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Figure 1.
Preoperative vertical height measurements of the lower eyelid were taken. The distance from the ciliary margin to the eyelid-cheek junction was measured at the midpupillary line.

Preoperative vertical height measurements of the lower eyelid were taken. The distance from the ciliary margin to the eyelid-cheek junction was measured at the midpupillary line.

Figure 2.
Before the operation, a mark was placed midway between the lateral canthus and the lateral limbus to designate the point of skin excision to be measured (see Figure 3).

Before the operation, a mark was placed midway between the lateral canthus and the lateral limbus to designate the point of skin excision to be measured (see Figure 3).

Figure 3.
The excised skin was gently spread to eliminate any folds and was measured at the preoperative mark.

The excised skin was gently spread to eliminate any folds and was measured at the preoperative mark.

Figure 4.
Demonstration of the dramatic change in lower eyelid vertical height achieved in a typical patient when a midface-lift is performed. A, Preoperative vertical height measurement of 16 mm. B, Immediate postoperative vertical height measurement of 9 mm.

Demonstration of the dramatic change in lower eyelid vertical height achieved in a typical patient when a midface-lift is performed. A, Preoperative vertical height measurement of 16 mm. B, Immediate postoperative vertical height measurement of 9 mm.

Table 1. 
Characteristics of the 25 Patients Studied
Characteristics of the 25 Patients Studied
Table 2. 
Change in Lower Eyelid
Change in Lower Eyelid
1.
Quatela  VCChoe  KS Endobrow-midface lift. Facial Plast Surg 2004;20 (3) 199- 206
PubMedArticle
2.
Quatela  VCJacono  AA The extended centrolateral endoscopic midface lift. Facial Plast Surg 2003;19 (2) 199- 208
PubMedArticle
3.
Hester  TR  JrCodner  MA McCord  CDNahai  FGiannopoulos  A Evolution of the technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: maximizing results and minimizing complications in a 5-year experience. Plast Reconstr Surg 2000;105 (1) 393- 408
PubMedArticle
4.
Mendelson  BC Surgery of the superficial musculoaponeurotic system: principles of release, vectors and fixation. Plast Reconstr Surg 2001;107 (6) 1545- 1552
PubMedArticle
5.
Quatela  VCLeake  DVillano  MJacono  AASabini  P Assessment of lower lid laxity following midface lift.  Paper presented at: Eighth International Symposium of Facial Plastic Surgery May 5, 2002 New York, NY
6.
Hamra  ST The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg 1998;102 (5) 1646- 1657
PubMedArticle
Original Article
Jul/Aug 2008

Lower Eyelid Aesthetics After Endoscopic Forehead Midface-lift

Author Affiliations

Author Affiliations: Marotta Facial Plastic Surgery, Smithtown (Dr Marotta), and Lindsay House Center for Plastic Surgery, Rochester (Dr Quatela), New York.

Arch Facial Plast Surg. 2008;10(4):267-272. doi:10.1001/archfaci.10.4.267
Abstract

Objective  To assess and quantitate the immediate effect of endoscopic forehead midface-lift on infraorbital hollowing and lower eyelid skin excision.

Methods  Twenty-five patients who underwent an endoscopic forehead midface-lift with a lower eyelid blepharoplasty or lower eyelid blepharoplasty without a midface-lift between January 1, 2005, and May 15, 2005, were included in the study. Preoperative and immediate postoperative measurements of the vertical height of the lower eyelid were taken in all patients. The change in the vertical height of the lower eyelid after endoscopic forehead midface-lift with blepharoplasty was compared with the change in lower eyelid height after either transconjunctival or lower eyelid skin pinch blepharoplasty or skin muscle flap blepharoplasty alone. The amount of lower eyelid skin excised after endoscopic forehead midface-lift with blepharoplasty was compared with both transconjunctival or lower eyelid skin pinch blepharoplasty and skin muscle flap blepharoplasty when a midface-lift was not performed.

