1213410

research-article2023
ACSXXX10.1177/07488068231213410The American Journal of Cosmetic SurgeryFakih-Gomez

Technical Note
The American Journal of

Lower Blepharoplasty With Fat Transposition Cosmetic Surgery

1­–14
© The Author(s) 2023
and Three-Vector Suspension Technique Article reuse guidelines:
sagepub.com/journals-permissions
https://doi.org/10.1177/07488068231213410
DOI: 10.1177/07488068231213410
journals.sagepub.com/home/acs

Nabil Fakih-Gomez, MD, MSc1

Abstract
The aging appearance of the lower eyelids is multifactorial, involving changes in the skin, orbital fat, orbicularis muscle, soft
tissue of the midface, tear trough, and tear valley. Traditional techniques of lower blepharoplasty are based on transcutaneous
or transconjunctival approaches with skin removal, followed by adjunctive procedures, such as canthal suspension, fat
resection, or repositioning. However, these approaches can hardly achieve excellent transitions simply because they do not
effectively address every age-related issue affecting the lower eyelid. Conversely, the approach presented herein, focuses
on blending the lid-cheek junction by means of skin resection, fat transposition, and three periosteal suspension vectors,
including canthal, skin-muscle flap, and sub-orbicularis oculi fat (SOOF) suspensions. It provides adequate volume restoration
in the tear trough and tear valley, along with enhanced support and stability to the eyelid with canthopexy, double muscle
flap, and SOOF suspension. The aim of this article is to provide a detailed step by step description of this technique along
with the results of 269 patients who underwent this procedure from 2019 to 2023. This technique offers a safe and effective
solution for lower eyelid aging, yielding long-lasting aesthetic results with excellent transitions.

Keywords
lower blepharoplasty, 3-vector suspension, lower eyelid lift, fat transposition, cheek lift

Introduction Contemporary lower blepharoplasty focuses on smoo­

thing the lid-cheek junction for a more youthful look, by
Most patients seeking cosmetic surgery of the lower eyelid means of retaining ligaments release, fat transposition, and
are mostly concerned with excess skin, protruding fat bags mid-face augmentation or suspension. Access to the lower
and a tired looking appearance. However, the lower eyelid eyelid fat bags can be accomplish by either a transcutaneous
cannot be conceived as a separate unit without considering or a transconjunctival approach. While the transcutaneous
the surrounding structures. As described by Mendelson approach provides better anatomic exposure and the advan-
et al., the mid-cheek is comprised by the lid-cheek segment, tage of allowing skin excision and redraping, it carries a
the malar segment, and the nasolabial segment. While the higher risk of postoperative lower eyelid malposition.2-5
youthful mid-cheek typically appears as a uniform rounded In recent years, lid-tightening procedures, such as cantho-
fullness, aging makes these three segments become evident, pexy and canthoplasty have been emphasized as adjunctive
separated by 3 cutaneous grooves: the palpebromalar groove procedures to both the transcutaneous and transconjunctival
(tear valley), the nasojugal groove (tear trough), and the approaches. These procedures are used to address lid laxity
mid-cheek groove (anterior cheek fold).1 and serve as a preventive measure to avoid postoperative
Traditional lower lid blepharoplasty generally focuses on lower eyelid malposition.
excision of skin, muscle, and fat, which can be aesthetically The aim of this article is to describe the authors app­
effective in many patients. However, this approach may lead roach to blepharoplasty, known as X3 Vector Suspension
to possible long-term complications, including lower lid
retraction and malposition, scleral show, rounded palpebral
fissures, and hollowness in the lower eyelid region.2 As a 1
Fakih Hospital, Khaizaran, Lebanon
matter of fact, distortion of the natural shape and aperture of
the eye is strongly feared by both patients and surgeons. Corresponding Author:
Nabil Fakih, Chief of Department of Facial Plastic & Cranio-Maxillo-Facial
Moreover, these undesired changes can be difficult to control Surgery, Fakih Hospital, Khaizaran Main Street (Sarafand), Khaizaran,
with traditional techniques, with the same technique leading Saida, 00000, Lebanon.
to very different outcomes among patients. Email: [email protected]
2 The American Journal of Cosmetic Surgery 00(0)

Figure 1. Anatomy of the lower eyelid.

