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Transconjunctival Septal Suture Repair for Lower Lid Blepharoplasty

Atiyeh, Bishara S. M.D.; Hayek, Shady N. M.D.

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Plastic and Reconstructive Surgery: April 2008 - Volume 121 - Issue 4 - p 1505-1506
doi: 10.1097/01.prs.0000305373.52386.e2
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Lower lid blepharoplasty has evolved drastically over the last few decades. As rightly mentioned by Dr. Sadove,1 many complications have been described following external subciliary skin incision. The need for safer procedures, stressing the importance of orbicularis muscle and orbital fat preservation, has long been recognized. The technique originally described2 and now revived by Sadove definitely preserves both structures; however, is this what is really required to correct the stigma of lower lid aging?

Orbital septum tightening would correct the bulging lower eyelid, but it does not rejuvenate the lower lid. Facial aging is a summation of both hard- and soft-tissue changes.3 Optimal rejuvenation of the lower eyelid should correct not only prolapse of orbital fat but also descent of the cheek tissues, accentuation of the orbital rim, and the tear trough groove.4 To obtain a truly youthful eyelid-cheek complex, simple tightening of the orbital septum to place the protruding fat back into position cannot be enough. It is essential to restore midface volumes, reposition shifting tissues, and create a narrower, shallower orbit with a shorter lower lid.4 In fact, lower lid blepharoplasty should be considered a complex reconstructive procedure, part of an overall holistic approach to facial surgery aimed at restoring youthful volumes by redistributing and shifting local tissues, and whenever indicated by the addition of soft tissues or other substitutes.

The described technique does not address all the changes of aging and definitely does not result in optimal rejuvenation. As rightly mentioned by Dr. Sadove, it is not a universal technique.1 It is not an acceptable method when cheek sagging with elongation of the lower lid vertical length is present. The patient shown in Sadove’s Figure 13 clearly illustrates this point. Shortening lower lid vertical length by elevating the lid-cheek skin junction and camouflaging the inferior orbital rim is essential.4 It seems that risking muscle weakness of a small pretarsal strip, if any, is a small price to pay to achieve optimal lower lid and periorbital rejuvenation, provided lower lid sagging, rounding of the lateral corners of the palpebral aperture, and widening of the palpebral aperture are avoided by proper orbicularis sling suspension, canthoplasty, and lower lid tightening. It is not true, also as claimed, that preservation of the original palpebral aperture is desirable. On the contrary, elevation of the lower lid margin with a simultaneous decrease in the palpebral aperture may be highly warranted in most older patients.

Dr. Sadove is to be commended on his meticulous presentation and his honesty in reporting his complications. We are surprised, though, that he did not encounter more lower lid tethering, a dreadful complication that has detracted many from orbital septum tightening. This is definitely an indication of his excellent surgical skills. As a general principle and irrespective of the surgical technique, local assessment, careful preoperative planning, and conservative tissue resections can help minimize complications and optimize results.4 Dr. Sadove’s technique is certainly a valuable addition to our surgical armamentarium.

Bishara S. Atiyeh, M.D.

Plastic and Reconstructive Surgery

American University of Beirut Medical Center

Beirut, Lebanon

Shady N. Hayek, M.D.

Plastic and Reconstructive Surgery

University of Minnesota

Minneapolis, Minn.


1. Sadove, R. C. Transconjunctival septal suture repair for lower lid blepharoplasty. Plast. Reconstr. Surg. 120: 521, 2007.
2. de la Plaza, R., and Arroyo, J. M. A new technique for the treatment of palpebral bags. Plast. Reconstr. Surg. 81: 677, 1988.
3. Atiyeh, B. S., and Hayek, S. N. Combined arcus marginalis release, preseptal orbicularis muscle sling, and SOOF plication for midfacial rejuvenation. Aesthetic Plast. Surg. 28: 197, 2004.
4. Pessa, J. E., Desvigne, L. D., Lambros, V. S., Nimerick, J., Sugunan, B., and Zadoo, V. P. Changes in ocular globe-to-orbital rim position with age: Implications for aesthetic blepharoplasty of the lower eyelids. Aesthetic Plast. Surg. 23: 337, 1999.

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