Results  The average change in the vertical height of the lower eyelid after the endoscopic forehead midface-lift was 5 mm. Lower eyelid blepharoplasty alone, whether transconjunctival with skin pinch or skin muscle flap, did not affect the vertical height of the lower eyelid. The change in the vertical height of the lower eyelid with midface surgery over blepharoplasty alone was statistically significant (P < .001). The average amount of lower eyelid skin excised after endoscopic forehead midface-lift and lower eyelid skin pinch was 7.0 mm compared with 5.5 mm for both the transconjunctival lower eyelid skin pinch and the skin muscle flap techniques. The difference in skin excision when a midface-lift was performed compared with blepharoplasty alone was statistically significant (P = .008).

Conclusions  The endoscopic forehead midface-lift can reduce the vertical height of the lower eyelid by an average of 5 mm and allows more skin excision over blepharoplasty alone. The endoscopic forehead midface-lift is a powerful tool for decreasing the vertical height of the lower eyelid, lessening infraorbital hollowing, and improving dermatochalasis.

The endoscopic forehead midface-lift is a powerful technique for addressing the age-related changes that occur in the upper two-thirds of the face.1,2 A correction of brow ptosis, midfacial drop, infraorbital hollowing, nasolabial folds, and jowling has been previously reported with this operation.2 To our knowledge, the beneficial effects of the endoscopic forehead midface-lift over blepharoplasty alone with regard to lower eyelid aesthetics have not been previously characterized or quantified.

Midfacial ptosis contributes significantly to the pathophysiological features of the aged lower eyelid. With advancing age, the descent of the malar fat pad and suborbicularis oculi fat (SOOF) causes a loss of soft tissue padding of the infraorbital rim.3 This loss leads to an apparent increase in the vertical height of the lower eyelid as measured from the ciliary margin to the eyelid-cheek junction.3 Although the youthful lower eyelid has a vertical length of 8 to 10 mm from the ciliary margin to the eyelid-cheek junction, with increased age this measurement can easily exceed 12 mm.3 In addition, both skin and muscle laxity occur with the orbicularis oculi muscle undergoing centripetal stretch.4 Excess skin in the lower eyelids can become significant, leading to pleating and cross-hatching of the skin.

This study was conducted to determine the immediate effect of the endoscopic forehead midface-lift over blepharoplasty alone on lower eyelid vertical height and skin excision. By comparing the preoperative with the postoperative vertical heights and the amount of skin excision in these operations, we are able to obtain an immediate, objective measurement of the power of these techniques to treat 2 areas that contribute significantly to the aged appearance of the lower eyelid: a lengthened lower eyelid and redundant lower eyelid skin.

METHODS
STUDY PARTICIPANTS

A prospective, nonrandomized, before-and-after study was performed on 25 patients (50 eyes; 5 men and 20 women; mean age, 56 years; age range, 40-73 years). All patients who underwent an endoscopic forehead midface-lift and lower eyelid blepharoplasty or lower eyelid blepharoplasty alone between January 1, 2005, and May 15, 2005, were included in the study. The total number of patients was 25 (Table 1). Five patients underwent transconjunctival or lower eyelid skin pinch blepharoplasty, 5 underwent skin muscle flap blepharoplasty, and 15 underwent an endoscopic midface-lift in addition to lower eyelid skin pinch blepharoplasty with or without transconjunctival lower eyelid blepharoplasty.

SURGICAL TECHNIQUES
Transconjunctival Lower Eyelid Blepharoplasty With Skin Pinch

Transconjunctival lower eyelid blepharoplasty with skin pinch was the operative technique performed in 5 patients in this study. Transconjunctival lower eyelid blepharoplasty with skin pinch was used as the sole rejuvenative technique for the lower eyelid in patients who had a mild or moderate amount of infraorbital hollowing and dermatochalasis. These patients had either refused a midface-lift or, because of less infraorbital hollowing, dermatochalasis, and nasolabial fold thickening, a midface-lift was believed not to be indicated.

