Blepharoplasty: Difficult Cases.

Lower lid blepharoplasty surgery can be a challenging procedure for both the neophyte and the accomplished surgeon. It requires mastering complex periorbital anatomy and choosing the correct approach from a wide variety of patient presentations. This article spans the meticulous clinical evaluation, diagnostic approaches, and surgical techniques required to address challenging clinical scenarios of the lower eyelid, lid-cheek junction, and midface.

Applied Anatomy of the Lower Eyelid.

Lower eyelid function and appearance depend on the complex anatomic relationship between the soft tissue lamellae, supportive tarsoligamentous sling, and bone. Aging in the lower lid area may be caused by changes in the anterior lamella (skin and orbicularis oculi muscle), middle lamella (orbital septum and lower lid fat pads), posterior lamella (tarsus, lower eyelid retractors, and conjunctiva), tarsoligamentous sling (lateral retinaculum), or any combination of the previously described.