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.
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.1–5
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
The authors have no financial interest to declare in relation to the content of this communication.
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.
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.
Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.
Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/prs/.
We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.
The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.