Prevention of Lower Eyelid Malposition After Blepharoplasty


Prevention of Lower Eyelid Malposition After Blepharoplasty 
-Anatomic and Technical Considerations of the Inside-Out Blepharoplasty

David B. Rosenberg, MD; Jessica Lattman, MD; Anil R. Shah, MD

Objective: To determine the position of the lower eyelid
and lateral canthus after release of the lower eyelid
retractors with the “inside-out technique” by measuring
the marginal reflex distance 2 (MRD2) and using the
lateral canthal rounding scale.
Design: Retrospective analysis.
Results: Of the 171 patients who underwent inside-out
blepharoplasty, 78 were followed up for 3 months. Preoperative
MRD2 was 0.942 pixels. Postoperatively, the
modifiedMRD2 was 0.903. Although the score of the modified
MRD2 was found to decrease postoperatively, the decrease
was not statistically significant (P.07). The lateral
rounding scale reviewed an average preoperative score
of 2.04 and a postoperative score of 1.99. There was no
statistical difference between pre- and postoperative observations
based on a 1-tailed ttest. No complications were
Conclusion: Using photographic analysis, the study
found no difference in lateral canthal shape or MRD2 before
and after surgery in patients who underwent insideout
Arch Facial Plast Surg. 2007;9(6):434-438

Author Affiliations: Division of
Facial Plastic & Reconstructive
Surgery, Department of
Otolaryngology–Head and Neck
Surgery (Drs Rosenberg and
Shah), and the Division of
Oculoplastic Surgery,
Department of Ophthalmology
(Dr Lattman), Manhattan Eye,
Ear, & Throat Hospital, New
York, New York; and the
Division of Facial Plastic
& Reconstructive Surgery,
Department of
Otolaryngology–Head and Neck
Surgery, New York University
School of Medicine, New York
(Dr Shah)


