"If the incision is made in the first wrinkle line, then quite a bit of orbicularis muscle on the lid margin is left behind, providing support to the (lower) lid," says Dr. McCollough, founder of the McCollough Plastic Surgery Clinic, Gulf Shores, Ala. "The incision also coincides, ironically, with the lower border of the tarsal cartilage."
Dr. McCollough's transcutaneous approach, a technique he developed 15 years ago, is gaining acceptance by colleagues who now realize its effectiveness in preventing scleral show and ectropion."Many were concerned that the (lower) scars would be unacceptable, but it's been my experience that once the scars are healed, they are less noticeable when placed in the first wrinkle line than when placed under the lash line," Dr. McCollough says.
In the middle-aged and older patient who has loose skin and a large amount of fat under the eye, the transcutaneous approach is best when completing a lower lid blepharoplasty, yet the traditional incision placed immediately below the eyelashes often results in scleral show. Many surgeons try to correct the complication with suturing techniques used deep in the lower lid, suspended up to the bone of the orbit creating a hammock effect, but this approach often leads to inflammation and infection.
"It occurred to me that one of the problems when we made an incision immediately below the lashes (was that) we were destroying part of the support mechanism of the eyelid due to the destruction of the tarsus cartilage — a major support to the lower eyelid that, when incised, is destroyed immediately, making it necessary to do something to correct it," Dr. McCollough says. "However, if the incision is made in the first wrinkle line, quite a bit of the orbicularis muscle on the lid margin is left behind."
One reason for acceptance of the lower incision is its ability to prevail aesthetically. An important contributor to the end result is how the incision is closed.
Temporary temptation While the avoidance of scleral show and potential complications from additional procedures is key to Dr. McCollough's approach, he is reserved in his application of adjuvant therapies.
"If the patient has wrinkles, caused by loose, sagging skin, Botox is not going to correct the problem. Restylane and other fillers will provide some temporary improvement, but the only way to correct the problem is with surgery. If the patient's condition is bulging fat, then certainly Botox or Restylane is not going to benefit them," Dr. McCollough says. "I personally do not use Botox on my patients."
His stance places him in the minority among cosmetic surgeons, but Dr. McCollough bases his belief on theoretical concerns that point to the possibility of future problems from the overuse of botulinum toxin. He points to other models in medicine that prove that paralyzing muscles can cause loss of strength and ultimately atrophy.