No More Ectropion! Lower Lid Rejuvenation with Helium RF Plasma and Fat Grafting

Goals/Purpose: Traditional lower eyelid Blepharoplasty techniques with skin excision involves a significant risk of ectropion and lagophthalmos, despite incorporating intra-operative techniques such as lateral canthopexies or canthoplasties. In order to avoid these complications that are difficult to correct, the author presents lower eyelid rejuvenation without any skin excision, thereby avoiding trauma to the lower eyelid middle lamella, the most common area for scarring that can lead to post-operative cicatricial ectropion. Instead of skin excision, the author describes her technique of lower eyelid rejuvenation utilizing helium RF plasma skin resurfacing combined with structural macrofat grafting in the tear trough and lid-cheek junction areas.

Methods/Technique: The author presents her single surgeon retrospective experience of 60 patients treated in a five year period (2017-2022). Patients age range from 55-74, with 55 females and 5 males. Fifty patients underwent the procedure in conjunction with full face resurfacing and fat grafting, while ten patients had peri-orbital resurfacing only, along with fat grafting. Fifty five patients had their procedures performed under IV Sedation, and five patients were under general anesthesia. Patient follow up was one day after surgery, followed by weekly, then monthly for three months, then annually. The longest follow up is five years.

Technique:

Following successful induction of IV Anesthesia or General Anesthesia, the face is prepped and draped in the usual sterile fashion. The peri-orbital areas were then prepped with acetone, then corneal protectors placed. Tumescent solution was then infiltrated into the lower eyelids, approximately 7-10 cc per side. Next, helium RF plasma resurfacing was performed at 40% with 4 liter helium flow at a single pass. Next, macro fat grafting was performed utilizing blunt cannulas via radial Coleman technique, beginning from the tear trough or nasojugal fold, going laterally along the lid-cheek junction. Approximately 1 cc is placed along the nasojugal fold, and a range of 4-7 cc along the lid-cheek junction, just superficial to the infra-orbital periosteum. The patient is then instructed to wash their face twice a day and apply laser balm for the next two weeks.

Results/Complications: There were no patients who experienced ectropion or lagophthalmos post-operatively. There were two patients in the full face resurfacing group who experienced complications. One patient experienced post-inflammatory hyperpigmentation of her forehead at three weeks post-op, but resolved after six weeks of treatment with hydroquinone based skin care. One patient experienced cellulitis of her forehead at eight weeks post-operative, but resolved after two weeks of oral antibiotics. All patients treated had significant improvement of the skin laxity in the lower eyelid area and correction of the volume loss in the nasojugal fold and the demarcation between the lid-cheek junction.

Conclusion: Lower eyelid rejuvenation can be effectively and safely achieved utilizing a combination of helium RF plasma for lower eyelid skin resurfacing, along with macro fat grafting to correct the volume loss of the nasojugal area and the lid-cheek demarcation. By avoiding any skin excision, possible trauma to the middle lamella compartment of the lower eyelid is avoided, therefore preventing the occurrence of cicatricial ectropion and lagophthalmos. This technique also avoids the presence of a visible lower eyelid incision line. The author’s goal is to continue to treat more patients and have longer post-operative follow up.