Correction of a Hollow Lower Eyelid with Hypertrophy of the Pretarsal Portion of the Orbicularis Oculi Muscle

Abstract

Summary Our method of correcting the hollow lower eyelid is based on fabrication of the triangular flap from the pretarsal portion of the orbicularis oculi muscle of the lower eyelid and its transposition downward. The reasons for the “hollow” lower eyelid can be the involutive changes in the periorbital area, ptosis of the midface soft tissues, or the excessive removal of fatty hernia during the lower blepharoplasty. This concavity of the lower eyelids is particularly evident if it is adjacent with the convexity above it, which forms the pretarsal roll. This bulging roll may be inherited, or resultant of a classic lower blepharoplasty, when a thick muscle flap is juxtapositioned onto the pretarsal orbicularis oculi muscle (OOM). Such a deformation may be expected whenever an excessive amount of OOM is left at surgery. A number of surgical corrections have been proposed, including simple excision of the skin and muscle roll under the ciliary margin, lifting the soft tissues of the midface, and filling volume deficit of the lower eyelid by the transfer of a pedicled musculofascial flap from the upper eyelid and by the fillers or lipofilling. 1–4 We had always been intuitively reluctant to discard a piece of OOM at traditional lower blepharoplasty. MATERIAL AND METHODS The flap is made of excessive pretarsal OOM (Fig. 1A) as an elongated triangle with a pedicle at the lateral side. The created muscle flap is sutured to the pretarsal portion of the OOM above and to the arcus marginalis below, ie, above the upper edge of the orbital portion of the OOM (Fig. 1B). Thus, the flap compensates for the deficit of preseptal portion of OOM. The wound is closed by continuous intradermal suture. Fig. 1. A, Outline of the OOM flap based at the canthal area. Arrows depict the intended flap transposition. B, The schema of fixation of the flap to the arcus marginalis below and the pretarsal OOM above, by the Prolene 6/0 stitches. RESULTS This technique was used in 11 cases, where a marked musculocutaneous roll was visible at the upper edge of the lower lid. The results were satisfying (Fig. 2). Fig. 2. The same patient before (A) and 3 months after (B) surgery. CONCLUSIONS The elongated operating time is an understandable trade-off for this method. However, conserving surgery looks more prudent than a resectional one.