Technique, an extended transcutaneous skin-muscle flap (ZCL) (inferiorly). Laterally, redundant OOM and SOOF
lower blepharoplasty that includes orbicularis retaining relapse accentuate the palpebromalar groove superiorly and
ligament (ORL) release, fat transposition, and 3 vectors of contributes to the creation of malar festoons inferiorly, above
periosteal suspension. the mid-cheek groove.
The transcutaneous approach allows for a much larger
surgical field, better identification of structures, precise fat
Preoperative Evaluation
transposition for optimal orbital rim contouring, canthal
suspension procedures, skin resection, and orbicularis oris All participants had a detailed medical and ocular history
muscle (OOM) redraping. To minimize the risk of post­ with a facial examination with measurement of periocular
operative lower eyelid malposition, this technique incorpo- parameters. Several key evaluations are essential to assess
rates 3 vectors of periosteal suspension to support the eyelid: before surgery: lower lid position, lower lid margin dysfunc-
canthal suspension, skin-muscle flap suspension and sub- tion, snap-back test, distraction test, lateral canthus laxity,
orbicularis oculi fat (SOOF) suspension (cheek lift). This medial canthal laxity, punctal dysfunction, lower lid fat pads
comprehensive approach is able to address age-related medial, central, and lateral, presence of tear trough, tear val-
aspect of the lower lid and achieve optimal and long-lasting ley and malar edema or festoons (position of malar fat pad),
aesthetic results. negative malar cheek vector, skin changes and redundancy,
and xerophtalmia.10
This technique is recommended for patients with derma-
Anatomical Considerations tolochalasis, steatoblepharon, tear trough, tear valley, and
The lower eyelid has 3 fat pads (Figure 1). The nasal and cen- SOOF relapse, which collectively result in a double convex-
tral fat pads are divided by the inferior oblique muscle (IOM), ity appearance and a sagging cheek aspect.
which is a key anatomical landmark that must be identified Patients with preoperative lower eyelid laxity, OOM
and preserved. The arcuate expansion of Lockwood’s liga- weakness and negative vector are at higher risk of develop-
ment separates the central from the lateral fat pad, which is ing postoperative lower eyelid malposition and ectropion.
located in a slightly deeper plane than the central fat pad.5,6 The transconjunctival approach is more suitable for this
The ORL is an osteocutaneous ligament that originates in population. For the author, excessive lower eyelid laxity,
the anterior lacrimal crest and continues along the orbital OOM weakness, negative vector and prominent eyes consti-
rim. The medial segment of the ORL has also been referred tute absolute contraindications for transcutaneous lower
as the tear trough ligament by some authors.7 blepharoplasty. Patients with bone deficiency or lack of fat
Below and separated from the preseptal space by the ORL leading to negative vector should be considered a relative
lies the prezygomatic space.8,9 The SOOF is a layer of fatty contraindication since there are different ways to correct this
tissue that lies in between the prezygomatic space (poste­ issue, such us fat grafting, dermal fillers, or facial implants.
riorly), the orbicularis oculi muscle (OOM) (anteriorly), the Other contraindications that are related to ideal patient
ORL (superiorly), and the zygomatic cutaneous ligament selection for this procedure are patient with only excess
Fakih-Gomez 3

Figure 2. Incision design: Subciliary incision (yellow) should begin 2 mm lateral to the inferior punctum (point A) and extend laterally
10 mm lateral to the lateral canthus along an imaginary line across the canthal angle that is at the resting line (pale blue). Two points
are marked on the line of repose, one at the lateral canthus (point B) and another at 10 mm (point C). A vertical line across point
B is drawn and another point (D) is marked at 10 mm inferior to point B. The lateral part of the lower line should be a straight line
measuring 14 mm (points C-D) (light red), while the medial part is a parabola joining point D-A (green). Two additional lines are drawn
to mark the 2 points that are added, point X at 5 mm lateral to point B at the extension of the subciliary incision and point X’ is 5 mm
medial to point D on the parabola line. Two additional vertical lines for reference are drawn across point X (line 1) and X’ (line 2). The
tear trough and tear valley is marked with a non-dotted dark red line. The SOOF is marked with a big red X and its indentation with a
non-dotted purple line.

skin (a boomerang technique could be indicated), only fat Step 2. Submuscular transition and release of ORLs. The OOM
prolapse without excess skin or tear trough, tear valley or is incised just above the end of the skin flap (Figure 3D). Dis-
SOOF prolapse (a transconjunctival approach would be section continues in the preseptal space raising a skin-muscle
indicated). flap until reaching the orbital rim. Using monopolar cautery
and a periosteal elevator, complete release of the ORL is car-
ried out in the preperiosteal plane extending just beyond the
Surgical Technique inferior-most aspect of the marked tear trough (Figure 4A).
Step 1. Skin flap elevation and preservation of orbicularis oculi Care must be taken to preserve the infraorbital bundle and to
muscle. This technique is performed always under general leave a small layer of fatty tissue over the periosteum for bet-
anesthesia. The incision marking is design in the same fash- ter anchoring of the sutures (Figure 4B). This space created
ion as the boomerang technique11 (Figure 2). Local anes- caudal to the level of the orbital rim is the recipient site for
thetic infiltration is done with the previously mentioned transposed orbital fat.
formula subcutaneously, inside the fat pads, in the preperi-
osteal plane of the infraorbital and lateral orbital rim. Skin is Step 3. Releasing the prezygomatic space. From the lateral can-
incised with Colorado tip Ellman radiofrequency (Figure 3A). thus laterally, there is no skin nor muscle undermining. The
A Frost suture (5/0 Nylon) is placed at the midline lower incision is made from the skin until the periosteum without
eyelid line to protect the globe and facilitate retraction supe- elevating a composite skin-muscle flap (Figure 5A-C). The
riorly. A skin flap is elevated inferiorly with a sharp iris lateral aspect of the ORL is released to enter the prezygomatic
scissors preserving a robust sling of functional OOM until space connecting it medially with the plane of the skin-­muscle
the lateral canthus line (Figure 3B). Subcutaneous dissec- flap (Figure 5D). Dissection is continued inferiorly in the
tion should not be performed lateral to this line. The skin prezygomatic space to release all the area behind the malar
flap should have a “U shape” leaving approximately 15 mm mounds until the cheek can be lifted freely (Figure 6A-B).
of intact OOM in stretching (10 mm in repose) in the central
part, 8 mm in the medial aspect, and 5 mm at the level of the Step 4. Medial, central, and lateral fat pads transposition. The
lateral canthus (Figure 3C). skin-muscle flap is retracted inferiorly with a Desmarres
4 The American Journal of Cosmetic Surgery 00(0)

