, balloting the globe can aid in judging whether excess retroseptal fat has been adequately excised. The negative effects of over-resection of lower lid retroseptal fat include a hollowed-out, cadaveric appearance.

In the event that a skin flap has been elevated, button-hole type incisions can be made in the orbicularis muscle through the septum over the medial, central and lateral fat compartments, depending on which compartments contain excess fat. A skin-muscle flap affords the surgeon exposure to all of fat compartments. After injecting the target of excision with local anesthetic, the septum is incised. Excess orbital fat can then be teased out with fine forceps and a cotton-tip applicator, and subsequently resected with a fine-tip insulated electrocautery (see the image below). Routine identification of the inferior oblique muscle prior to fat resection of the medial and lateral compartments is not necessary.

Depiction of retroseptal fat compartments and fat Depiction of retroseptal fat compartments and fat resection.

Release of the arcus marginalis and the orbicularis oculi muscle attachments at the medial and central aspects of the inferior orbital rim is a useful adjunct that can blunt a prominent tear trough/nasojugal groove. [13] Our practice is to mark the nasojugal groove in the preoperative setting with the patient sitting. Once adequate exposure is achieved whether the approach is transcutaneous or transconjunctival, the medial and central attachments of the arcus marginalis are released along the previously marked line. After hemostasis achieved, blunt dissection in a supraperiosteal plane is performed along the inferior orbital rim with a Freer elevator to create a pocket for the transposed fat. The retroseptal fat in the medial and central compartments is then gently transposed over the inferior orbital rim and secured with several interrupted 5-0 Vicryl suture to the base of the pocket.

Liapakis et al described a subciliary technique that uses fat redraping blepharoplasty and a midface lift to address tear nasojugal groove deformity and midface laxity. The procedure includes a subciliary incision in which fat removed from the nasal fat pad is repositioned, with suturing performed at the inner canthus, followed by a canthopexy to secure the lower eyelid. The technique also utilizes a cheek flap, which is suspended through a tunnel at the periosteum of the upper-lateral orbit. The study reported on 35 procedures, with stable results seen at 4-year follow-up. [41]

Alternative techniques have also been described to manage the pseudoherniation of retroseptal orbital fat. Huang proposed suture plication of the orbital septum to blunt the transition of the lower lid into the malar eminence by smoothing redundant septum (see the image below). [42] Hamra later described a septal reset procedure to address redundancy whereby the orbital septum is released from the arcus marginalis and re-sutured over the inferior orbital rim, smoothing the transition between the lid-cheek junction. [43]

Huang's technique for plication of the septum. Huang's technique for plication of the septum.

Stevens et al described a triple-layer midface lift procedure, performed in 512 patients, in which postseptal fat, suborbicularis oculi fat, and the musculocutaneous layer of skin and orbicularis oculi are repositioned through a subciliary incision. [44]

Orbicularis oculi muscle

After management of the orbital fat is completed, elevation and fixation of the orbicularis oculi muscle has been utilized to smooth redundant muscle and to aid in support of the lower lid. Hamra described using a laterally based pendant of redundant orbicularis oculi muscle and suspending it to the lateral orbital rim through an upper lid incision (see the image below). [13] McCord et al. proposed a similar maneuver in which the pretarsal orbicularis oculi muscle and overlying skin are affixed to the internal lateral orbital rim in superolateral vector. [45] If extra support is not indicated, 1-2 mm of orbicularis oculi muscle may be excised from the skin muscle flap.

Hamra's lateral orbicularis suspension. Hamra's lateral orbicularis suspension.

Lower lid support

Lower lid malposition including lower lid retraction, scleral show and ectropion is a potential complication especially in the morphogenically prone patient. Lower lid laxity as determined by excess anterior distraction of the lid, prolonged snap back testing, a negative vector relationship and prominence of the globe are all preoperative risk factors and in the opinion of many authors, definitive indications for lateral canthal tightening. [25, 26, 27, 45]

Multiple algorithms to determine the appropriate technique used for lateral canthal support have been described and are beyond the scope of this review. [25, 26, 27, 45] In our practice, we perform a canthopexy in patients with a negative vector relationship and mild-moderate lower lid laxity as defined by an abnormal snap back test (greater than 1 second) and in patients with less than 6mm of anterior lower lid distraction. [46]

Many different techniques utilizing various sutures and fixation methods have been published. [25, 26, 27, 45] It is our practice to approach the lateral retinaculum from the lateral aspect of an upper blepharoplasty incision similar to Fagien’s technique (see the image below). [27] The lateral retinaculum is grasped through the upper lid incision with fine tip forceps and manipulated to confirm its anatomic identity. A 5-0 vicryl suture is then passed through the lateral retinaculum from the upper lid incision into the lateral aspect of the lower subciliary incision. From the lower subciliary incision, the lateral retinaculum is captured again with the suture and brought out the upper lid incision. While protecting the globe, the suture is then passed into the periosteum approximately 4mm internal to the lateral orbit rim at the caudad border of the pupil. The suture is tightened to visualize the superoposterior movement of the lateral canthal angle, coapting thelowerlidtotheglobe.

