Extended Blepharoplasty: A return To Incisional Surgery

    In the 1990s, we also entered the age of the lateral canthus and the appreciation of this anatomic region for stabilization of the lower eyelid during blepharoplasty. As procedures such as the lateral tarsal strip were still the most popular, the previous history should have been a clue to potential future problems. Cantholytic canthoplasty was used primarily for the treatment and correction of lower eyelid malposition and ectropion, both involutional and iatrogenic. Despite its usefulness for the treatment of these misadventures, problems related to its use in primary hlepharoplasty were soon to follow. Canthal asymmetry, misalign¬ment, and most of all eventual shortening of the hori¬zontal palpebral aperture, all made these procedures suboptimal (except in certain circumstances) for the average patient who presented for cosmetic lower hlepharoplasty. Flowers, Jelks, and McCord's contri¬butions in the advancement of routine canthopexy/ plasty have been enormous.

    May and colleagues in 1990 described sculpting and resection of the retroorbicularis oculi fat as a solution to the perceived heaviness and fullness of the infrabrow region in selected patients. In 1995, Aiche and Ramirez also described the excision of the suborbicularis oculi fat. Knize and Guyuron and colleagues described resection and/or interruption of the corrugator supercilii and procerus muscles through eyelid incisions; this process has only recently gained popularity. Owsley initially described a cheek lift by elevating the malar fat pad to reduce prominent nasolabial folds.
This was performed through a preauricular incision. May and associates described malar augmentation and a cheek lift through a subciliary incision. That same year, McCord and colleagues described a subperiosteal malar cheek lift combined with lower eyelid hlepharoplasty that is still currently used. The aim was to discover a solution to midfacial descent, and improve the deflationary changes of the lower periorbita by elevating the stronger tissue of the midface into the atrophic lower periorbita. A continuum of techniques has been developed, combined with simpler and more effective suture suspension methods for the lateral canthus. These address the descent of the orbicularis oculi and associated retaining ligaments for lower periorbital rejuvenation, resulting in fewer complications. Midfacial suspension has also been well-described through distant incisions (i.e. away from the eyelid; posterior hairline via the endoscope) and the process continues to evolve.

    A major focus has also been on fixation and suspension devices that continue to emerge. Barbed suture technology is evolving, whereby soft tissue can be more reliably suspended by sutures that can better grasp the affected regions with a greater drag coefficient (compared with simple braided or monofilament sutures). Absorbable plastic devices such as the CoApt systems offer the potential for better bone attachment during the healing (scarring) period to give longer lasting results.