Recognizing the Need for an “Effective” Cheek Suspension When Treating Lower Lid Malposition: Application of the Jelks 7-Step Lower Lid Analysis
Lower lid malposition is one of the most challenging problems faced by aesthetic and reconstructive plastic surgeons. In cases of significant lower lid malposition, standard lateral canthopexy or canthoplasty techniques are rarely adequate to correct the problem, and thus may require more invasive procedures such as horizontal lid shortening techniques (i.e. tarsal strip) or dermal orbicular pennant lateral canthoplasty. Although these procedures improve lower lid position, they may also create a hazardous setting in which the lower lid provides the only mechanism of support for the cheek. Accordingly, most plastic surgeons today agree that severe cases of lower lid malposition requires concomitant cheek elevation with an ‘effective’ anchor that relieves tension from the lower lid reconstruction. The following study offers a retrospective review of the authors experience with cheek elevation and anchor-fixation to the zygomatic complex. Additionally, we review the application of a standardized preoperative analysis of lower lid and its utility for proper patient selection for cheek suspension.
Methods/Technique:
A retrospective review was performed of patients that underwent lower lid canthoplasty with cheek suspension from 2005-2012. The surgical technique for cheek suspension/fixation was recorded (suture vs mitek anchor), as well as the type of lower lid canthoplasty and additional procedures performed. Patient characteristics, pre-operative anatomic findings, relevant past surgical history, and operative indications were all documented. Postoperative patient satisfaction and surgeon assessment were documented for a minimum of 1 year follow-up.
Results/Complications:
A total of 125 patients underwent lower lid canthoplasty with cheek elevation/suspension. Average patient age was 50.1 years old (range 16-82), and bilateral cheek suspension procedures were performed in 70% of patients (vs 30% unilateral). Fixation techniques consisted of either suture or Mitek anchor screw fixation in 48% and 52% of patients, respectively. Based on our preoperative surgical algorithm, 7 variables were key to the preoperative examination (1) palpebral aperature, (2) vector analysis, (3), midface descent, (4) canthal tilt, (5) lateral canthus-to-lateral orbit soft tissue distance, (6) mid lamellar cicatrix, and (7) tarsoligamentous integrity. Of these, midlamellar-cicatrix, midface descent, and lateral canthus-to-lateral orbit were the most significant factors determining the need for mitek anchor fixation.
Conclusion:
Cheek elevation/fixation with lateral canthoplasty is a useful technique for correction of severe lower lid malposition. Unlike other procedures, which rely on lower lid fixation alone to suspend the cheek, the authors report their experience with surgical elevation and ‘effective fixation’ of the midface. Based on our experience, the 7-step lower lid checklist helps to identify patients who have benefited from the above, and who otherwise may have undergone less aggressive canthoplasty techniques with potentially less success rates. Interestingly, as growing numbers of patients may present with midface deformities following midface-lifting procedures, or skin-muscle flap lower lid blepharoplasty, recognizing the need to treat the lower lid with proper cheek suspension may be of increasing importance.
Patients with midface malposition may be the result of midface-lifting procedures that do not provide long-lasting cheek support, and/or lower blepharoplasty techniques with skin-muscle flaps that may cause postoperative cicatrix and poor orbicularis occuli muscle tone.