Cosmetic

The Pinch Blepharoplasty RevisitedLorne K. Rosenfield, M.D.Burlingame, Calif.

Background: The prevention of scleralshow is truly one of plastic surgery’s HolyGrails. This postoperative problem may beconsidered subtle, but it represents the mostcommon cause of the “operated” look that weall strive to avoid. Of course, the postopera-tive fear of a true ectropion is all too common.These concerns, borne out in patient resultsfollowing the traditional skin-muscle tech-nique, are what drove the author to considerthe “pinch” blepharoplasty.

Methods: All patients who were candidatesfor a lower blepharoplasty, primary or second-ary, underwent the pinch blepharoplasty. Pa-tientsexcludedwereonly thosewhounderwenta carbon dioxide laser resurfacing of the lowereyelid, as no skin excision was planned.

Results: Of the 77 blepharoplasties per-formed, there were no postoperative findingsof lower eyelid malposition: no taping wasnecessary, no significant scleral show wasevident, and no ectropion was produced.There was also noticeably less bruising andswelling postoperatively with this technique.Moreover, it was apparent that the crepe-likeskin at the lower eyelid was often fully effacedor improved significantly.

Conclusions: The pinch blepharoplastyhas proved to be a superior approach to lowereyelid rejuvenation. This series suggests thatwith this technique significantly more crepe-like skin can be removed with reliably lesschance of scleral show. (Plast. Reconstr. Surg.115: 1405, 2005.)

One of the most desirable attributes of theplastic surgical specialty is our unflagging de-

sire to hone our skills. The lower blepharo-plasty represents a true study in this premise.The surgeon is challenged to incise into one ofthe most unforgiving, complex structures, cor-rect the aesthetic deformity, and leave no sur-gical trace. The catalyst of this study was one ofthe most maddening of surgical traces: scleralshow (Fig. 1). The product of this surgicalseries has essentially eliminated this postsurgi-cal stigma while allowing for the excision ofeven more redundant skin often left behind bythe skin-muscle flap approach (Fig. 2).

PATIENTS AND METHODS

Patients

All patients who were candidates for a lowerblepharoplasty, primary or secondary, under-went the “pinch” blepharoplasty. Patients ex-cluded were only those who underwent a car-bon dioxide laser resurfacing of the lowereyelid, as no skin excision was planned. In mostinstances, the surgery was conducted underlocal anesthesia with sedation. Seventy-sevenconsecutive patients were included in the studybetween January of 2001 and November of2003. Follow-up was no less than 3 months. Theresults were considered successful if no postop-erative eyelid taping was required, there was noearly or late scleral show, and most of theexcess eyelid skin had been resected.

Surgical Technique

The surgical technique is conducted under aconscious sedation or general anesthesia;therefore little or no local skin anesthetic isneeded. This approach is critical because itallows the surgeon to both judge and pinch the

From the University of California School of Medicine, San Francisco, and Stanford School of Medicine. Received for publication March 12,2004; revised June 16 2004.

Presented at the Annual Meeting of the American Society of Plastic Surgeons, in San Diego, California, October 28, 2003.

DOI: 10.1097/01.PRS.0000157020.67216.31

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lower eyelid skin excess without significant dis-tortion from local infiltration.

First, markings are made at the lower eyelid.Medially, the upper marking of the skin exci-sion is placed within a few millimeters of theciliary margin, progressing in a straight linelaterally, purposefully leaving a triangular is-land of intact skin, measuring 5 mm in height,below the lateral eyelid margin (Fig. 3, above,left). This maneuver further discourages scleralshow by lessening the purse-string like scarcontracture that may occur with a curvilinearincision hugging the ciliary margin.1

The transconjunctival removal of excess fat isconducted before skin excision because theamount of redundant skin can potentially beless once the redundant fat is extracted. Oneor two 6-0 plain catgut sutures are used to closethe conjunctival wound.

