Goals/Purpose: Lower eyelid and midface rejuvenation has been an area of great controversy and complications can be devastating. Orbicularis muscle lifting was introduced in 1972 and while it has been used by some in a variety of ways the benefits have not been commonly appreciated.For this author it has become standard procedure for all lower lid/midface rejuvenation surgery ranging from mild to severe cases of lower lid aging issues. The purpose of this 12 year experience is to demonstrate the progression of indications and techniques and how to integrate this fundamental component into rejuvenation of the lowerlid /midface region. The author presented his early experience with the first 50 cases at the ASPRS meeting in San Antonio in 2002. Over 12 years the author has performed this technique which developed out of dissatisfaction with the healing time of the subperiosteal technique for lower lid/midface rejuvenation..
Methods/technique: The study represents the last 100 consecutive cases of lower eyelid procedures on 92 females and 8 males ranging in age from 36 to 74. In the early experience the author noted that the lifting and tightening of the orbicularis was fundamental to the post operative result so this step was subsequently included on every lower lid procedure of any degree of severity. Eventually different degrees of muscle lifting proved necessary depending on the aging issues involved. The following indications have been developed.
Grade 1 - Mild - skin rhytids present but no excess skin. Early signs of aging with deepening of nasojugal groove and mild increase in lid height, some loss of lower lid volume . No exposure of fat pads. No canthal or lid laxity.
Grade 2 - Moderate - Excess skin present with skin rhytids. Nasojugal groove extends to midpupil line and lower lid height is increased. Midface descent evident. Lower lid fat pad herniation becoming noticeable. Mild canthal laxity. Lower lid tone and position still good.
Grade 3 - Severe - Lower lid tone poor with senile ectropion beginning or evident. Canthal laxity. Excess skin, severe rhytids, with obvious fat herniation. Severe volume loss with midface descent. Reoperative patients with scarring, malposition.
Based on the above indications the following techniques have been applied:
Grade 1 -”Minilift “of lower lid - Orbicularis muscle lift alone with medially based muscle flap and minimal skin resection in lateral third of lid only. No complete division of skin or muscle transversely. Pearl fat grafts to nasojugal groove if necessary. suborbicularis fat contouring if indicated. Occasional 3mm medial subciliary incision if indicated for medial fat pad transposition.
Grade 2 - Skin muscle flap with full length skin/muscle resection, extension of subcutaneaous dissection into midface anterior to muscles of facilal expression, lower lid fat transposition to blend with midface fat after Loeb/Hamra, release of medial orbicularis fibers, medially based orbicularis flap lifted and fixed vertically to temporalis fascia, pseudocanthopexy , midface lifting with fixation as indicated.
Grade 3 - as above with more extensive muscle lift and canthoplasty, more extensive midface lift with fixation of midface lift( endotine, bone screw, etc.).
Results/complications:
In the last 100 consecutive cases over 2 years there have been 2 cases of lateral ectropion requiring reoperation. Etiology was due to lack of ladequate ateral support which was corrected at reoperation ( gr 2 -1, gr 3 - 1). 3 other patients (gr 3 -2, gr 2 - 1)) experienced temporary lower lid retraction relieved with exercises and direct kenalog injection and alll resolved completely. Since the use of frost sutures for 5 days in the last 20 grade 2 and 3 patients there have been no further lid malposition problems. there has never been a lower lid malposition in a grade 1 patient. Chemosis has been decreased in later cases but was 10% in earlier cases. There was 1 case of post op steroid induced glaucoma.
Aesthetic results have been reliable and superior with shortening of the lower lid height, excellent lower lid support and shape, elevation of the midface, corretion of canthal position, and good long term results. Patient satisfaction has been 98%.
Conclusion: For this author, lower lid orbicularis muscle lifting has proved to be a necessary component of rejuvenation in the lower lid /midface region from mild cases to severe cases due to the excellent reshaping potential from the dynamic support which increases as the orbicularis sling is tightened and lifted. Incidence of lower lid malposition is uncommon even in advanced cases. Advantages include use of the lift alone in mild cases of early lower lid aging performed as a “minilift” of the lower lid with complete avoidance of entry into the central lower lid. However, in more advanced cases requiring more extensive techniques, muscle lifting always provides added benefit. Indications which help the surgeon choose the appropriate techniques integrating muscle lifting have been developed. The technique can be applied to secondary cases as well where rejuvenation is needed without further skin resection..