rejuvenation are to restore
youthful contours to the
face while minimizing any
complications or stigmata
of surgery. A central tenet of this goal is
maintenance of lower eyelid position. The
aesthetically pleasing lower eyelid is described
as having a slight lateral elevation
with little or no rounding. As part of
the normal aging process, the lower eyelid
may droop or round, leading to an unsightly
cosmetic appearance. Aside from
extraneous considerations, lower eyelid
retraction can lead to serious functional
morbidities such as ocular irritation, conjunctivitis,
epiphora, blurred vision, and
It is crucial for the facial plastic surgeon
to maintain lower eyelid position to
achieve satisfactory blepharoplasty results.
Lower eyelid malposition may range
from lateral canthal rounding to scleral
show to frank ectropion. There are 2 basic
surgical approaches to aesthetic rejuvenation
of the lower eyelids: transcutaneous
and transconjunctival. Subciliary
blepharoplasty has been associated with
lower eyelid retraction rates of up to 20%.2-4
Transconjunctival blepharoplasty has a
much lower rate of eyelid malposition,
even with incorporation of transcutaenous
skin removal or resurfacing.5
The factors responsible for lower eyelid
position include canthal integrity, muscular
dynamics, and tonicity.6 Typically,
the lateral canthal tendon is slightly superior
to the medial canthus, providing a
naturally pleasing slight elevation to the
lateral portion of the lower eyelid. In patients
with appropriate canthal strength,
muscular dynamics play a role in the prevention
of lower eyelid malposition. Hypotonicity
in the orbicularis oculi may lead
to ectropion without resupport of the canthal
tendon, as seen in patients with facial
nerve paralysis.7 The forces responsible
include a weakened orbicularis oculi
superior pull, combined with the downward
vector created by the inferior eyelid
retractors, and gravitational pull of soft tissues
of the eyelid-cheek area.
Anatomic studies have provided further
insight into the anatomy and function
of the lower eyelid.8-11 The retractors
of the lower eyelid are analogous to those
of the upper eyelid. The capsulopalpebral
fascia (CPF) and the inferior tarsal
muscle are directly comparable to the upper
eyelid retractors of the levator aponeurosis
and lower eyelids. The CPF originates
from the fascia of the inferior rectus
muscle and inferior oblique muscle and attaches to the
inferior tarsus. The CPF pulls the lower tarsus downward,
synchronized with the movement of the inferior
rectus muscle. When the globe turns upward on eyelid
closure (Bell phenomenon), the orbicularis oculi muscle
contracts, and the inferior rectus and CPF relax. The orbicularis
oculi and CPF are thought to be synchronized
by reciprocal innervation, which comprises an agonist/
antagonist relationship.
In upper eyelid surgery, if the levator aponeurosis,
the upper eyelid retractor, is divided during upper
blepharoplasty surgery, a postoperative ptosis will likely
occur. During transconjunctival blepharoplasty, the
lower eyelid retractors divide. Preservation of the lateral
tarsal orbicularis oculi’s innervation leads to an unopposed
superiorly based muscular vector pull, manifesting
as either maintenance or elevation of the lower eyelid
(Figure 1). We believe that alteration of muscular
dynamics plays an important role in preservation of
lower eyelid position.
A retrospective medical record review performed on the patients
seen by one of us (D.B.R.) from 2002 to 2005 identified
171 patients who had undergone an inside-out transconjunctival
blepharoplasty. Exclusion criteria were a history of blepharoplasty
or midface procedures and having no postoperative
photographs during at least 3 months’ follow-up. Patients with
prior blepharoplasty were excluded because of technical factors
that could not be accounted for, such as preservation of
orbicularis oculi supply, complete release of the lower eyelid
retractors, or septal scarring.
All patients underwent a preoperative assessment of canthal
integrity (snap test and eyelid distraction distance) and were
screened for dry eye. Patients with canthal laxity were treated
with lateral canthal shortening procedures and were excluded
from this study.
Standardized blepharoplasty photographs were taken, including
a frontal view in neutral gaze, with eyes closed, an upward
gaze, and corresponding lateral views. Photographs were
taken with a Sony Cybershot DSC-F828 camera (Sony Electronics
Inc, Tokyo, Japan) with a macrolens at a reproduction
ratio of 1:4.
Photographs were taken before and 6 months after surgery.
Photographs were examined at 6 months by comparison
of modified marginal reflex distance 2 (MRD2) and any physical
signs of lower eyelid malposition (rounding, increased scleral
show, or frank ectropion). Modified MRD2 was measured on
all preoperative photographs as were any signs of lower eyelid
malposition. Modified MRD2 is the measure of the light reflection
in primary gaze to the lower eyelid lash line. The lash line
was used rather than the eyelid margin to better account for
eyelid eversion (Figure 2). A standardizing multiplier was created
to compare pre- and postoperative photographs by using
the fixed point of the interpupillary distance. Measurements
were made with the measure tool on Adobe Photoshop 7.0
(Adobe Systems Inc, Santa Clara, California).
A scale was created to measure lateral canthal rounding
(Table). Authors were blinded to preoperative or postoperative
photographs and each eye was graded. In addition, a postoperative
physical examination was performed to determine the
mobility of the lower eyelid structures and formation of a cicatrix.
Statistics were analyzed with the 1-tailed t test and values
were considered significant at P.05.
In the preoperative holding area, significant fat herniation in
patients was identified. All procedures were performed with the
patient under general anesthesia. Corneal shields with bacitracin
ophthalmic were placed during the surgery. A local anesthetic
mixture (lidocaine, 1%, with 1:100 000 epinephrine on
a 30-gauge needle) was injected into the lower eyelid conjunctiva
in all patients and in a transcutaneous location if skin removal
was planned.
A transconjunctival approach was used to facilitate access to the
fat compartments and release thelower eyelid retractors.Thelower
eyelids were retracted with a sharp double-pronged retractor. An
incision was made with a guardedColorado tip needle 1 mmfrom
