The Aesthetic Guide is part of the Informa Markets Division of Informa PLC

This site is operated by a business or businesses owned by Informa PLC and all copyright resides with them. Informa PLC's registered office is 5 Howick Place, London SW1P 1WG. Registered in England and Wales. Number 8860726.

Achieving the lower eyelid ideal

Two cosmetic facial surgeons have found that a combination of transconjunctival lower lid blepharoplasty, fat grafting and 88% phenol peeling is superior to other eyelid rejuvenation approaches. When performed correctly, the combination consistently restores the aesthetic ideal of the lower lid and cheek junction, according to their recently published research.

Dr. WadeMany of today’s lower eyelid rejuvenation approaches fall short of achieving the aesthetic ideal, according to the paper’s lead author Wade D. Brock, M.D., an oculoplastic and cosmetic facial surgeon with Arkansas Oculoplastic Surgery, Little Rock, Ark.

“People really have trouble hanging their hat on a consistent way to rejuvenate that junction between the lower lid and cheek. And that’s really what people want,” Dr. Brock says

The paper features three patients treated with transconjunctival blepharoplasty, fat grafting and 8% phenol peel. All reported significant improvements with their postoperative appearances. There were only minimal complications reported, none of the patients requested surgical revisions and the results were stable over an average two-year followup. Two of the three patients had follow-ups at eight years or more.

Patient shown before and after combination of transconjunctival lower lid blepharoplasty, fat grafting and 88% phenol peeling. Photos courtesy of Jim English, M.D.

A History of Lackluster Outcomes

In the 1980s, cosmetic surgeons primarily removed fat from the lower lids. The transconjunctival approach was a step forward from the external approach but still fell short, Dr. Brock says.

“You get rid of the bag, but it’s not exactly a youthful appearance. When you restore that nice, full transition between the lower lid and the cheek, that’s really a more youthful subtle appearance. People have wrestled with ways to do that,” Dr. Brock says.

One option is the septal reset, where surgeons release the septal attachment, repositioning fat by taking some of the medial fat pad and positioning it lower into the nasojugal fold or the tear trough.

Dr. Brock says he has tried them all and consistently finds the combination approach he describes offers best results.

Patient shown before and after combination of transconjunctival lower lid blepharoplasty, fat grafting and 88% phenol peeling. Photos courtesy of Jim English, M.D.

Each of said combination elements has an important role in the results. With the transconjunctival blepharoplasty, surgeons are eliminating the tissue that’s really pronounced and herniated too far. With the fat, they’re replacing some of the areas that are depressed and need to be filled in order to create continuity, he says.

“[Surgeons] struggle with how to rejuvenate the outside of the eyelid. Is it laser, a [trichloracetic acid] peel… is it taking skin? I’ve taken care of complications when people take too much skin. That can cause eyelid malposition. Laser and peeling can do the same thing. Most people probably do laser or a pinch of skin or a TCA peel. But not many people do the phenol peel,” Dr. Brock says. “We’re not aggressively degreasing the area, and we’re just using a small amount without croton oil. The croton oil has been shown to increase the depth of penetration. In the absence of croton oil and in the absence of aggressive degreasing, you can get a nice presentation.”

NEXT: Patient & Surgical Nuances

 

Patient & Surgical Nuances

Dr. Brock says his and Dr. English’s combination blepharoplasty patients have been Fitzpatrick types I and II with a Glogau scale of 2 to 3.

“I can’t tell you with any science that it would work for any patient. I think it would probably be safe for the higher Fitzpatrick skin types, even in skin of color, just because of what I know using peels on skin of color,” he says. “The transconjunctival blepharoplasty is very well established for all patients. The fat grafting is established for all patients. With the phenol peel, you’d follow the standard protocols for peels. You’d use your basic precautions that you’d use for anybody that you’re doing a deeper peel on.”

Patient shown before and after combination of transconjunctival lower lid blepharoplasty, fat grafting and 88% phenol peeling. Photos courtesy of Jim English, M.D.

Dr. Brock says surgeons shouldn’t get carried away when making the transconjunctival blepharoplasty incision.

“Take what presents easily. No need to chase the fat behind the orbital rim,” he says.

Related: Tarsal sling for post-blepharoplasty repair

With regard to fat grafting, many choose the umbilical fat. It offers pretty easy access. But that’s not the fat Dr. Brock usually uses.

“Dr. English’s experience is that the fat from the abdomen can grow, and there’s certainly documentation that it has hormone receptors that can grow. I started choosing the leg fat mainly based on some of the publications and chapters written by Timothy Martin, and he found that he liked the quality of that fat. I’ve been very happy with it. It’s not difficult to harvest that fat,” Dr. Brock says. “I’ve found a very effective way to quickly harvest fat from the leg is [to] place the patient in a semirecumbent position, so you can have access to the inner thigh. That’s quick and easy, so you don’t have to reposition the patient.”

Patient shown before and after combination of transconjunctival lower lid blepharoplasty, fat grafting and 88% phenol peeling. Photos courtesy of Jim English, M.D.

Finally, don’t underestimate the peel, he says. While the phenol peel is safe when done the way Dr. Brock describes it, he says surgeons need to understand how to manage a burn. In other words, know how to manage a patient and recognize when the patient needs more acute attention to avoid scarring.

NEXT: Recovery and Results

 

Recovery and Results

There tends to be more postoperative edema with the combination compared to that with fat excision or a transconjunctival approach with fat transposition.

“A large part of the treatment is postoperative care. You can expect a significant amount of post-operative swelling, in some cases. At first, that can be discouraging, but, with time, you will get to where you want to be. Being sure the patient knows what to expect — that’s critical,” he says.

Dr. Brocks says that using this approach for his eyelid rejuvenation patients has given him more confidence that he can deliver the results that his patients want.

“Patients want to look younger and they want their eyelids to be rejuvenated. What they’re really asking for is to reconstitute that nice subtle, youthful transition between the lower lid and cheek. For me, I’ve found this consistently delivers that,” he says.

Conflicts: None

Hide comments
account-default-image

Comments

  • Allowed HTML tags: <em> <strong> <blockquote> <br> <p>

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Publish