Blepharoplasty

Blepharoplasty, or eyelid surgery, can fix bags, dark circles, droopy eyelids, and tear trough concerns. Dr. Yaremchuk employs several techniques in his eyelid surgeries to restore youthful contour and dimensions to the eyelids. The late medical anthropologist Leslie Farkas documented that the typical youthful eye among a large sample of young North American women had a narrow appearance, upward tilt from the inner to outer aspect, and short lower lid.

Illustration of Dr. Farkas’ measurements of the youthful eye with narrow fissure, upward tilt and short lower lid.


As the eye ages, it takes on a rounder appearance as gravity takes effect and supporting tissues relax over time.  Instead of creating the desired youthful effect, too often conventional blepharoplasty techniques exaggerate the aged appearance by resulting in a post-op “round eye” look.

Dr. Yaremchuk employs a variety of innovative techniques depending on the clinical situation. These techniques include the transconjunctival approach with arcus marginalis release and fat redistribution as opposed to excision, selective use of lateral canthopexy, skeletal augmentation and midface elevation. Dr. Yaremchuk has presented and written extensively about these techniques in scholarly articles, book chapters, and lectures.

The tear trough deformity is a challenging problem. It is often associated with "dark circles." Most often, Dr. Yaremchuk corrects the tear trough deformity using the transconjunctival arcus marginalis release with fat transposition. For severe deformities, he employs both the transconjunctival arcus marginalis release with fat transposition and a tear trough implant. The video here shows Dr. Yaremchuk's technique for correcting a severe tear trough deformity.

Patients with prominent eyes have long been known to be predisposed to complications after lower lid blepharoplasty. Dr Yaremchuk has developed techniques to improve the appearance of the lower lids in patients with prominent eyes. Eyes appear overly prominent because the upper midface skeleton (the bone directly beneath the eye) lacks projection. Without a projecting skeleton to support it, the lower lid and cheek tissues tend to fall, making the eyes prominent. Dr Yaremchuk treats this problem building up the skeleton with an infraorbital implant and performing a midface lift to elevate the cheek and lower lid tissues on the new, projecting skeletal framework.


Blepharoplasty for prominent eyes: The illustration shows cross section lateral views of the orbit taken at the level of the pupil. The diagram on the left shows the average relations of the lower lid and globe. The middle illustration depicts a prominent eye due to lack of projection of the skeleton and the subsequent descent of the lower lid and cheek. On the far right, the bone has been augmented with an infraorbital rim implant and the cheek and lid elevated (subperiosteal midface lift). Note how the lid margin rests higher on the globe making the eye appear less prominent.

Dr. Yaremchuk also performs revisional blepharoplasty to correct unfortunate results for patients who underwent prior unsatisfactory blepharoplasty procedures elsewhere.

Dr. Yaremchuk has shared his face and eyelid rejuvenation techniques with plastic surgeons in live surgery demonstrations around the world including Spain, Germany, Russia, Argentina and Taiwan. He has demonstrated his blepharoplasty and skeletal augmentation surgery at the Canadian Society for Aesthetic Plastic Surgery Annual Meeting and at the Annual Atlanta Oculoplastic Symposium.

before after

* This Asian patient underwent upper and lower lid blepharoplasty.

before after

* Underwent lower lid blepharoplasty by arcus margnalis release with fat transpositon to correct tear troughs and restore youthful lower lid contour


before after

* Underwent lower lid blepharoplasty by arcus margnalis release with fat transpositon to correct tear troughs and restore youthful lower lid contour

before after

* Underwent lower lid blepharoplasty by arcus margnalis release with fat transpositon to correct tear troughs and restore youthful lower lid contour


before after

* This patient with prominent eyes underwent orbital decompression, infraorbital rim augmentation, midface lift and medial fat transposition to improve periorbital aesthetics

before after

* This patient underwent transconjunctival blepharoplasty with arcus marginalis release and fat transposition.


before after

* This patient with prominent eyes underwent orbital decompression, infraorbital rim augmentation, midface lift and medial fat transposition to improve periorbital aesthetics

before after

* This patient underwent transconjunctival blepharoplasty with arcus marginalis release and fat transposition.


before after

* Underwent upper and lower lid blepharoplasty

before after

* Underwent Asian upper and lower lid bleph


before after

* This Asian patient underwent upper and lower lid blepharoplasty

 

Surgical Procedures to Reposition the Retracted Lower Eyelid

Background

Retraction of the lower eyelid
Retraction of the lower eyelid - demonstrated in the photograph to the right - can be the result of damage to the lower eyelid and surrounding periorbital and midface structures. Craniofacial trauma, tumors, facial paralysis, thyroid eye disease, and cosmetic blepharoplasty can alter the position of the normal lower eyelid.

In addition to the unappealing appearance with increased scleral can include the inability for the eyelids to close (referred to as lagophthalmos), and exposure keratitis. This can lead to dry eye syndrome, ocular discomfort, excessive tearing, photophobia, and blurred vision.

Dr. Yaremchuk utilizes many surgical procedures to correct lower eyelid retraction depending on the periorbital structures involved. Spacer grafts, bridge-of-bone lateral canthopexy, subperiosteal midface lifts and infraorbital rim bone augmentation are all part of his armamentarium. Certain clinical problems require a combination of these procedures to restore lower lid position.

Lower Lid Anatomy

The normal lower eyelid lies at or just above the inferior corneal limbus (the perimeter of the iris).

It is considered a trilamellar structure—the anterior lamella (skin and orbicularis oculi muscle), the middle lamella (orbital septum), and the posterior lamella (lower eyelid retractors and conjunctiva.