Figure 3. A. Skin incision with Colorado tip (Ellman radiofrequency). B. Skin flap elevation medially to the lateral canthus line. C. The
skin flap should have a “U shape” leaving approximately 15 mm of intact OOM in stretching (10 mm in repose) in the central part, 8 mm
in the medial aspect and 5 mm at the level of the lateral canthus. D. The OOM is incised with scissors just above the end of the skin flap.

Figure 4. A. Complete release of the ORL in the preperiosteal plane extending just beyond the inferior-most aspect of the marked
tear trough. B. A small layer of fatty tissue should be preserved over the periosteum, this tissue will be used for anchoring the sutures
during fat transposition.

retractor, gentle manual retropulsion of the globe helps to plane with interrupted 5/0 vicryl sutures (Figure 8A). The
identify the orbital fat compartments. The nasal, central, and central fat pad is transposed centrally in the same fashion,
lateral fat compartments are identified by blunt dissection and then both are sutured taking a bite to the supraperiosteal
using 2 sterile cotton tips (Figure 7A). The IOM is identified plane (Figure 8B). Excess fat is resected if needed. The lat-
separating the nasal and central compartments (Figure 7B). eral fat pad is usually partially excised (reduced) because, in
The orbital septum of the central and medial fat compart- most patients, the nasal and central fat pads are sufficient to
ments is opened with sharp scissors at its inferior-most point, correct the hollowness and tear trough deformity (Figure 8C).
teasing out the herniated fat pads. Finally, the arcuate expan- However, if needed it can be transposed centrally to correct
sion of Lockwood’s ligament is incised to release the lateral hollowness. Some surgeons transposed the lateral fat pad
fat pad (Figure 7C) and then it is exposed (Figure 7D). The laterally to fill the orbitomalar groove. However, in this
nasal fat pad is transposed inferiorly over the orbital rim into technique, this area will be corrected by lifting the lateral
the tear trough deformity and sutured to the supraperiosteal cheek. In this case, preserving the lateral fat pad may result
Fakih-Gomez 5

Figure 5. A. Laterally to the lateral canthal line, the incision is made from skin to preperiosteal fat (over the periosteum). B. Dissection
with the periosteotome is done without skin nor muscle undermining in the prezygomatic space. C. View of both pockets the
prezygomatic space pocket and the submuscular pocket. D. The lateral aspect of the ORL is released to enter the prezygomatic space
and both pockets are connected.

Figure 6. A. Blunt dissection within the prezygomatic space to release all the area behind the malar mounds until the cheek can be
lifted freely. B. A view of the extent of dissection with a finger.

in overcorrection or bumping. Final contouring of the orbital Then, the suture is passed through the lateral tarsal plate and
rim is achieved with conservative bipolar cauterization of the tied (Figure 9C). Canthopexy should be done without over-
transposed fat (Figure 8D). These maneuvers will smoothen tightening, to prevent any lateral canthal distortion or scleral
the tear trough deformity and correct the hollowness. show12,13 (Figure 9D).

Step 5. Canthopexy. Two single hooks and small sharp scis- Step 6. SOOF suspension (cheek lift). The release of the ORL
sors are used to dissect superiorly below the orbicularis and dissection into the prezygomatic space described in step 3
oculi muscle, under the lateral aspect of the incision, and will free the superior midface allowing for proper elevation of
superior to the attachment of the lateral canthal tendon the cheek. A 4/0 nylon suture is placed in the lateral orbital
(Figure 9A). A 6/0 nylon suture that is passed through the periosteum and sutured to the inferior cuff of the lower eye-
periosteum of the internal superior aspect of the lateral lid—upper cheek flap (Figure 10A). While the assistant ele-
orbital rim, 2 to 3 mm above the lateral canthus (Figure 9B). vates the cheek up and laterally the knot is tied (Figure 10B-C).
6 The American Journal of Cosmetic Surgery 00(0)

Figure 7. A. Identification of the nasal, central, and lateral fat pads. B. The inferior oblique muscle is identified in between the nasal and
central fat pads. C. Division of the arcuate expansion of Lockwood’s ligament. D. Access to the lateral fat pad.

Figure 8. A. Transposition of the nasal fat pad below the inferior orbital rim into the tear trough deformity with interrupted 5/0 vicryl
sutures. B. Transposition of the central fat pad in the same fashion. C. Partial excision of the lateral fat pad. D. Conservative bipolar
cauterization of the transposed fat for final contour.