A total of 1 mL of 2% lidocaine with 1:100 000 mixed in equal parts with 0.25% bupivacaine hydrochloride with 1:200 000 epinephrine was injected into the lower eyelid externally. Using an insulated Desmarres eyelid retractor (Bausch & Lomb, Rochester, New York) and a plastic Jaeger plate (Padgett Instruments, Integra Lifesciences Corp, Plainsboro, New Jersey) to protect the cornea, we topically applied 4% cocaine on a cotton-tipped applicator to the conjunctiva for vasoconstriction. An additional 0.5 mL of the local anesthetic mixture was injected into the conjunctival incision and fornix.

A Colorado tip (45° angled and insulated) bovie was used to make an incision through the conjunctiva approximately 4 mm from the ciliary margin. The incision was carried down through the lower eyelid retractors and capsulopalpebral fascia. A 5.0 silk suture was placed through the midpoint of the conjunctival edge and weighted with a hemostat, and the conjunctival flap was retracted over the cornea to protect this structure. The preseptal plane was developed by blunt dissection with cotton swabs to the infraorbital rim. Small incisions were made in the preseptal fascia with scissors and protruding fat compartments (medial, middle, and/or lateral) either excised after bipolar cautery or cauterized to ablation. Just enough fat was removed or ablated so that the fat remaining was in the same plane as the bony infraorbital rim. Attention was drawn to the opposite eye, in which a similar procedure was performed and symmetrical amounts of fat were removed. Hemostasis was carefully attained using bipolar electrocautery.

Attention was then drawn externally, where the excess infraorbital skin was crimped using Brown-Adson forceps just below the ciliary margin, extending from 1 mm lateral to the medial canthus to beyond the lateral canthus (in a crow's foot) by approximately 1 cm. The excess skin was pinched or crimped such that dermatochalasis was eliminated without tension or evidence of scleral show. The pinched skin was then excised using scissors. Hemostasis was achieved with bipolar electrocautery, and 7-0 silk was used to close the incision in a running locked fashion medially, whereas interrupted 6-0 nylon sutures were used to close the lateral aspect of the incision.

Skin Muscle Flap Blepharoplasty

Skin muscle flap blepharoplasty was the operative technique performed in 5 patients in this study. Skin muscle flap blepharoplasty was used as the sole rejuvenative technique for the lower eyelid in patients who had more severe infraorbital hollowing and dermatochalasis but refused a midface-lift.

A total of 1 mL of 2% lidocaine with 1:100 000 mixed in equal parts with 0.25% bupivacaine with 1:200 000 epinephrine was injected into the lower eyelid externally. A subciliary incision that extended 2 mm laterally to the inferior punctum and then laterally 1 cm into a crow's foot was made with a No. 15 blade. The skin was elevated off the pretarsal orbicularis with bipolar forceps for 4 mm. The orbital septum was located laterally in the submuscular plane. A skin muscle flap was then bluntly dissected with blunt-tipped scissors to just beyond the infraorbital rim. The lateral dissection was joined with the medial dissection by incising the preseptal orbicularis oculi in a beveled fashion. The skin or muscle flap was pulled away with a 9-prong sharp retractor by an assistant and hemostasis was achieved with bipolar cautery. Small incisions were made in the preseptal fascia with scissors, and protruding fat compartments (medial, middle, and/or lateral) were either excised after bipolar cautery or cauterized to ablation. Just enough fat was removed or ablated so that the fat remaining was in the same plane as the bony infraorbital rim.

The skin muscle flap was then suspended to the periosteum of the lateral orbital rim with 6-0 clear nylon. The redundant lower eyelid skin was then trimmed along the incision with tenotomy scissors. The lateral portion of the incision was closed with 6.0 nylon vertical mattress sutures. The remainder of the incision was closed with a running locking 7.0 silk.

Endoscopic Forehead Midface-lift

An endoscopic forehead midface-lift was performed in 15 patients. The endoscopic forehead midface-lift was recommended to those patients with the most severe infraorbital hollowing, dermatochalasis, and nasolabial fold thickening. In addition, all patients undergoing an endoscopic forehead midface-lift had lower eyelid skin pinch with or without transconjunctival excision or cauterization of pseudoherniated fat. If there was significant lower eyelid fat pseudoherniation, a transconjunctival blepharoplasty was performed before the endoscopic forehead midface-lift.