The lid is tethered at both ends by its canthal tendons which are attached to the orbit.

The lid is supported by its underlying obital rim.

Deficiency of any layer of this trilamellar structure and its supporting orbital rim can result in lower eyelid retraction.

Lower eyelid anatomy demonstrating the anterior lamella (skin and orbicularis oculi muscle), the middle lamella (orbital septum), and the posterior lamella (lower eyelid retractors and conjunctiva).

Spacer Grafts

Scarring and subsequent shortening of middle and posterior lamellae most often results after surgical violation to the middle and posterior lamella approaches to expose the orbital anatomy or to correct traumatic orbital injuries or to cosmetically improve intraorbital fat. Traumatic or iatrogenic soft tissue injury or hemorrhage can result in untoward healing with contracture and lamellar shortening.

Correction of posterior and middle lamellar shortening is accomplished by incising the lamellae which results in a space between the edges. The space is then bridged with a graft. The graft effectively lengthens and supports the lamella and hence the lower lid. Palatal mucosa, conchal cartilage and treated alloplastic dermal matrices are all used as spacer grafts.

Lower lid malposition secondary to vertical contracture of scarred septum. C-E. Hard palate mucosal graft used as a spacer between the lower tarsal plate and the recessed conjunctiva, lower eyelid retractors, and orbital septum. Note the difference in lid position between image B and C,D,E

Subperiosteal Midface Lift

Malposition of the lower lid is a frequent problem after transcutaneous blepharoplasty. Overresection of the lid skin and underlying muscle (outer lamella) with scarring of the orbital septum (middle lamella) causes the lower lid to descend and the lateral canthus to descend medially in a “round eye”. An operation intended to rejuvenate the lower lid unfortunately ages it as shown below.

The subperiosteal midface lift is an ideal procedure to correct lower lid malposition due to overresection of the lid skin and underlying muscle. Using intraoral and periorbital incisions, the full thickness of the midface tissues (skin, subcutaneous flat and muscles) are elevated from the underlying skeleton and fixed to the infraorbital rim after scarring in this area is released. The fat from the underlying of the midface tissue supports the lid margin while the elevated midface skin effectively adds skin to the deficient lower lid.

 Normal           After blepharoplasty

During midface elevation           After elevation of midface tissues

Lateral Canthopexy

The youthful palpebral fissure is long and narrow with a slight lateral upward inclination. Distortions of this shape may be secondary to heredity, aging, paralysis, trauma or previous surgery. This distortion of shape inevitably manifests as rounding of the fissure with inferomedial descent of the lateral canthus and concomitant descent of the lower lid margin. Lateral canthopexy, the surgical repositioning of the lateral canthus is fundamental to altering or restoring the shape of the palpebral fissure.

The lateral canthal structures are purchased with a figure of eight suture. Drill holes are placed in the lateral orbital rim using the zygomaticofrontal sutures as reference landmarks. This measured placement aids in achieving symmetric canthal repositioning. The bridge of bone between the drill holes provides a stable platform over which the suture ends can be tied.

Infraorbital Rim Augmentation

The relationship of the globe to the infra orbital rim is a primary determinant of the appearance of the upper portion of the midface. In young healthy Caucasian adults, the average projection of the soft tissues overlying the supraorbital rim beyond the surface of the cornea is about 10 mm, and the projection of the beyond the soft tissues overlying the infraorbital rim is 3 mm.

A lack of midface skeleton projection results in a deficiency for the support of the soft tissue envelope. Clinical manifestations include decent of the lower lid with a tendency for scleral show and a long lid and cheek sag. With this lack of skeletal support for the lower lid, aesthetic blepharoplasty is prone to lower lid malposition. This anatomy was termed as “morphologically prone” to lid descent after blepharoplasty by plastic surgeons Rees and La Trenta. Jelks and Jelks later referred to average globe-lower rim relation as a positive vector. A deficient infraorbital rim was termed a negative vector. Dr. Yaremchuk Designed infraorbital rim implants to “Reverse” the negative vector.

Lid malposition after lower lid blepharoplasty can be corrected by freeing periorbital scarring, augmenting the infraorbital rim with an infraorbital rim implant and elevating the midface tissues in the subperiosteal plane.

Clinical Examples Using These Techniques

This patient was referred with lid retraction from scarring after lower lid blepharoplasty and attempts for correction with a tarsal strip lid tightening. The lid retraction was corrected with a palatal spacer graft.


This patient had suffered massive right sided orbital trauma with loss of her globe. The orbital structures were reconstructed. However, the lower lid was insufficient to cover the orbital prosthesis. A conchal cartilage spacer graft and lower lid shortening provided lid support and prosthesis coverage and position stability.


This patient had lid descent after lower lid blepharoplasty with tarsal strip in negative vector patient. Surgery required Infraorbital rim augmentation, subperiosteal midface lift and palatal spacer grafts.


This patient was involved in an MVA and had orbital fractures the patient suffered a post-op infection resulting in the obvious lid malposition. Surgery was corrected with a palatal spacer graft to restore preinjury lower lid symmetry.


This patient with Graves Ophthalmopathy had her lower lids elevated with a palatal spacer graft.


This patient with Treacher-Collins Syndrome was left with lower lid distortion after reconstructive surgery. Lower lid shape and reconstruction involved augmentation of the infraorbital rim, a subperiosteal midface lift and a bridge-of bone lateral canthopexy.


This patient had an aggressive lower lid blepharoplasty resulting in lower lid descent. It was corrected by scar release and subperiosteal midface lift.


These two patients had agressive lower lid blepharoplasties resulting in lower lid descent. It was corrected by scar release, subperiosteal midface lift and lateral canthopexy.


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