In most cases, a 4/0 nylon suture is also placed in the same suspension will effectively correct malar mounds, soften the
fashion, laterally to the previous 4/0 nylon sutures as mid-cheek groove, and fill the orbitomalar groove (tear valley)
reinforcement (Figure 10D). By lifting the cheek, SOOF hollowness.
Fakih-Gomez 7

Figure 9. A. Superior dissection below the OOM to expose the lateral orbital rim just above the superior attachment of the lateral
canthal tendon. B. A 6/0 nylon suture is anchored through the periosteum of the internal superior aspect of the lateral orbital rim, 2 to
3 mm above the lateral canthus. C. The same suture is passed through the lateral tarsal plate and tied. D. Canthopexy should be done
without overtightening, to prevent any lateral canthal distortion or scleral show.

Figure 10. A. Anchoring of the SOOF suspension suture with nylon 4/0 to the lateral orbital rim periosteum. B. SOOF suspension
suture is passed through the SOOF to suspend the lid-cheek flap. C. While the assistant elevates the cheek up and laterally the knot is
tied. D. A second lateral suspension suture with nylon 5/0 is placed in the same fashion as reinforcement in most patients.
8 The American Journal of Cosmetic Surgery 00(0)

Figure 11. A. The skin is redraped with a supero-lateral vector in a Boomerang fashion technique B. Since the skin-muscle flap will
overlap the remaining upper OOM, there will be 2 layers of OOM to support the eyelid margin (muscle doubling). C. Subciliary skin
excision, the skin is resected where the flap naturally approximates the cut skin edge beneath the lash line. D. Subciliary skin closure is
performed with simple interrupted nylon 6/0 sutures, from medial to lateral (up to the lateral canthus).

Step 7. Skin resection and medial skin closure. Skin excision (canthopexy) sutures, and sutured to the superior cuff of the
should be performed cautiously, since overzealous excision skin-muscle edge of the lower eyelid flap (Figure 12B).
can lead to lid retraction and scleral show. The skin is Before suspension, it is of outmost importance to perfectly
redraped supero-laterally into the part of the skin incision redrape and adapt the OOM over the remnant muscle to
lateral to the lateral canthus as the boomerang technique avoid irregularities beneath the skin.4 This could be accom-
(Figure 11A). The skin-muscle flap will be covering the plished by introducing a cotton tip from the lateral aspect.
remaining OOM, meaning doubling the muscle in the supe-
rior part (Figure 11B). This will aid to fill the upper eyelid Step 9. Lateral skin closure. Beyond the lateral canthus, the
beneath the eyelashes and to create a nice transition, while subcutaneous is closed with buried stitches of vicryl 5/0
providing more support the lid. An oblique cut is made from (Figure 12C) and the skin is closed with simple interrupted
lateral to medial up to the lateral canthus and a stay suture is nylon 6/0 suture (Figure 12D). Results at 12 months are
placed. The excess skin medial to the lateral canthus is shown in before and after cases (Figures 13-17).
resected as it naturally approximates the cut skin edge
beneath the lash line, hence, only 2 to 3 mm of skin usually
Patient Results
needs to be removed medially (Figure 11C). In contrast,
skin excess laterally ranges from 7 to 10 mm. Resecting So far, 269 patients have undergone this technique, 10 men
most of the skin lateral to the canthus, and minimally sub- and 259 women, from July 2019 to July 2023. The mean age
ciliary further reduces the risk of lower eyelid margin retrac- was 42.5 years (range, 25-60 years). A total of 61 patients
tion. The skin is closed with simple interrupted nylon a (22.6 %) required additional volume correction: intraopera-
6/0 sutures from medial to lateral up to the lateral canthus tive fat grafting in 1 patient (0.3%), postoperative fat grafting
(Figure 11D). The remaining free lateral skin triangle is injection (at 3 months) in 8 patients (2.9%) and postoperative
pulled up (Figure 12A) and excised in a straight line along filler injection in 16 patients (19.3%). Filler correction was
the extension of the subciliary incision. performed with Belotero Balance (Merz Aesthetic) by injec-
tion with a 38 mm 25G cannula in the needed additional
Step 8. Composite skin-muscle flap suspension (OOM suspension). areas to improve transitions. Surgical recovery was achieved
A 5/0 nylon suture is placed in the lateral orbital peri­ in a mean of 13 days (range, 10-16 days) while complete
osteum between the 4/0 (SOOF suspension) and 6/0 nylon recovery took a mean of 2.8 months (range, 2.4-3.2 months).
Fakih-Gomez 9

Figure 12. A. The lateral skin triangle is pulled up and resected across a straight line that follows the extension of the subciliary
incision. B. The skin-muscle flap suspension suture is placed over the lateral orbital rim in between the SOOF suspension (nylon 4/0) and
canthopexy (nylon 6/0) sutures and sutured to the superior cuff of the skin-muscle edge of the lower eyelid flap. C. Subcutaneous buried
sutures of vicryl 5/0 are placed lateral to the lateral canthus. D. Skin closure with simple interrupted nylon 6/0 sutures.

Figure 13. A. Preoperative photograph of 37-year-old female patient presenting excess skin, fat bags, tear trough, tear valley and SOOF
relapse. B. Postoperative result of lower blepharoplasty with 3-vector suspension technique at 12 months. Note: The patient underwent
a direct browlift and an upper blepharoplasty 1 year before the lower blepharoplasty, along with fat grafting to correct volume loss in
the right cheek after removing permanent filler 3 years ago.

