The authors present their personal technique on lower blepharoplasty with preserving a strong orbicularis oculi sling and maintaining lower eyelid position with periosteal fixation of the lateral canthus and skin- muscle flap. In their technique, after elevation of skin flap, the orbicularis muscle is incised for the length of the orbit from medial to lateral and from this point inferiorly, a composite skin muscle flap is elevated off the orbital septum to the orbital rim. They performed volumisation with fat transposition by rotation of fat pads inferiorly over the orbital rim into the tear trough. In their experience the excessive fat of the lateral fat pad is resected rather than transposed because the lateral fat pad is more fibrous and creates contour irregularities when transposed, so it is conservatively excised to the level of the superficial aspect of the orbital rim. Superior midface elevation was performed with orbicularis flap and the skin is redraped superolaterally into the part of the skin incision lateral to the lateral canthus. This technique should be avoided in patients with negative vector lower eyelids and poor orbicularis muscle strength because they are at increased risk for lower eyelid malposition postoperatively.

Extended submuscular blepharoplasty with orbitomalar ligament release and orbital fat repositioning.
Jacono AA, Malone MH.