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

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We read with great interest the article entitled “Evidence-Based Medicine: A Graded Approach to Lower Lid Blepharoplasty” by Hashem et al.1 We believe that the authors have clearly described all of the crucial aspects of the different lower eyelid blepharoplasty procedures, discussing their benefits and limits. After meticulously reporting the weakest points of each lower blepharoplasty technique, a graded approach was suggested. As the aging process of the orbital region usually affects skin, muscle, and fat of the eyes in a different manner, periorbital rejuvenation is a global process that requires the treatment of all of the anatomical components. The rejuvenation of individual anatomical components requires specific treatments according to their particular needs. However, separate management of each single tissue, by splitting skin and muscle into different flaps, might weaken the anterior lamella, resulting in a higher risk of complications. We fully agree with the authors that, to reduce the risk of postoperative defects, the surgical approach to the lower eyelid must be as conservative as possible, sparing orbicularis oculi muscle denervation and middle lamellar scarring.2,3 Although the separate setup of skin and muscle flaps during transcutaneous blepharoplasty is widely debated in the literature, a transconjunctival access, even if more conservative, does not fully allow muscle remodeling. Furthermore, a musculocutaneous flap does not permit both skin and muscle rejuvenation demands to be addressed simultaneously. We recently published an article that analyzes reinforcement of the anterior lamella, resulting in preservation from lower eyelid malposition during transcutaneous blepharoplasty.4 Although canthopexy or canthoplasty is mandatory for supporting lower lid laxity, orbicularis oculi muscle flap fixation to the periosteum of the upper lateral orbital rim seems to work efficiently to stabilize lower eyelid position after transcutaneous blepharoplasty. Even if canthal support is instrumental in transcutaneous procedures, the technique we proposed reinforces directly the anterior lamella by retensioning and lifting the orbicularis oculi muscle, avoiding procedures that involve directly the complex anatomy of the lateral canthus itself. (See Video, Supplemental Digital Content 1, which shows the harvesting of the orbicularis oculi muscle flap and its anchorage to the periosteum of the upper orbital rim, http://links.lww.com/PRS/C339.) Moreover, multiple innervation sources to the orbicularis oculi muscle protect the muscle itself from complete denervation during muscle flap harvesting.5 In conclusion, orbicularis oculi flap anchorage to the periosteum of the upper orbital rim during transcutaneous blepharoplasty represents a safe and simple additional surgical step that works efficiently to reinforce the anterior lamella. It permits separate management of skin and muscle components according to their specific needs, preserving postoperative natural cosmetic appearance and reducing the requests for more complex surgical procedures (Fig. 1).

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