Then, using two fine Brown-Adson forceps,the excess skin is firmly pinched, creating avirtual “wall” of skin. Throughout this maneu-ver the posture of the lower eyelid is observedto ensure that there is no downward drawing ofthe lid margin. Should this happen, theamount of excess skin pinched can be reducedeasily (Fig. 3, above, right). With the wall of skinstanding, the eyelid is rechecked for properposition (Fig. 3, below, left). Straight scissors arethen used to excise the “wall” of skin (Fig. 3,below, center), leaving the underlying orbicularis

muscle intact. At this point the skin marginsshould be just kissing. This finding is the ulti-mate indicator that the appropriate amount ofskin has been removed (Fig. 3, below, right).Closure of the lower eyelid wound is per-formed using a running 7-0 nylon suture. Steri-Strip taping should not be necessary. Suturesare removed within 4 to 5 days. Routine eyedrops and ointment are ordered and, again,usually no taping is needed during the postop-erative course. It should be noted that a stitch/suture canthopexy, fashioned after Fagien’s de-scription, is performed whenever indicated.2The author performed all operations.

RESULTS

Of the 60 blepharoplasties performed, therewere no postoperative findings of significantlower eyelid malposition. There was also no-ticeably less bruising and swelling postopera-tively with this technique. Furthermore, it wasapparent that the crepe-like skin at the lowereyelid was often fully effaced or improved sig-nificantly. Between 8 and 12 mm of skin wasroutinely excised from the lower eyelid (Fig.4). Because the wound edges are meant to be

FIG. 1. A 55-year-old woman preoperatively (above) and 1year after a traditional skin-muscle lower blepharoplasty dem-onstrating the telltale postoperative scleral show (below).

FIG. 2. A 48-year old woman preoperatively (above) and 1year after a traditional lower blepharoplasty revealing residualcrepe-like skin (below).

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“kissing” after the excision of the pinched skin,the wound was opened manually without ten-sion to demonstrate the extent of skin resec-tion. A secondary “re-pinch” was sometimessuggested in the case of residual wrinkled skin.

At the very beginning of the series, therewere two cases in which there was clear evi-dence of lower lid retraction after closure ofthe wound. In each case, there had been alarge wound “gap” after the skin pinch exci-

sion, indicating possible excessive skin re-moval. In one instance, the replacement of theexcised lower eyelid skin as a graft successfullyprevented the retraction. In the other case, aconcomitant pexy solved the problem. Interest-ingly, later in the series, it became clear that ifthere was a slight amount of eyelid retractionafter an appropriate skin pinch, one couldsafely ascribe this to swelling and not intervenewith additional surgery to support the eyelid.

FIG. 3. (Above, left) Surgical marking at the lower eyelid, demonstrating the critical placement of the incision 5 mm belowthe lateral margin of the eyelid. (Above, right) Pinching of the excess lower eyelid skin with two Brown-Adson forceps whilemaintaining normal eyelid posture. (Below, left) The creation of the “wall” of excess skin after the pinch. Note the relative heightof the wall indicating the significant skin excision. (Below, center) Excising the wall of pinched skin with a straight scissors. (Below,right) The lower eyelid wound seen “kissing,” confirming an appropriate amount of skin resected.

FIG. 4. Examples of the extent of skin resection possible in two different patients from 8 to 12 mm.

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Only one patient, male, paradoxically requiredprolonged postoperative taping and eye drops,although he demonstrated only nominalscleral show. Eventually a stitch canthopexyresolved the problem. Five patients have re-quired a further “pinch” removal of persistentexcess skin, producing very satisfactory finalresults in all cases. In general, the incidence ofunplanned “re-pinching” decreased as the se-ries progressed.

DISCUSSION

Although the true incidence of eyelid mal-position after the traditional muscle flap tech-nique is not well documented, the plethora ofarticles on the subject attests to its persistence.Scleral show has been ascribed to multiplecauses: excess skin removal, untreated eyelidlaxity, denervation of the orbicularis muscle,and scarring of the outer or middle lid lamel-lae. In fact, I am impressed with how littleexcess skin is often excised during a skin-muscle procedure in an effort to avoid scleralshow. Indeed, the prevention of scleral show istruly one of plastic surgery’s Holy Grails. Thispostoperative problem may be considered sub-

tle and indeed is often not even acknowledged,but it represents what could also be seen as aglaring example of the “operated” look that weall strive to avoid. Of course, the postoperativefear of a true ectropion is all too common.These concerns, borne out in patient resultsfollowing the traditional skin-muscle tech-nique, are what drove the author to considerthe pinch blepharoplasty.

