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Subciliary Approach Blepharoplasty


Some say that the eyes are one of the most striking features of a person’s face. They transmit emotions and feelings and form part of the personality and “soul” of a person. Eyelid changes occur with aging and are influenced by genetic factors. Initially, blepharoplasties were performed to correct acquired (ie, secondary to trauma or carcinoma) or congenital deformities, not for cosmetic purposes. However, once the physiological changes of aging became better understood, new blepharoplastic techniques were developed for their correction. Even though modern cosmetic blepharoplasty techniques have been around for 50 years, only in the last 2 decades has the number of blepharoplasty procedures increased worldwide.

Looking sleepy or tired because of physiologic changes is considered a sign of old age rather than a sign of maturity. To look young is fashionable. Furthermore, a younger-looking face is extremely useful in this competitive world in which the transmission of a good image is more important than ever before in the public, professional, social, and private environment. See the image below.

A: The lower eyelid has been cross-sectioned in or

A: The lower eyelid has been cross-sectioned in order to appreciate the anatomy at this level. B: A magnified view of the cross-section is shown. Note the anatomic details at the level mentioned. From lateral to medial, the eyelid skin, the ciliary line, the orbicularis muscle, the gray line, the tarsal plate, the meibomian gland orifices, and the conjunctiva are visualized. C: Note the 2 fat compartments of the upper eyelid, the middle and the nasal. Note also the position of the lacrimal gland in the lateral aspect of the orbital area. Note the 3 fat compartments of the lower eyelid, the temporal, the middle, and the nasal. The largest compartment is the middle. D: Note the sphincteric structure of the orbicularis muscle and its portions, the orbital, preseptal, and pretarsal portions.

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A good analysis of eyelid changes, proper patient selection, and precise surgical technique results in a high level of satisfaction for both patient and surgeon. Therefore, blepharoplasty plays a role in dramatically diminishing the appearance of aging in contemporary society.

Classic blepharoplasty involves removal of the pseudoherniated fat pad that protrudes through a weakened orbital septum. This can be accomplished through the transcutaneous or transconjunctival route. The transcutaneous approach is still the most common approach used for lower eyelid blepharoplasty. The advantage of this approach is that it corrects excess skin and muscle laxity, and the disadvantage of this approach is a higher possibility of lower eyelid retraction. The advantage of the transconjunctival lower eyelid blepharoplasty is a lower possibility of lower eyelid retraction, and the disadvantage of transconjunctival lower eyelid blepharoplasty is an inability to correct excess skin and muscle laxity.

In the second half of the 1990s, the blepharoplastic literature has disseminated a new concept: the fat preservation technique. This technique redrapes and repositions the fat pad over the orbital rim in order to correct the groove over the nasojugal fold and the vertical fall of the anterior cheek.

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