the tarsal border along the lower eyelid conjunctiva. The incision
was extended from the medial puncta to the area just medial
to the lateral canthus to ensure complete release of the lower eyelid
retractors, irrespective of the location of fat removal. A preseptal
plane was dissected bluntly in an avascular plane with a
cotton-tipped applicator to the level of the orbital rim.
Fat was removed only in those areas in which preoperative
analysis revealed excess. The fat was removed to allow a 1-mm
smooth level of fat below the orbital rim. The inferior oblique
muscle was identified in all cases in which fat was removed. Fat
was not repositioned and nasojugal asymmetries were addressed
with fat transplantation techniques. The transconjunctival
incision was not closed to allow for egress of fluid and to
prevent reapproximation of the lower eyelid retractors (Figure 3).
A transcutaneous approach to skin removal was used in all cases.
An incision with a No. 15 blade was made at the lateral border
of thelower eyelid,following alower eyelid crease. Straight Stevens
scissors were used to dissect 3 mm from the border of the lower
eyelid margin to the medial puncta. The transcutaneous flap was
elevated and skin was removed so that no tension was placed
on the closure of the skin. A 6-0 polypropylene suture was used
in a running nonlocking fashion. In instances of excessive muscular
orbicularis oculi, a small portion of the septal orbicularis
oculi was resected, preserving the tarsal orbicularis oculi. Postoperative
care consisted of aggressive lower eyelid massage for
2 to 4 weeks to prevent cicatrix formation.
Of the 171 patients who underwent inside-out blepharoplasty,
78 were followed up for 3 months. Preoperative
MRD2 was 0.942. Postoperatively, the modified MRD2
was 0.903 (Figures 4, 5, and 6).
The score of the modified MRD2 was found to decrease
postoperatively but this decrease was not statistically
significant (P.07). Forty-three of the 171 patients
had follow-up evaluations at 6 months, with no
changes in modified MRD2.
The lateral rounding scale revealed an average preoperative
score of 2.04 and a postoperative score of 1.99. There
was no statistical difference between preoperative and postoperative
observations based on a 1-tailed t test.
No complications were reported, including hematoma
or postoperative dry eyes. Patients did not demonstrate entropion
or decreased ability to look downward as a result
of the lower eyelid retractors on physical examination.
Several technical factors in the inside-out technique warrant
mentioning. The release of the retractors is complete
and occurs from the medial puncta and approaches the
lateral canthus of the eye. Retractor release does not typically
occur with a subciliary approach with preservation
of the underlying conjunctiva and associated eyelid retractors.
Both a preseptal or postseptal approach will theoretically
provide release of the retractors.
A function of the lower eyelid retractors is to assist in
lowering the eyelid, particularly when the inferior rectus
muscle pulls the eye inferiorly. Despite this contribution
to eyelid lowering, inferior gaze restriction or discomfort
has not been reported after transconjunctival
blepharoplasty. Our study supports the literature, with
none of the patients reporting gaze restriction after release
of the lower eyelid retractors.
Putterman12 described a sole case of ectropion as a result
of resection of the lower eyelid retractors. However,
this case had severe lateral canthal laxity; no subsequent
cases of ectropion have been reported.
Epiblepharon was reported in a subciliary approach
used in an Asian patient after repair of a trimalar fracture.13
In Asian patients, the capsulopalpebral fascia is
attenuated with weaker attachment to the tarsal plate and
dermis. The incidence of epiblepharon in Asian patients
is much higher because of the unopposed muscular force
vector provided by the orbicularis oculi muscle. Epiblepharon
has never been reported after a transconjunctival
blepharoplasty. The downward effects of gravity and
shortening of the middle lamellae during surgery are possible
explanations for the lack of this phenomenon in patients
who have undergone blepharoplasty.
DiFrancesco et al14 performed an electromyographic
study on the orbicularis oculi after subciliary blepharoplasty
and found that the tone and innervation were maintained
after subciliary blepharoplasty. The main difference
between a standard subciliary blepharoplasty and
the inside-out approach is the resection of the lower eyelid
retractors. While patients who have had subciliary
blepharoplasty have much higher rates of lower eyelid
malposition, those who have had the inside-out or the
standardized transconjunctival blepharoplasty do not seem
to suffer from eyelid malposition. Clearly, the transection
of the lower eyelid retractors plays a role in the preservation
of eyelid position in these patients.
Lateral rounding and eyelid positioning remained unchanged
after surgery despite transcutaneous skin removal
and trichloroacetic acid peels. Inside-out blepharoplasty
offers a safe alternative to standard subciliary
blepharoplasty in achieving commendable aesthetic results
without compromising eyelid position or canthal
Maintaining the position of the lower eyelid after lower
eyelid blepharoplasty is a difficult endeavor. Few studies
have used objective measures to critically examine the
MRD2. A lateral canthal rounding scale was developed
using pre- and postoperative photographs to provide additional
analysis of the lateral canthal shape or MRD2 in
patients who underwent inside-out blepharoplasty.
Accepted for Publication: July 16, 2007.
Correspondence: David B. Rosenberg, MD, Department
of Otolaryngology–Head and Neck Surgery, Manhattan
Eye, Ear, & Throat Hospital, 115 East 61st St, New
York, NY 10021 (
Author Contributions: Study concept and design: Rosenberg,
Lattman, and Shah.Acquisition of data:Rosenberg, Lattman,
and Shah. Analysis and interpretation of data: Rosenberg,
Lattman, and Shah. Drafting of the manuscript:
Rosenberg, Lattman, and Shah.Critical revision ofthe manuscript
for important intellectual content: Rosenberg, Lattman,
and Shah. Statistical analysis: Rosenberg and Shah.
Obtainedfunding:Lattman.Administrative,technical, and material
support: Rosenberg, Lattman, and Shah. Study supervision:
Rosenberg, Lattman, and Shah.
Financial Disclosure: None reported.
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