Pinch Blepharoplasty for Lower Eyelid Skin Excess

• The Problem With a Skin or Skin-Muscle Flap

Traditional transcutaneous blepharoplasty requires dissection of a large "flap" of skin or skin and muscle through which any bulging orbital fat may then be approached. While excess skin can be trimmed at the end of the operation, the technique is highly disruptive to normal eyelid anatomy (especially the middle support layers) and not very precise.

As a consequence, there is a significant incidence (15-20%) of lower lid distortion or malposition, such as downward retraction, an unnatural rounding, or too much white of the eye showing, all undesirable changes that contribute to a "surgical look."

Intense postoperative swelling and bruising are typical, and the healing period is long.

• The Problem of Ignoring Skin While Removing Fat

If the only feature degrading the appearance of the lower eyelid is fat bulging, removing skin is, of course, not a good idea.

However, reducing the volume of larger fat bags in some patients may eliminate over-inflation of the skin and unveil preexisting but partially camouflaged skin excess (like letting the air out of a balloon). If not recognized and treated simultaneously, improvement may be less than it could have been.

• Skin Resurfacing is Seldom Enough

Simply resurfacing the skin without surgically removing any skin seldom makes that much of a difference in a patient with more than the mildest amount of skin excess.

Treatments such as chemical peel and laser resurfacing can do a nice job at helping surface wrinkling and the textural changes from sun damage, but reducing true skin excess and deeper folding still requires excision.

• Less Lid Invasion Equals Less Risk and Faster Healing

Since pinch blepharoplasty does not involve dissection of a flap and fully preserves the integrity of the eyelid's closing muscle and middle support structures, there is much less chance of later problems. While a scar just below the lashes is indeed created, skin removal is more precise, wound healing is more controlled, and recovery is faster.

If lower lid fat bulging needs help, it can be addressed through a minimally invasive transconjunctival incision hidden along the inside surface of the lid. If the skin's texture needs improvement, it can be treated by chemical peel. If canthopexy is required because of, for instance, poor lid tone from age or smoking, it, too, can be done as the same time (although it doesn't need to be "routinely" included as with other skin flap approaches).