Because blepharoplasty is done frequently without facelifts and orbital fat is usually removed in standard conventional blepharoplasty, a more concave or hollow-appearing lower eyelid is commonly seen. If one examines typical photographs of pre-and postoperative patients who have undergone a blepharoplasty, either conjunctival or transcutaneous, there is never a postoperative difference in the vertical height of the lower eyelid compared with the preoperative diameter (Fig. 42.13). Laser blepharoplasty, which has become a highly marketed procedure in the last few years, has been promoted as a scarless procedure for peri-orbital rejuvenation; however, many problems are now seen owing to the indiscriminate removal of lower-eyelid fat and the inability to move the cheek in an upward position. The removal of the lower-eyelid fat creates a more concave appearance than before as the skin drops into this concavity and wrinkling may occur. It is for this that the surgeon uses laser techniques to remove the excessive wrinkling that was created by the transconjunctival fat removal. The surgeon then advocates a canthopexy to prevent the "round eye" appearance. If one examines the eyes of the patient when she/he was younger there is usually a convex lower eyelid with a very short vertical height of the lower eyelid. The idea of the surgery is to make youthful contours. It is easy to see why standard blepharo-plasties may fail in rejuvenation and may in fact create an unfavorable result since the youthful lower eyelid is not only convex but has a shortened vertical height. One can apply the composite principles to create this. The proof that an arcus marginalis release and zygorbicular advancement is ideal for the primary patient can be seen when approaching the secondary hollow lower eyelid. In many cases the hollow lower eyelid from previous conventional bleparoplas-ty can be made or totally corrected and the unfavorable appearance can be totally negated by a secondary procedure. (Figs. 42.14-42.16) If the hollow lower eyelid can be corrected, one can only assume that this procedure as a primary procedure will prevent that patient from the ill effects that are possible with conventional blepahroplasty surgery. This repositioning
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