Biplanar Contour-Oriented Approach to Lower Eyelid and Midface Rejuvenation

IMPORTANCE: Cosmetic rejuvenation of the lower eyelid-midface complex has evolved as our understanding of 3-dimensional midfacial aging and anatomy has become more sophisticated. Treating the lower eyelid and the midface as a single aesthetic unit leads to a more effective and natural-appearing rejuvenation. OBSERVATIONS: This is a review of midfacial anatomy and a 5-step approach to lower blepharoplasty and midface rejuvenation: (1) midfacial autologous fat transfer, (2) canthoplasty, (3) transconjunctival orbicularis-retaining ligament release and orbital fat manipulation, (4) transcutaneous midface-superficial muscular aponeurotic system elevation and orbicularis contouring, and (5) skin treatment. In addition, long-term aesthetic outcomes and complications are reviewed for 43 patients (86 eyelids) who underwent the 5-step biplanar approach lower blepharoplasty and midfacial rejuvenation (40 women and 3 men, with a mean age of 60 years). Follow-up averaged 10.8 months. Forty-one patients rated their outcome as "excellent," and 3 patients rated their outcome as "good." No patients rated their outcome as "fair," "no improvement," or "worsening." Seven patients (7 eyelids) had unilateral complications requiring postoperative intervention. CONCLUSIONS AND RELEVANCE: The biplanar contour-oriented approach to lower blepharoplasty and midfacial rejuvenation is an option for treatment for aging of the lower eyelid-midface complex. The aesthetic outcomes appear natural owing to the synergy of reconstructing the aging changes of multiple lower eyelid and midface structures.