FIG. 5. A 52-year-old patient with significant excess crepe-like skin (above) and 8 months after pinch blepharoplasty,demonstrating essentially complete excision of crepe-likeskin with maintenance of good eyelid posture (below).

FIG. 6. A 49-year-old man with a negative cheek vector andprominent globe (above) preoperatively (center) and 1.5 yearsafter pinch with intact lower eyelid shape (below).

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There have been many efforts to reduce theincidence of eyelid malposition following tra-ditional blepharoplasty. As documented by Za-rem and Rosnick, one approach has been toforgo the skin incision entirely, thus preservingthe integrity of the outer and middle eyelidlamellae, and to approach the eyelid insteadthrough the conjunctiva only.3 Although theincidence of scleral show may be less, there canbe a greater chance of untreated eyelid skinexcess. In another effort to avoid the skin inci-sion and still “treat” the skin, skin resurfacingby way of chemical or laser, in conjunction witha transconjunctival approach, can indeed re-duce the incidence of scleral show. Because ofthe inherent inability to exactly gauge thedepth of treatment, the consistent preventionof malposition can be difficult. Also, many pa-tients do not need or desire skin resurfacing.

Another adjunctive technique is the applica-tion of the canthopexy in the patient with a laxeyelid. There is no question that this repair canreduce the incidence of lid malposition but itmay not eliminate the risk entirely. We have all

seen scleral show after the traditional blepha-roplasty despite the use of a canthopexy. Theadditional inciting factors of muscle denerva-tion and middle lamellar scaring probably ex-plain this dichotomy.

The idea of pinching the excess skin fromthe lower eyelid is not a new one. In 1973,Parkes was the first to suggest the technique.4This technique, which predated the transcon-junctival approach, defeated some of its ownbenefits by having to divide the underlyingorbicularis muscle to retrieve the excess fat.Then in 1992, Dinner et al. described the ulti-mate combination of the skin pinch with thetransconjunctival approach in the “no flap”

FIG. 7. A 54-year-old patient with asymmetry at the lowereyelids (above) and 9 months after surgery demonstrating arelatively balanced result (below).

FIG. 8. A 64-year-old woman preoperatively (above), 9months after a pinch blepharoplasty, with some residual ex-cess skin (center), and 6 months after “re-pinch” with remain-ing excess skin removed and normal eyelid posture main-tained (below).

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technique published, essentially, as a case re-port.5 Ristow, in 1994, included the concept inhis transconjunctival blepharoplasty chapter inMimis Cohen’s text.6

The impetus to revisit and refine this tech-nique emanated from a personal communica-tion with Glenn Jelks (2000). This article is thefirst effort in the plastic surgical literature tohone the pinch technique and report on theexperience of a large series of patients.

The findings from this study suggest that thepinch blepharoplasty is capable of producingbetter, more consistent results than the tradi-tional skin-muscle flap technique. The pinchapproach has two distinctive advantages: morecrepe-like skin can be safely removed, andthere is less risk of scleral show or bowing ofthe eyelid (Fig. 5).

More skin can be removed with less scleralshow for several reasons: there is not only lessvertical traction on the eyelid margin with theabsence of a heavy skin-muscle flap, but thereis also less postoperative swelling, potentialscarring, and laxity with the orbicularis muscle

and orbital septum left intact. Also, the excessskin can be removed more completely and withgreater confidence because of the inherent ac-curacy of the pinch technique. That is, thesurgeon is able to watch in real time the effectthe potential skin removal will have on theposture of the eyelid by first pinching the pro-spective skin for removal. These benefits werespecifically relevant in the “negative vector”patient with poor cheek support, where theblepharoplasty could be performed more con-fidently with the pinch technique (Fig. 6). Inaddition, the patient with asymmetric quanti-ties of lower eyelid skin could be addressedmore accurately (Fig. 7). Also, should it beplanned or necessary to remove additionalskin, a simple “re-pinch” under local anesthesiacould be accomplished. In effect, it is possibleto excise almost all the crepe-like skin at thelower eyelid in stages with a “re-pinch” (Fig. 8).Another possible reason for the improved re-sults is the unexpected amelioration of theeyelid-cheek groove with a more youthful ver-

FIG. 9. A 48-year-old patient with orbital groove particu-larly visible at right lower eyelid (above) and 1 year postop-eratively with a “shortened,” more youthful eyelid (below).