Prolonged edema lasting up to 3 months is expected in all sessions of laser treatment with ND-YAG 1064 nm—650 ms
patients, but it eventually resolves in everyone. No serious (Aerolase Neo Elite) on the lateral scar to accelerate the heal-
complications were observed, including infection, dry eyes, ing of redness. In addition, 85 patients (31.5%) received
or ectropion. Only 1 patient (0.3%) experienced an aesthetic laser treatment with ERBIUM-YAG 2940 nm—300 ms
scar, and another patient (0.3%) had wound dehiscence. (Aerolase Era) on the lateral scar to enhance its cosmetic
Both of these cases required further surgical correction. appearance, along with treatment on the entire skin surface
Postoperatively, a total of 199 patients (73.9%) underwent 3 of the lower eyelid. Mean follow-up time was 23 months
10 The American Journal of Cosmetic Surgery 00(0)

Figure 14. A. Preoperative photograph of a 26-year-old female patient with previous lower blepharoplasty presenting anesthetic scar,
excess skin, fat bags, tear trough, tear valley and SOOF relapse. B. Postoperative result of lower blepharoplasty with 3-vector suspension
technique at 12 months.

Figure 15. A. Preoperative photograph of 57-year-old female patient presenting excess skin, fat bags, tear trough, tear valley and
SOOF relapse. B. Postoperative result of lower blepharoplasty with 3-vector suspension technique at 12 months. Note: The patient
underwent a direct browlift and an upper blepharoplasty 1 year before the lower blepharoplasty.

Figure 16. A. Preoperative photograph of 35-year-old female patient presenting excess skin, fat bags, tear trough and SOOF relapse.
B. Postoperative result of lower blepharoplasty with 3-vector suspension technique at 4 months. Note: The patient also underwent an
upper blepharoplasty 3 months before the lower blepharoplasty.
Fakih-Gomez 11

Figure 17. A. Preoperative photograph of 57-year-old female patient presenting excess skin, fat bags, tear trough, tear valley, and
SOOF relapse. B. Postoperative result of lower blepharoplasty with 3-vector suspension technique at 12 months. Note: The patient also
underwent an upper blepharoplasty one 3 months before the lower blepharoplasty.

(range, 4-42 months). Overall patient satisfaction was high major postoperative complications. While this technique bears
(Figures 13-17). some similarities to Rohrich’s 5-step blepharoplasty23 or
Jacono’s technique,5 it also incorporates notable differences.
The author firmly believes that these additional suspensions
Discussion contribute significantly to achieving the desired aesthetic
In the past, the primary objectives of lower blepharoplasty changes.
surgery were the removal of lower eyelid bags and excess The detailed evaluation of the malar fat and other fat com-
skin. However, contemporary lower blepharoplasty focuses partments of the face has provided valuable knowledge for
on achieving a smoother lid-cheek junction for a more youth- optimizing the efficacy of lower lid and cheek balance.24-26
ful appearance. This shift requires more complex and riskier Traditionally, the skin is incised 1 to 3 mm below the lash
procedures, which, in turn, necessitate additional measures line in the subciliary area. Once the skin is incised, there are
to safeguard the endangered eyelid position. Techniques, 2 possible variations depending upon the plane of dissection:
such as the release of retaining ligaments, fat transposition, A “skin flap” can be raised, elevating the thin eyelid skin off
and mid-face augmentations or suspensions are employed the orbicularis oculi muscle, which is best suited for eyelids
to achieve this goal. with excess skin laxity and atonic orbicularis muscle.24-26
There has always been a focus on correcting malar bags or Alternatively, a skin-muscle flap technique is proposed for
suspending the cheek-SOOF prolapse. Initially, the approach use in younger patients with robust orbicularis muscle tone,
involved resecting the orbicularis muscle and suspending the where both skin and muscle are raised as a flap after the ini-
lower eyelid to the lateral orbital rim.14 An alternative method tial incision below the eyelashes.27 McCollough suggests
was then introduced, involving the excision of herniated placing the skin incision inferior to the tarsal margin, thus
fat and plication of the orbital septal.15 Later, the dissection preserving a cuff of pretarsal orbicularis oculi muscle, which
of the skin-muscle flap below the infraorbital rim was plays an important role in blinking and tear drainage.28
extended.12 Subsequently, the release of the arcus marginalis This technique is based on the 3 previous ideas. After the
was proposed for patients with prominent nasojugal or malar incision is made 2 to 3 mm below the eyelash, a skin flap is
folds to enhance the results.13,16 A combination of face lift elevated up to 10 mm, preserving an intact sling of functional
and blepharoplasty was proposed next to correct malar bags OOM. Subsequently, the muscle is incised and a skin-muscle
using a subciliary incision and suspending the orbicularis flap elevated. We believe that maintaining this wider func-
muscle.17-19 A subperiosteal facelift was also suggested tional sling of OOM and minimizing trauma to the muscle
through a coronal or superior orbital rim incision.20,21 Another reduces the risk of lower lid retraction.
proposition involved a middle face lift with the placement of Fat preservation techniques have become more preva-
3 sutures: one to elevate the malar fat pad, one to increase lent, wherein the herniated fat is transposed and sutured
malar volume, and one to suspend the orbicularis muscle.22 beneath the lower orbital rim.29 A prospective comparative
However, many of these techniques have not been widely study involving 26 patients compared the “fat preserving”
adopted due to the difficulty of the technique or the cost of approach with the “traditional approach,” revealing compa-
materials. rable aesthetic outcomes. However, the “fat preserving
Cumulative anatomical knowledge, understanding, and group” showed lower recurrence rates and an absence of
advances have significantly influenced our surgical technique, the typical hollowing of the lower lid or sunken appearance
leading to improved aesthetic results and reduced rates of of the globe.30-32
12 The American Journal of Cosmetic Surgery 00(0)

