Achieving aesthetic balance in the brow, eyelids, and midface

An approach to the brow, eyelids, and midface emphasizing release and advancement of the orbicularis oculi muscle, conservative removal of orbital fat, preservation of the nerve supply to the orbicularis oculi muscle, and avoidance of canthal division was evaluated in 100 consecutive patients. The technique describes the selected release of three key retaining ligaments to the forehead, brow, and upper eyelid; mobilization of the lateral retinaculum and division of the lower lid retaining ligament; and division of the midface malar retaining ligament (zygomatic-cutaneous ligament). Preservation of motor branches to the lower lid orbicularis is stressed. Of significance to this series of patients is the inclusion of 50 patients with morphologically prone lower eyelids defined as atonic lower lids, exorbitism, and/or negative vector orbits. Three sites had failure of brow fixation, two patients had midface asymmetry requiring revision, and three patients failed to have complete correction of their preoperative lower lid retraction. There was zero incidence of scleral show or lower lid retraction that was not present preoperatively. No patients required division of the lateral commissure with canthoplasty, taping or suture suspension, massage, or steroid injections. Only two patients required division of the deep head of the lateral canthus, and these patients were noted to have had lateral canthal malposition preoperatively.