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    Achieving the lower eyelid ideal

    Two cosmetic facial surgeons have found that a combination of transconjunctival lower lid blepharoplasty, fat grafting and 88% phenol peeling is superior to other eyelid rejuvenation approaches. When performed correctly, the combination consistently restores the aesthetic ideal of the lower lid and cheek junction, according to their recently published research.

    Dr. WadeMany of today’s lower eyelid rejuvenation approaches fall short of achieving the aesthetic ideal, according to the paper’s lead author Wade D. Brock, M.D., an oculoplastic and cosmetic facial surgeon with Arkansas Oculoplastic Surgery, Little Rock, Ark.

    “People really have trouble hanging their hat on a consistent way to rejuvenate that junction between the lower lid and cheek. And that’s really what people want,” Dr. Brock says

    The paper features three patients treated with transconjunctival blepharoplasty, fat grafting and 8% phenol peel. All reported significant improvements with their postoperative appearances. There were only minimal complications reported, none of the patients requested surgical revisions and the results were stable over an average two-year followup. Two of the three patients had follow-ups at eight years or more.

    Patient shown before and after combination of transconjunctival lower lid blepharoplasty, fat grafting and 88% phenol peeling. Photos courtesy of Jim English, M.D.

    A History of Lackluster Outcomes

    In the 1980s, cosmetic surgeons primarily removed fat from the lower lids. The transconjunctival approach was a step forward from the external approach but still fell short, Dr. Brock says.

    “You get rid of the bag, but it’s not exactly a youthful appearance. When you restore that nice, full transition between the lower lid and the cheek, that’s really a more youthful subtle appearance. People have wrestled with ways to do that,” Dr. Brock says.

    One option is the septal reset, where surgeons release the septal attachment, repositioning fat by taking some of the medial fat pad and positioning it lower into the nasojugal fold or the tear trough.

    Dr. Brock says he has tried them all and consistently finds the combination approach he describes offers best results.

    Patient shown before and after combination of transconjunctival lower lid blepharoplasty, fat grafting and 88% phenol peeling. Photos courtesy of Jim English, M.D.

    Each of said combination elements has an important role in the results. With the transconjunctival blepharoplasty, surgeons are eliminating the tissue that’s really pronounced and herniated too far. With the fat, they’re replacing some of the areas that are depressed and need to be filled in order to create continuity, he says.

    “[Surgeons] struggle with how to rejuvenate the outside of the eyelid. Is it laser, a [trichloracetic acid] peel… is it taking skin? I’ve taken care of complications when people take too much skin. That can cause eyelid malposition. Laser and peeling can do the same thing. Most people probably do laser or a pinch of skin or a TCA peel. But not many people do the phenol peel,” Dr. Brock says. “We’re not aggressively degreasing the area, and we’re just using a small amount without croton oil. The croton oil has been shown to increase the depth of penetration. In the absence of croton oil and in the absence of aggressive degreasing, you can get a nice presentation.”

    NEXT: Patient & Surgical Nuances

    Lisette Hilton
    Lisette Hilton, president of Words Come Alive, has written about health care, the science and business of medicine, fitness and wellness ...

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