Our technique for the endoscopic forehead midface-lift has been previously described and is summarized herein.1,2 Preoperatively, the Pitanguy line, representing the path of the frontal branch of the facial nerve, and the temporal line were marked bilaterally. The incisions are similar to an endoscopic brow-lift with a 3-cm lateral (temporal) incision and a 2-cm medial incision outlined on each side. The incisions, the entire forehead, and the midface were injected with an equal mixture of 0.5% lidocaine with 1:200 000 epinephrine and 0.25% bupivacaine with 1:200 000 epinephrine.

The temporal incision was made with a No. 10 blade down to the level of the deep temporal fascia. A Ramirez Endoforehead “T” Dissector No. 4 (Snowden-Pencer; Cardinal Health, Dublin, Ohio) was used to elevate the superficial temporal fascia and overlying tissue off the deep temporal fascia to the temporal line. The forehead and scalp tissues were then elevated in a subperiosteal plane through the lateral incision. Release of the arcus marginalis was accomplished to within 1 cm of the supraorbital neurovascular bundle with a Ramirez Endoforehead Arcus Marginalis Dissector No. 6 (Snowden-Pencer). The medial incisions were made, and then the Ramirez Endoforehead Arcus Marginalis Dissector No. 6 was used to elevate blindly in the subperiosteal plane among the neurovascular bundles, over the glabella, and onto the nasal radix. An endoscope was then introduced through the medial incision and the neurovascular bundles were dissected under visualization. If significant glabellar rhytids were present, the corrugator and procerus muscles were horizontally sectioned and cauterized under endoscopic visualization.

Dissection proceeded with a Ramirez Endoforehead “T” Dissector No. 4 toward the zygomatic arch. The periosteum over the entire superior aspect of the arch was exposed and incised at the anterior aspect of the arch. Subperiosteal dissection then proceeded over the entire arch with the Ramirez Endoforehead Arcus Marginalis Dissector No. 6. Dissection continued on the anterior face of the maxilla toward the piriform aperture and medially along the infraorbital rim both superior and inferior to the infraorbital nerve. The infraorbital nerve was protected by manual palpation. Laterally, some of the tendinous attachments of the masseter to the zygoma were lysed. The medial and lateral dissections were then joined by finger dissection. This dissection accomplished mobility of all the midfacial tissues, including the malar fat pad and SOOF.

Then, 4-mm screws were placed at the medial incisions and staples were used to maintain forehead suspension. These screws were removed on postoperative day 7. To suspend the midface, a polyglactin 910 0.0 suture (Vicryl; Ethicon Inc, Somerville, New Jersey) on a UR6 needle was then passed through the periosteum just lateral to the zygomaticofacial foramen and tacked to the deep temporal fascia using a superolateral vector of pull. A second midfacial suspension suture was placed lateral to the Pitanguy line and secured to the deep temporal fascia. Three more suspension sutures were placed through the superficial temporal fascia just inferior to the incision and suspended higher to the deep temporal fascia to elevate the temporal tissue and prevent skin bunching from midfacial elevation. After the endoscopic midface-lift, a lower eyelid skin pinch, as described herein, was performed.

MEASUREMENTS

Preoperative and postoperative lower eyelid measurements were obtained from all 25 patients (50 eyes). The vertical height of the lower eyelid was defined as the distance from the ciliary margin to the junction of the lower eyelid with the thicker skin of the cheek. Measurements of the vertical height were taken at the midpupillary line. After induction of anesthesia and before local injection, the preoperative vertical height of the lower eyelid was measured with the patient in the supine position (Figure 1). Immediately on completion of the procedure and before any appreciable edema, postoperative measurements of the vertical height of the lower eyelid were taken.

The amount of lower eyelid skin excised was measured in all 25 patients (50 eyes). Preoperatively, the lower eyelid was marked vertically at the midpoint between the lateral canthus and the lateral limbus (Figure 2). After blepharoplasty, the excised skin was spread gently to eliminate any folds. The excised skin was then measured at the preoperative mark (Figure 3). Preoperative and postoperative vertical height measurements and the amount of skin excised were recorded for all 25 patients (Table 1).

