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The Five-Step Lower Blepharoplasty: Blending the Eyelid-Cheek Junction

Rohrich, Rod J. M.D.; Ghavami, Ashkan M.D.; Mojallal, Ali M.D., Ph.D.

Plastic and Reconstructive Surgery: September 2011 - Volume 128 - Issue 3 - p 775–783
doi: 10.1097/PRS.0b013e3182121618
Cosmetic: Original Articles

Background: Lower lid blepharoplasty has potential for significant long-lasting complications and marginal aesthetic outcomes if not performed correctly, or if one disregards the anatomical aspects of the orbicularis oculi muscle. This has detracted surgeons from performing the technical maneuvers necessary for optimal periorbital rejuvenation. A simplified, “five-step” clinical approach based on sound anatomical principles is presented.

Methods: A review of 50 lower lid blepharoplasty patients (each bilateral) using the five-step technique was conducted to delineate the efficacy in improving lower eyelid aesthetics. Digital images from 50 consecutive primary lower blepharoplasty patients (100 lower lids: 37 women and 13 men) were measured using a computer program with standardized data points that were later converted to ratios.

Results: Of the 100 lower eyelid five-step blepharoplasties analyzed, complication rates were low and data points measured demonstrated improvements in all aesthetic parameters. The width and position of the tear trough, position of the lower lid relative to the pupil, and the intercanthal angle were all improved. There were no cases of lower lid malposition.

Conclusions: Aesthetic outcomes in lower lid blepharoplasty can be improved using a five-step technical sequence that addresses all of the anatomical findings. Lower lid blepharoplasty results are improved when (1) the supportive deep malar fat compartment is augmented; (2) lower lid orbicularis oculi muscle is preserved with minimal fat removal (if at all); (3) the main retaining structure (orbicularis retaining ligament) is selectively released; (4) lateral canthal support is established or strengthened (lateral retinacular suspension); and (5) minimal skin is removed.


Dallas, Texas; Beverly Hills, Calif.; and Lyon, France

From the Department of Plastic Surgery, University of Texas Southwestern Medical Center; private practice; and the Department of Plastic Surgery, University of Lyon.

Received for publication October 10, 2010; accepted January 18, 2011.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Rod J. Rohrich, M.D.; Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, Texas 75390-9132,

©2011American Society of Plastic Surgeons