Reply: Evidence-Based Medicine
The technique described by Innocenti et al.2 differs from the conventional transcutaneous approach in delamination of the anterior lamella into separate skin and orbicularis oculi layers followed by fixation of the muscle flap craniolaterally to correct muscular redundancy and simultaneously reinforce the anterior lamella and achieve lid tightening.2 Their study suggests improved postoperative lower lid position secondary to this orbicularis suspension.2 Zoumalan et al. in 2010,3 also using digital image analysis, documented comparable findings. Authors such as Schiller4 and Hester et al.5 similarly believe postoperative lid position to be more dependent on midface lifting rather than canthal tightening. Orbicularis suspension, it should be noted, is not novel and has been previously described in conjunction with face lifts and lower blepharoplasty to improve midface and lower eyelid contours. Although the approach described by Innocenti et al.2 is quite acceptable in select patients with no or mild laxity, blepharoplasty, it should be remembered, has evolved from a standardized technique to a more customized procedure where sound clinical analysis guides appropriate treatment strategies. Thus, patients with greater tarsoligamentous redundancy might still require “procedures that involve directly the complex anatomy of the lateral canthus,”2 namely, canthopexy or canthoplasty.
In blepharoplasty, it is now clear that a dichotomy exists between transconjunctival and transcutaneous approaches. The former, though less injurious to skin and orbicularis oculi, precludes meaningful cutaneous and muscular modifications unless some form of resurfacing is added. The traditional transcutaneous access, in contrast, permits more comprehensive treatment of these elements but at the expense of more aggressive anterior and middle lamellar violation. Consequently, lid malposition is more prone to develop postoperatively and may manifest as rounding of the palpebral fissure, increased margin reflex distance-2, scleral show, or frank ectropion. The “inside outside” approach is believed to mitigate these drawbacks. In this technique, fat is removed/redraped transconjunctivally and cutaneous redundancy excised with either a pinch or skin-only flap.
Irrespective of the technique chosen, lid tone (snap-back and distraction), vector, canthal tilt, canthal-rim distance, and margin reflex distance-2 are critical predictors of postoperative lid malposition and should be analyzed meticulously in every patient. Specifically, in the conventional skin-muscle flap approach, given the obligatory anterior and middle lamellar manipulation, a lid-tightening procedure is mandatory. In conjunction with orbicularis suspension, this is most appropriately accomplished with an additional canthopexy or canthoplasty based on a lid-globe distraction distance that is inferior or superior to 6 mm, respectively.