RESULTS

The average reduction in the vertical height of the lower eyelid was 5.1 mm in those patients who underwent an endoscopic midface-lift compared with a 1-mm reduction with skin muscle blepharoplasty and a 0-mm reduction with transconjunctival blepharoplasty and skin pinch (without a midface-lift) (Table 2). The change in vertical height of the lower eyelid achieved in the endoscopic midface group was statistically significant when compared with the lower eyelid skin muscle flap blepharoplasty and transconjunctival lower eyelid and skin pinch blepharoplasty groups (P < .001). The reduction in the vertical height of the lower eyelid in those who underwent skin or muscle blepharoplasty was not a statistically significant difference when compared with the reduction in those who underwent transconjunctival lower eyelid blepharoplasty with skin pinch. In those patients who underwent an endoscopic midface-lift, the average vertical height of the lower eyelid preoperatively was 12.7 mm; postoperatively, it was reduced to 7.6 mm, which was statistically significant (P < .001).

The average amount of skin excised with transconjunctival lower eyelid blepharoplasty and skin muscle flap blepharoplasty was 5.5 mm. When an endoscopic midface-lift was performed, the average amount of lower eyelid skin excised was 7 mm. Comparing the amount of skin excised with both blepharoplasty techniques alone with the amount excised when an endoscopic midface-lift was added achieved statistical significance (P = .008).

COMMENT

This study demonstrates that the endoscopic forehead midface-lift is a powerful tool for reversing aging changes in the lower eyelid. The endoscopic forehead midface-lift decreases the vertical height of the lower eyelid an average of 5.1 mm. Aged lower eyelids, with even the most severe infraorbital hollowing and vertical height measurements that exceed 12 mm, can be brought to well within the range of a youthful-appearing eyelid (<10 mm; mean change, 12.7-7.6 mm) (Figure 4). The surgery accomplishes vertical vector elevation of all the midfacial tissue, including the malar fat pad and SOOF relative to the facial skeleton. This leads to a reduction in infraorbital hollowing, pads the infraorbital rim, and, along with transconjunctival excision of pseudoherniated fat, helps correct any double contour deformity.

In addition, the endoscopic forehead midface-lift allows a more aggressive resection of lower eyelid skin and correction of dermatochalasis. An average of 7 mm of skin was excised in patients who underwent an endoscopic forehead midface-lift compared with 5.5 mm when blepharoplasty alone was performed. The increase of 1.5 mm in the average skin excised may seem modest when considering that the vertical height of the lower eyelid changed 5.1 mm. If the vertical height of the lower eyelid is reduced by 5.1 mm, why does a corresponding increase of approximately 5.1 mm of skin excision not exist? We believe this apparent discrepancy can be accounted for by the fact that with midfacial ptosis some amount of the lower eyelid skin is stretched and when this ptosis is relieved the skin undergoes contracture at removal. An additional factor that may account for the discrepancy in vertical height change and lower eyelid skin excision is that the soft tissue padding of the orbital rim (ie, SOOF–malar fat pad complex) may be differentially elevated as a result of the endoscopic forehead midface-lift when compared with the skin.

In any case, the endoscopic forehead midface-lift makes it possible, in most cases, to excise 7 mm or more of lower eyelid skin. This defies the common rule of thumb to avoid excision of more than 6 mm of lower eyelid skin for fear of causing ectropion. In our experience with more than 800 endoscopic forehead midface-lifts, ectropion does not occur when a midface-lift is performed with lower blepharoplasty. A previous study5 has demonstrated that the midface increases the force required to pull the lower eyelid away from the globe by 2-fold.

One of the limitations of this study is nonrandomization. Patients with the most severe infraorbital hollowing and dermatochalasis are generally first offered an endoscopic forehead midface-lift, and if they refuse, a skin muscle flap blepharoplasty is the chosen technique. Transconjunctival blepharoplasty with lower eyelid skin pinch is generally reserved for those patients with a less severely lengthened lower eyelid and dermatochalasis. Despite this potential selection bias, the average preoperative vertical height in this study was 13 mm in all 3 groups (Table 2). An additional limitation of this study is the lack of long-term follow-up with regard to vertical height changes and improvement in dermatochalasis. An ongoing study with this same group of patients will examine if the change in vertical height achieved by the endoscopic forehead midface-lift is maintained at 1 year. This study will also compare the improvement in dermatochalasis in the 3 treatment groups at 1 year.