The ORL forms the superior border of the malar fat pad, along with the skin, to the inner aspect of the lateral rim.37
and releasing this tethering allows for lifting the fat pad and We prefer a composite muscle-skin suspension as it pro-
overlying skin with minimal tension.33 A more effective vides both skin and muscle tightening in the lower eyelid.
release of tethering may result in less inferior traction on the This technique doubles the orbicularis muscle under the
lid margin, reducing the chances of lower lid retraction or subciliary incision within the first 10 mm, creating a smooth
rounding, and thus requiring less powerful lateral canthal transition from the eyelash to the tear trough. In addition,
stabilization. Fat transposition plays an important role in this filling effect provides more support to the lower eyelid
camouflaging the bony inferior orbital rim, which is a sign of and reduces wrinkling.
aging.34 The transposed fat fills the medial tear trough defect35 The achievement of a good postoperative lower lid posi-
and smoothens the lower eyelid-cheek contour,36 resulting tion relies on muscle-skin flap and SOOF elevation, suspen-
in an improved final outcome. sion and fixation with appropriate lower lid skin excision and
Undiagnosed and untreated lower lid laxity during lower soft canthal fixation. In addition, the aggressive release of
lid blepharoplasty can lead to potential complications, such midface tethering, followed by suspension, is also a crucial
as ectropion and lower lid retraction. To identify candidates factor in preventing lower eyelid retraction and facilitating
for lateral canthal tightening, preoperative assessments midface elevation.19
should include the snap-back test and lid distraction test. Further investigations and comparative studies are war-
Various suture canthopexy techniques are described in the ranted to validate the long-term benefits and safety profile of
literature.37-40 In his practice, the author performs cantho- this innovative technique.
pexy and horizontal tightening to prevent lateral distortion,
ectropion, or lid retraction.41 Conclusion
Although the orbitomalar sulcus is a predominant fea-
ture of aging in the lower eyelid and midface, its correction The X3-vector suspension technique provides a comprehen-
has only recently become a focus of lower blepharoplasty. sive approach to lower eyelid rejuvenation surgery. This pro-
McCord et al37 mentioned the improvement of midface cedure can address every age-related change in the lower
contour achieved by orbicularis lifting in lower blepharo- eyelid, such as protruding fat bags, tear trough deformity,
plasty. In addition to the individualized management of tear valley hollowness, and malar mounds, while lifting and
orbital fat, which is redistributed to correct the tear trough restoring smoothness to the lid-cheek junction. Moreover,
deformity.4-23 the 3-vector periosteal suspension provides reinforcement to
The majority of patients above 40-year-old experience a the lid and protection against postoperative lower eyelid
certain relapse in the midface, characterized by malar malposition. In the author experience, this technique has
mound and tear valley hollowness. Neglecting to address been able to provide effective correction with excellent
this issue may lead to more prominent malar mounds and long-term results.
increased hollowness in the future, hindering the achieve-
Declaration of Conflicting Interests
ment of the best possible long-term final result. This tech-
nique introduces an intriguing modification to the latters: The author(s) declared no potential conflicts of interest with respect
the release and elevation of an upper midface flap through to the research, authorship, and/or publication of this article.
the prezygomatic space up to the zygomatic cutaneous
Funding
retaining ligament, and its lifting and suspension to the lat-
eral orbital rim periosteum. The author(s) received no financial support for the research, author-
The primary advantages of this technique are its ability to ship, and/or publication of this article.
achieve more aggressive tightening of the lower eyelid, sus-
ORCID iD
pension of the midface, correction of the malar mounds, and
filling of the tear valley hollowness. It is minimally invasive Nabil Fakih-Gomez https://orcid.org/0000-0003-4464-8258
compared to the mid-cheek facelift, as it does not require
References
drilling of the inferior orbital rim or making an incision in the
upper eyelid for mid-cheek suspension.22-42 1. Mendelson BC, Jacobson SR. Surgical anatomy of the mid-
After performing the SOOF suspension, muscle suspen- cheek: facial layers, spaces, and the midcheek segments. Clin
sion becomes crucial to tighten the lower eyelid, reducing Plast Surg. 2008;35(3):395-404; discussion 393. doi:10.1016/j.
cps.2008.02.003
the necessity for skin resection and minimizing tension on
2. Maffi TR, Chang S, Friedland JA. Traditional lower blepha-
the incision line, thus preventing scleral show. Hamra roplasty: is additional support necessary? A 30-year review.
described a technique that utilizes the orbicularis muscle to Plast Reconstr Surg. 2011;128(1):265-273. doi:10.1097/
support the lower lid. A laterally based flap of redundant PRS.0b013e3182043a88
orbicularis is suspended to the lateral orbital rim via an 3. Hidalgo DA. An integrated approach to lower blepharoplasty.
upper lid incision.43 A similar technique described by Plast Reconstr Surg. 2011;127(1):386-395. doi:10.1097/
McCord includes the fixation of the pretarsal orbicularis, PRS.0b013e3181f95c66
Fakih-Gomez 13