Fagien's simplified lateral canthopexy. Fagien's simplified lateral canthopexy.

Canthoplasty is best reserved for patients with significant lower lid laxity as defined by McCord as greater than 6 mm of anterior distraction of the lower lid from the globe. [45] In general, canthoplasty as it pertains to aesthetic blepharoplasty, involves lysis of the lower lid’s contributions to the lateral canthus, excision of the excess lateral lower lid followed by anatomic re-suspension of the lower lid and tarsal plate to the lateral orbital rim (see the image below). Other horizontal lower lid shortening and support techniques have been described such as the tarsal strip canthoplasty and Kuhnt-Symanowski procedures and are beyond the scope of this review. [27, 45, 47, 48]

Fagien's lateral canthoplasty. Fagien's lateral canthoplasty.

Skin excision

Management of the excess lower eyelid skin is performed in a judicious manner, given that overly aggressive skin excision is a contributing factor to lower lid malposition. Under no tension, the skin is gently re-draped over the underlying lower lid structures. A vertical “pilot cut” is made at the level of the lateral canthus and a 6-0 nylon suture is placed approximating the superficial skin edges at this point. Once this point is affixed, the skin medial and lateral to this point is excised at the level of the subciliary incision (see the image below).

Skin excision and closure. Skin excision and closure.

If a skin–muscle flap was elevated, the suture is then removed and the redundant orbicularis oculi muscle is excised so it approximates under no tension to the pretarsal orbicularis that was preserved with flap elevation. The superficial skin edges are then re-approximated using alternating interrupted 6-0 nylon sutures and 6-0 fast absorbing gut sutures.


Postoperative Details

Postoperatively, chilled gel or ice compresses are applied to the periorbita for the first 24-48 hours and for comfort thereafter to control edema. Patients should be observed for at least 1-2 hours in the recovery unit and discharged only after checking their vision. Postoperative instructions should include elevation and avoidance of strenuous activity to decrease edema, lower intraocular pressures and to reduce the likelihood of hemorrhage.

Ocular lubrication with artificial tears and nighttime lubrication with ophthalmic bacitracin ointment is recommended for all patients. This is particularly important if the patient has a preexisting history of dry eyes or if lagophthalmos is present subsequent to edema. While the use of lubrication can prevent corneal abrasions and reduce exposure, prophylactic treatment with an ophthalamic tobramycin and dexamethasone solution can aid in the prevention and hasten the resolution of chemosis.

Clear lines of communication should exist between the patient and surgeon, particularly in the first few days after surgery. Any reports of unusual pain or visual disturbances merit careful attention and evaluation. Sutures are removed 4-7 days following surgery.



Visual loss/Retrobulbar hemorrhage

The most devastating complication from an aesthetic procedure is the loss of normal physiologic function. Although rare, visual loss is the most feared complication in periorbital rejuvenation, resulting primarily from retinal/optic nerve ischemia secondary to increased intraocular pressure caused by retrobulbar hemorrhage. The frequency of this complication is 0.0045% or one case in 22,000 procedures. A more common complication is the incidence of retrobulbar hemorrhage, which was reported in 1 of 2000 cases or 0.05%. In this series, 96% of the reported hemorrhages occurred within the first 24 hours and more than half within 6 hours of the procedure. [49] Thus, timely recognition and emergent intervention is of paramount importance.

In this circumstance, patients will report a constellation of symptoms including periorbital pain and pressure. These complaints should be taken seriously as these patients may initially present only with periorbital edema and subconjunctival hemorrhage. As intraorbital and intraocular pressures increase, superior orbital fissure syndrome may ensue, defined by proptosis, ptosis and diplopia secondary to paralysis of the extraocular muscles. The addition of visual deterioration defines orbital apex syndrome.

