Preventing and treating complications in the lid-cheek junction demands a cautious approach, as well as the ability to match procedures to the underlying problem, says Michael P. Grant, M.D., Ph.D.
For starters, "It's always better to try and prevent these sorts of complications rather than fix them, because they're difficult to fix," says Dr. Grant, director of Oculoplastic Surgery and assistant professor of ophthalmology and plastic surgery, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore.
In treating the lower eyelid and cheek areas, Dr. Grant says that since he completed his training in 2002, "The pendulum has swung towards conservative resection of tissues, or sometimes no resection of tissues — just repositioning the fat. After I've had the opportunity to follow my patients now for several years, I probably resect less skin and fat than I did even five years ago."HIGH-RISK PATIENTS When contemplating procedures or revisions of prior procedures, Dr. Grant says high-risk patients most commonly have prolapsed orbital fat, excess lower eyelid skin plus lower eyelid instability, often with accompanying midface descent.
To begin addressing these problems, he says, plastic surgeons traditionally are taught to extend their incision under the lower eyelid with a downward-sloping tail past the outer corner of the eye.
"If you try to make that incision and let it heal, you'll end up with a very unnatural lump of tissue" there as the incision area contracts, he says. Therefore, "I always make my incision at about a 45 degree to 60 degree angle and follow the natural smile line."
Another error involves completely "filleting" and delaminating the lower eyelid, Dr. Grant says. Instead, "I try to preserve the middle lamellar structures of the eyelid because that's where you get into problems with scarring and lower eyelid retraction. I do a subcutaneous dissection first, and a selective submuscular dissection when I need to." Dr. Grant says he also decides at this point whether or not to perform a canthoplasty.
When indicated, Dr. Grant says he also performs fat repositioning through a small buttonhole incision at the orbicularis nasally and/or temporally. "Or it can be done transconjunctivally," he says. "In patients who don't have excess skin, the entire procedure can be done transconjunctivally."
In most patients, "Elevating the origin of the orbicularis is indicated and helpful," he explains. "Then in patients who require transpalpebral midface lifting or stabilization, I favor a preperiosteal dissection over the orbital rim, then anchoring that tissue to the orbital rim, followed by skin redraping and judicious incision of any excess skin."
In terms of preventing complications, "The wildcard is undiagnosed thyroid-related orbitopathy (TRO)," Dr. Grant says. "Many of these patients will present with puffy eyelids and a translucent, edematous appearance to their skin. If you don't recognize that that patient potentially has TRO and you operate on them, the patient could have a miserable postoperative course."
Dr. Grant also says that in patients with cosmetic concerns of the lower eyelid and upper midface, it's important to consider the extent of the problem. Milder cases might involve orbital fat herniation; more severe cases might involve nasojugal grooves and malar bags. "If you try to apply the same sort of solution to these types of patients, many of them will not do well because these are very different problems in terms of the underlying anatomy that produces these deformities (Hester TR Jr, Codner MA, McCord CD, et al. Plast Reconstr Surg. 2000;105(1):393-406; discussion 407-408)," he says.
One patient that Dr. Grant treated had undergone prior upper and lower eyelid blepharoplasty performed by another surgeon that resulted in significant dry eye and prolapsed fat in her lower eyelid. Additionally, "She had about 2 mm of lagophthalmos preoperatively," Dr. Grant says. "She couldn't afford to have any more lower eyelid retraction" or other surgically induced lower eyelid problems. Therefore, Dr. Grant had to be very cautious when performing her upper and lower blepharoplasty, fat transposition, lateral canthoplasty and preperiosteal midface stabilization.