4. Codner MA, Wolfli JN, Anzarut A. Primary transcutaneous experience. Plast Reconstr Surg. 2000;105(1):393-406; discus-
lower blepharoplasty with routine lateral canthal support: a com- sion 407. doi:10.1097/00006534-200001000-00063
prehensive 10-year review. Plast Reconstr Surg. 2008;121(1): 20. Tessier P. Le lifting facial sous-périosté [Subperiosteal face-
241-250. doi:10.1097/01.prs.0000295377.03279.8d lift]. Ann Chir Plast Esthet. 1989;34(3):193-197.
5. Jacono AA. Transcutaneous blepharoplasty with volume pres- 21. Psillakis JM, Rumley TO, Camargos A. Subperiosteal approach
ervation: indications, advantages, technique, contraindications, as an improved concept for correction of the aging face. Plast
and alternatives. Facial Plast Surg Clin North Am. 2021;29(2): Reconstr Surg. 1988;82(3):383-394. doi:10.1097/00006534-
209-228. doi:10.1016/j.fsc.2021.01.008 198809000-00001
6. Masry G, Nassif P. Transconjunctival lower blepharoplasty: fat 22. Le Louarn C. The concentric malar lift: malar and lower eyelid
excision or repositioning. In: Masry G, Murphy M, Azizzadeh rejuvenation. Aesthetic Plast Surg. 2004;28(6):359-372; dis-
B, eds. Master Techniques in Blepharoplasty and Periorbital cussion 373-374. doi:10.1007/s00266-004-0053-1
Rejuvenation. Springer; 2011:173-184. doi:10.1007/978-1- 23. Rohrich RJ, Ghavami A, Mojallal A. The five-step lower
4614-0067-7 blepharoplasty: blending the eyelid-cheek junction. Plast
7. Wong CH, Hsieh MKH, Mendelson B. The tear trough Reconstr Surg. 2011;128(3):775-783. doi:10.1097/PRS.0b013
ligament: anatomical basis for the tear trough deformity. e3182121618
Plast Reconstr Surg. 2012;129(6):1392-1402. doi:10.1097/ 24. Rohrich RJ, Pessa JE. The fat compartments of the face:
PRS.0b013e31824ecd77 anatomy and clinical implications for cosmetic surgery. Plast
8. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the Reconstr Surg. 2007;119(7):2219-2227. doi:10.1097/01.prs.
ligamentous attachments in the temple and periorbital regions. 0000265403.66886.54
Plast Reconstr Surg. 2000;105(4):1475-1490; discussion 25. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the
1491. deep medial fat compartment. Plast Reconstr Surg. 2008;
9. Duan J, Cong LY, Luo CE, Luo SK. Clarifying the anatomy of 121(6):2107-2112. doi:10.1097/PRS.0b013e31817123c6
the zygomatic cutaneous ligament: its application in midface 26. Rohrich RJ, Arbique GM, Wong C, Brown S, Pessa JE. The
rejuvenation. Plast Reconstr Surg. 2022;149(2):198e-208e. anatomy of suborbicularis fat: implications for periorbital
doi:10.1097/PRS.0000000000008716 rejuvenation. Plast Reconstr Surg. 2009;124(3):946-951.
10. Rees TD. Prevention of ectropion by horizontal shortening doi:10.1097/PRS.0b013e3181b17b76
of the lower lid during blepharoplasty. Ann Plast Surg. 1983; 27. Castanares S. Blepharoplasty for herniated intraorbital fat: ana-
11(1):17-23. doi:10.1097/00000637-198307000-00003 tomical basis for a new approach. Plast Reconstr Surg (1946).
11. Fakih-Gomez N, Haneef M, Zarate JM, Rodriguez-Chaker S, 1951;8(1):46-58.
Fakih-Gomez I. The boomerang technique: redefining skin-only 28. McCollough EG, English JL. Blepharoplasty. Avoiding plas-
lower blepharoplasty. Am J Cosmetic Surg. 2022;40: 153-158. tic eyelids. Arch Otolaryngol Head Neck Surg. 1988;114(6):
doi:10.1177/07488068221124720 645-648. doi:10.1001/archotol.1988.01860180059030
12. Adamson PA, Tropper GJ, McGraw BL. Extended blepharo- 29. de la Plaza R, Arroyo JM. A new technique for the treatment
plasty. Arch Otolaryngol Head Neck Surg. 1991; Jun117(6):606; of palpebral bags. Plast Reconstr Surg. 1988;81(5):677-687.
discussion 610-619. doi:10.1001/archotol.1991.0187018004 doi:10.1097/00006534-198805000-00005
2008 30. Massiha H. Combined skin and skin-muscle flap technique in
13. Hamra ST. Repositioning the orbicularis oculi muscle in the lower blepharoplasty: a 10-year experience. Ann Plast Surg.
composite rhytidectomy. Plast Reconstr Surg. 1992;90(1): 1990;25(6):467-476. doi:10.1097/00000637-199012000-00007
14-22. doi:10.1097/00006534-199207000-00002 31. Parsa FD, Miyashiro MJ, Elahi E, Mirzai TM. Lower eyelid
14. Furnas DW. Festoons of orbicularis muscle as a cause of hernia repair for palpebral bags: a comparative study. Plast
baggy eyelids. Plast Reconstr Surg. 1978;61(4):540-546. Reconstr Surg. 1998;102(7):2459-2465. doi:10.1097/00006534
doi:10.1097/00006534-197804000-00007 -199812000-00032
15. Huang T. Reduction of lower palpebral bulge by plicating 32. Parsa AA, Lye KD, Radcliffe N, Parsa FD. Lower blepharo-
attenuated orbital septa: a technical modification in cosmetic plasty with capsulopalpebral fascia hernia repair for palpebral
blepharoplasty. Plast Reconstr Surg. 2000;105(7):2552; dis- bags: a long-term prospective study. Plast Reconstr Surg. 2008;
cussion 2559-2860. doi:10.1097/00006534-200006000-00040 121(4):1387-1397. doi:10.1097/01.prs.0000304469.81239.f0
16. Hamra ST. The zygorbicular dissection in composite rhytid- 33. Yoo DB, Peng GL, Massry GG. Effacing the orbitoglabellar
ectomy: an ideal midface plane. Plast Reconstr Surg. 1998; groove with transposed upper eyelid fat. Ophthalmic Plast
102(5):1646-1657. doi:10.1097/00006534-199810000-00051 Reconstr Surg. 2013;29(3):220-324. doi:10.1097/IOP.0b013e
17. Hinderer UT, Urriolagoitia F, Vildósola R. The blepharo- 3182873d65
periorbitoplasty: anatomical basis. Ann Plast Surg. 1987;18(5): 34. Griffin G, Azizzadeh B, Massry GG. New insights into physi-
437-453. doi:10.1097/00000637-198705000-00009 cal findings associated with postblepharoplasty lower eyelid
18. Hester TR Jr, McCord CD, Nahai F, Sassoon EM, Codner retraction. Aesthet Surg J. 2014;34(7):995-1004. doi:10.1177
MA. Expanded applications for transconjunctival lower lid /1090820X14544306
blepharoplasty. Plast Reconstr Surg. 2001;108(1):271-272. 35. Little JW, Hartstein ME. Simplified muscle-suspension
doi:10.1097/00006534-200107000-00066 lower blepharoplasty by orbicularis hitch. Aesthet Surg J.
19. Hester TR Jr, Codner MA, McCord CD, Nahai F, Giannopoulos 2016;36(6):641-647. doi:10.1093/asj/sjw052
A. Evolution of technique of the direct transblepharoplasty 36. Flowers RS, Flowers SS. Precision planning in blepharoplasty.
approach for the correction of lower lid and midfacial aging: The importance of preoperative mapping. Clin Plast Surg.
maximizing results and minimizing complications in a 5-year 1993;20(2):303-310.
14 The American Journal of Cosmetic Surgery 00(0)