Prevention begins by thoroughly screening the patient at the time of the preoperative assessment for risk factors that may exacerbate hemorrhage. Intraoperative measures are equally important, including perioperative blood pressure control, meticulous hemostasis, retroseptal fat excision under direct vision and the avoidance of deep injections. Postoperatively, antiemetics should be administered and patients are instructed to avoid strenuous activity for 2 weeks.

If retrobulbar hemorrhage or visual changes occur postoperatively, the patient must be evaluated emergently for medical and surgical intervention. Elevated intraocular pressures can be treated with topical and systemic glaucoma medications. Systemic corticosteroids can also be administered. Surgical management consists of suture removal and evacuation of hematoma with subsequent control of any hemorrhage. If no improvement is noted, a lateral canthotomy and cantholysis is performed. In rare circumstances, decompression of the orbital apex is warranted if computed tomographic scan confirms the diagnosis of more posterior hemorrhage. [50]

Lower lid malposition

Lower lid malposition can be an equally devastating complication. In the intermediate postoperative period it is one of the most common complaints, usually attributed to excess skin resection, edema, superficial hematoma, tethering of the orbital septum or failure to provide lower lid support in the morphogenically prone patient. Temporary paralysis of the orbicularis oculi muscle can also result in lid malposition. Mild scleral show and lid malposition can be initially managed with massage and lubrication. [51] Another option is to remove sutures on postoperative day 2 or 3 to allow for a gap in the wound, which is less aesthetically ideal, but decreases the chance of an ectropion. [52] The failure of conservative measures indicates that there is either deficient tissue from overresection, cicatrization or horizontal lid laxity. The first two causes are usually amenable to skin grafting whereas lower lid laxity is addressed with a combination of lid shortening and lateralcanthalrepositioningprocedures.

Corneal abrasion

Corneal abrasion is another preventable cause of vision loss, albeit temporary in most circumstances. Patients will report symptoms of eye pain, complaints of a foreign body sensation, altered vision and light sensitivity that manifests immediately after surgery. If a corneal abrasion is suspected, ophthalmologic evaluation is warranted. The diagnosis is confirmed by examining the eye under a Woods lamp after the application of fluorescein drops. Prevention of epithelial desiccation and intraoperative corneal injury is accomplished with careful attention to technique, lubrication and the use of eye shields. Ophthalmic antibiotic ointment is an effective treatment of superficial injuries, and the patient’s progress should be monitored daily until their symptoms resolve. A prolonged course should prompt a referral to an ophthalmologist for evaluation.

Dry eye syndrome

Postoperative prevention of dry eye syndrome should focus on minimizing edema, maximizing hydration and lubrication, and preventing infection. Head elevation, cool compresses, artificial tears and lubricating ointments should be routinely used. Strategies for reducing the risk of postoperative dry eye in high-risk patients include staggering the timing of the upper and lower procedures, temporary tarsorrhaphy, lateral canthal support and punctal occlusion. Judicious excision of lower lid skin is also extremely important for preventing lid malposition and its sequelae.


Chemosis is defined as edema of the bulbar and fornical conjunctiva which is often associated with inflammation. It is the result of intraoperative dissection resulting in lymphatic dysfunction and edema, which leads to a self-propagating cycle of conjunctival exposure, inflammation and worsening chemosis. [53] As with corneal abrasions, patients may present with complaints of a foreign body sensation, irritation and epiphora. Weinfield et al. presents a comprehensive treatment algorithm for chemosis ranging from conservative measures to surgical intervention. In general, the initial steps for management are similar to the treatment for corneal abrasion and dry eye syndrome, utilizing wetting drops and ophthalmic ointment. More aggressive measures for refractory cases include ophthalmic steroid drops, patching, surgical intervention and systemic steroids. [53]

Other complications

Less common complications include globe perforation during local anesthetic infiltration, central retinal artery embolization, diplopia and infection. While all complex surgical procedures carry some element of risk for complications, transcutaneous lower lid blepharoplasty can performed in a safe, efficient manner as long as proper patient selection, counseling, surgical technique and surgical judgment are exercised.



In a study of 100 patients who underwent bilateral skin-muscle flap lower eyelid blepharoplasty, Sultan et al found that the procedure led to a small change in eyelid position, with a mean increase found in the distance from the pupil to the lower eyelid margin of 0.33 mm and a mean increase seen from the lateral limbus to the lower eyelid margin of 0.32 mm. A significantly greater change in both measurements was found in patients who underwent concurrent canthopexy. Revision surgery was need in only two patients secondary to eyelid malposition. New onset of dry-eye symptoms occurred in 25 patients. [54]