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Is Traditional Lower Blepharoplasty a Superior Technique?

Parsa, Fereydoun Don M.D.; Murariu, Daniel M.D., M.P.H.; Parsa, Alan Ali M.D.; Siah, Michael Cyrus B.A.; Armstrong, Jennifer B.A.

Plastic and Reconstructive Surgery: June 2012 - Volume 129 - Issue 6 - p 1001e–1002e
doi: 10.1097/PRS.0b013e31824efe2e
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John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii

Correspondence to Dr. Fereydoun Don Parsa, John A. Burns School of Medicin, University of Hawaii, 1329 Lusitana Street, Suite 807, Honolulu, Hawaii 96813-2421 fdparsa@yahoo.com

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Sir:

Figure

Figure

We read with interest the article entitled “Traditional Lower Blepharoplasty: Is Additional Support Necessary? A 30-Year Review” by Maffi et al. (Plast Reconstr Surg. 2011;128:265–273). This article describes the senior author's experience with traditional blepharoplasty and concludes that external incision with fat removal has a low complication rate and that routine support procedures are unnecessary.

We have used both the traditional lower blepharoplasty and the fat-preserving technique1 for over 30 years and have only used the latter for the past 20 years. This technique consists of reducing the fatty hernia and approximating the capsulopalpebral fascia to the arcus marginalis15 (Fig. 1). Prospective studies comparing the “traditional” method with the “fat-preserving” method show that hernia repair is simple, safe, and reproducible, with very low morbidity and superior long-term results2,5 (Table 1).

Fig. 1

Fig. 1

Table 1

Table 1

Although we agree with Maffi et al. that a tightening procedure is not indicated when the eyelid tone is “adequate,” we disagree with their concept of concomitant “canthopexy” when the preoperative distraction test is “less than 6 mm” and “canthoplasty” when it measures more. We have found that both the values that reflect the muscle tone (snap-back test) and the degree of stretching of the canthal ligaments (distraction test) are necessary in selecting patients for lower lid support procedures and that over 80 percent of our patients qualify for such an intervention in contrast to their very small percentage. We define “adequate/normal tone” when the snap-back test and the distraction test are less than 1 second or less than 2 mm, respectively. In “mild” and in the majority of “moderate” and “severe” cases, we perform a tightening/anchoring procedure we call musculoplasty, as shown in Figure 2. Only in a small percentage of moderate and severe cases (<5 percent) do we perform other procedures in addition to musculoplasty. Musculoplasty consists of a single stitch of 5-0 absorbable monofilament that approximates the lower lid's orbicularis muscles to the dense fibrous tissue of the lateral orbital rim. No soft-tissue dissection and no undermining is performed in the lateral canthal region, and chemosis is typically either minimal (<5 percent of patients) or absent and, when present, subsides within 7 to 14 days without the use of steroid preparations. We have observed that chemosis is absent when the lateral canthal area is not invaded, and we attribute postoperative chemosis to surgical trauma to this region and not to lower blepharoplasty per se because in our experience chemosis is absent in these instances.

Fig. 2

Fig. 2

Finally, we disagree with Maffi et al. that the “traditional” approach of fat removal is easier to teach. We have found that surgeons in training who have been exposed to the basic principles of hernia repair in general surgery understand and learn readily the principles of hernia repair in the lower eyelids and are impressed by its simplicity2,5 (Fig. 1). In addition, the procedure requires less sedation, and no intraorbital bleeding/blindness has ever been reported because fatty tissue is not injected or manipulated.15

Fereydoun Don Parsa, M.D.

Daniel Murariu, M.D., M.P.H.

Alan Ali Parsa, M.D.

Michael Cyrus Siah, B.A.

Jennifer Armstrong, B.A.

John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication.

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REFERENCES

1. de la Plaza R, Arroyo JM. A new technique for the treatment of palpebral bags. Plast Reconstr Surg. 1988;81:677–687.
2. Parsa FD, Miyashiro MJ, Elahi E, Mirzai TM. Lower eyelid hernia repair for palpebral bags: A comparative study. Plast Reconstr Surg. 1998;102:2459–2465.
3. Camirand A, Douchet J, Harris J. Anatomy, pathophysiology, and prevention of senile enophthalmia and associated herniated lower eyelid fat pads. Plast Reconstr Surg. 1997;100:1535–1546.
4. de la Plaza R. Septo-orbitoperiostoplasty for the treatment of palpebral bags: A 10-year experience (Discussion). Plast Reconstr Surg. 1998;101:1664–1665.
5. Parsa AA, Lye KD, Radcliffe N, Parsa FD. Lower blepharoplasty with capsulopalpebral fascia hernia repair for palpebral bags: A long-term prospective study. Plast Reconstr Surg. 2008;121:1387–1397.
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