37. McCord CD, Boswell CB, Hester TR. Lateral canthal anchor- 41. Paul MD, Calvert JW, Evans GR. The evolution of the mid-
ing. Plast Reconstr Surg. 2003;112(1):222; discussion 238-379. face lift in aesthetic plastic surgery. Plast Reconstr Surg. 2006;
doi:10.1097/01.PRS.0000066340.85485.DF 117(6):1809-1827. doi:10.1097/01.prs.0000218839.55122.c0
38. Glat PM, Jelks GW, Jelks EB, Wood M, Gadangi P, Longaker 42. Liapakis IE, Paschalis EI, Zambacos GJ, Englander M,
MT. Evolution of the lateral canthoplasty: techniques and indi- Mandrekas AD. Redraping of the fat and eye lift for the correc-
cations. Plast Reconstr Surg. 1997;100(6):1396-1405; discus- tion of the tear trough. J Craniomaxillofac Surg. 2014;42(7):
sion 1406. doi:10.1097/00006534-199711000-00003 1497-1502. doi:10.1016/j.jcms.2014.04.020
39. Jelks GW, Glat PM, Jelks EB, Longaker MT. The inferior reti- 43. Hamra ST. The role of orbital fat preservation in facial aes-
nacular lateral canthoplasty: a new technique. Plast Reconstr thetic surgery. A new concept. Clin Plast Surg. 1996;23(1):
Surg. 1997;100(5):1262-1270; discussion 1271. doi:10.1097/ 17-28.
00006534-199710000-00030
40. Fagien S. Algorithm for canthoplasty: the lateral retinacular
suspension: a simplified suture canthopexy. Plast Reconstr Author Biography
Surg. 1999;103(7):2042-2053; discussion 2054. doi:10.1097/ Nabil Fakih-Gomez, MD, MSc, Department of Facial Plastic &
00006534-199906000-00039 Cranio-Maxillo-Facial Surgery, Fakih Hospital, Khaizaran, Lebanon.