FIG. 10. A 41-year-old woman with limited lower eyelid agingchanges (above) and 2 years after a pinch blepharoplasty (below).

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tical shortening of the eyelid, perhaps second-ary to the effacing effect of the significant skinresection (Fig. 9).

This technique proved to be particularlyhelpful in the younger patient with minimalaesthetic deformity in whom a less invasive sur-gery was attractive (Fig. 10) and the moderatelywrinkled patient in whom the carbon dioxidelaser could be obviated (Fig. 11). Furthermore,the older patient could be treated with lesschance of lid retraction (Fig. 12).

Finally, it should be made clear that any stitchcanthopexy conducted in this series was plannednot because of but rather despite the extent ofthe pinch excision of skin. As in any blepharo-plasty, less skin at the lower eyelid may need to beremoved as a result of the “lifting” effect of thecanthopexy. As such, the canthopexy should beperformed before the blepharoplasty skin resec-tion. The same indications for the canthopexy

were used for the pinch blepharoplasty as wouldbe used for the traditional skin-muscle flap re-pair: treatment of a lax eyelid or a potentially“compromised” eyelid. This might include anelderly patient with a lax eyelid or the negativevector patient with poor cheek support and thepatient with a down-turned lateral canthus, re-spectively. With this apparent variable actually aconstant, one should not ascribe the improvedresults with the pinch blepharoplasty techniquedirectly to the canthopexy. If the canthopexywere to prevent scleral show consistently thenthere would not be an apparent greater rate ofscleral show following the skin-muscle flap tech-nique performed with a similar canthopexy. In-deed, it is this very fact that encouraged thedescribed change of blepharoplasty technique.

CONCLUSIONS

The “pinch” blepharoplasty has proved to bea superior approach to lower eyelid rejuvena-

FIG. 11. A 59-year-old patient with moderate lower eyelidcrepe-like skin excess (above) and 1 year postoperatively withgood correction without the need for laser or other resur-facing technique (below).

FIG. 12. An 89-year-old man with a lax eyelid and signif-icant aesthetic deformity (above) and 18 months after a pinchblepharoplasty revealing excellent eyelid position (below).

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tion. This series suggests that with this tech-nique significantly more crepe-like skin can beremoved with reliably less chance of scleralshow. The pinch blepharoplasty may be partic-ularly efficacious in the younger patient inwhom less surgery is desirable, the older pa-tient with a more lax eyelid in whom any sur-gical manipulation can upset eyelid posture,and the patient with excess crepe-like skin inwhom significant skin resection is necessaryand carbon dioxide laser treatment is not fa-vored. The essence of the pinch blepharoplastyis to fully rejuvenate the lower eyelid withoutaltering its functional or aesthetic shape.

Lorne K. Rosenfield, M.D.1750 El Camino Real, Suite 405Burlingame, Calif. 94010lkrmd@pacbell.net

ACKNOWLEDGMENTS

The author thanks Dr. Gilbert Gradinger for his criticalanalysis, Dr. Richard Bloom for his intraoperative photogra-phy, and Jennifer Seeley, his scrub nurse, for her significantassistance in assembling the manuscript.

REFERENCES

1. Gradinger, G. Personal communication.2. Fagien, S. Algorithm for canthoplasty: The lateral reti-

nacular suspension: A simplified suture canthopexy.Plast. Reconstr. Surg. 103: 2010, 1999.

3. Zarem, H. A., and Rosnick, J. L. Minimizing deformitiesin lower eyelid blepharoplasty: The transconjunctivalapproach. Clin. Plast. Surg. 20:317: 321, 1999.

4. Parkes, M. Pinch technique for repair of cosmetic eye-lid deformities. Arch. Ophthalmol. 89: 324, 1973.

5. Dinner, M. I., Glassman, H., and Artz, J. S. The “no flap”technique for lower-lid blepharoplasty. Aesthetic Plast.Surg. 16: 155, 1992.

6. Ristow, B. Transconjunctival blepharoplasty. In M. Co-hen (Ed.), Mastery of Plastic and Reconstructive Surgery,Vol. 3, 1st Ed. Boston: Little, Brown, 1994.

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