In conclusion, traditional blepharoplasty techniques include subciliary or transconjunctival incisions with orbital fat removal. After these procedures, the appearance of the eyelid is usually smoother, but deeper, as a result of pseudoherniation correction. The patient may have a worsening of the “hollow” appearance of the lower eyelid with skeletonization of an already visible bony infraorbital rim.6 More conservative fat resection or ablation characteristic of modern blepharoplasty may lessen hollowing, but because the malar fat pad and SOOF ptosis is not addressed, the vertical height of the lower eyelid remains unchanged. Removal of orbital fat may cause collapse of existing skin cover and more skin wrinkling than before, necessitating more skin removal to fully correct dermatochalasis.6 Yet, the aggressive excision of excess skin may be limited without suspension of the midface.

The endoscopic forehead midface-lift changes the dynamics of the lower eyelid and allows a more complete periorbital rejuvenation than traditional blepharoplasty techniques alone. Superolateral elevation of the cheek tissue with attachment to the temporalis fascia creates the vertical vector necessary to elevate the SOOF–malar fat pad complex over the infraorbital rim.2,4 This vertical vector elevation of the cheek tissue leads to a decrease in the vertical height of the lower eyelid and a more youthful-appearing lower eyelid and cheek. The suspension of the periosteum and a composite musculoligamentous flap containing all midfacial soft tissue allows the aggressive resection of excess lower eyelid skin without fear of ectropion.

Aging of the periorbital complex is multifactorial. Brow ptosis, fat pseudoherniation, and upper eyelid skin laxity develop. The descent of the midfacial tissues leads to an increase in the vertical height of the lower eyelid and infraorbital hollowing. Fat pseudoherniation and dermatochalasis occur in the lower eyelid. Complete periorbital rejuvenation requires a procedure that can address all the factors that contribute to aging around the eye. The endoscopic forehead midface-lift is a powerful technique for remedying the aging changes around the eye and is a critical component for achieving full periorbital rejuvenation.

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Article Information

Correspondence: James C. Marotta, MD, Marotta Facial Plastic Surgery, 267 E Main St, Smithtown, NY 11787 (Drm@marottamd.com).

Accepted for Publication: February 2, 2008.

Author Contributions:Study concept and design: Marotta and Quatela. Acquisition of data: Marotta and Quatela. Analysis and interpretation of data: Marotta and Quatela. Drafting of the manuscript: Marotta. Critical revision of the manuscript for important intellectual content: Marotta and Quatela. Statistical analysis: Marotta and Quatela. Obtained funding: Marotta. Administrative, technical, and material support: Marotta. Study supervision: Marotta and Quatela.

Financial Disclosure: None reported.

References
1.
Quatela  VCChoe  KS Endobrow-midface lift. Facial Plast Surg 2004;20 (3) 199- 206
PubMedArticle
2.
Quatela  VCJacono  AA The extended centrolateral endoscopic midface lift. Facial Plast Surg 2003;19 (2) 199- 208
PubMedArticle
3.
Hester  TR  JrCodner  MA McCord  CDNahai  FGiannopoulos  A Evolution of the technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: maximizing results and minimizing complications in a 5-year experience. Plast Reconstr Surg 2000;105 (1) 393- 408
PubMedArticle
4.
Mendelson  BC Surgery of the superficial musculoaponeurotic system: principles of release, vectors and fixation. Plast Reconstr Surg 2001;107 (6) 1545- 1552
PubMedArticle
5.
Quatela  VCLeake  DVillano  MJacono  AASabini  P Assessment of lower lid laxity following midface lift.  Paper presented at: Eighth International Symposium of Facial Plastic Surgery May 5, 2002 New York, NY
6.
Hamra  ST The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg 1998;102 (5) 1646- 1657
PubMedArticle
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