COSMETIC

The Five-Step Lower Blepharoplasty: Blendingthe Eyelid-Cheek Junction

Rod J. Rohrich, M.D.Ashkan Ghavami, M.D.

Ali Mojallal, M.D., Ph.D.

Dallas, Texas; Beverly Hills, Calif.;and Lyon, France

Background: Lower lid blepharoplasty has potential for significant long-lastingcomplications and marginal aesthetic outcomes if not performed correctly, or if onedisregards the anatomical aspects of the orbicularis oculi muscle. This has detractedsurgeons from performing the technical maneuvers necessary for optimal perior-bital rejuvenation. A simplified, “five-step” clinical approach based on sound ana-tomical principles is presented.Methods: A review of 50 lower lid blepharoplasty patients (each bilateral) usingthe five-step technique was conducted to delineate the efficacy in improvinglower eyelid aesthetics. Digital images from 50 consecutive primary lower bleph-aroplasty patients (100 lower lids: 37 women and 13 men) were measured usinga computer program with standardized data points that were later converted toratios.Results: Of the 100 lower eyelid five-step blepharoplasties analyzed, complica-tion rates were low and data points measured demonstrated improvements inall aesthetic parameters. The width and position of the tear trough, position ofthe lower lid relative to the pupil, and the intercanthal angle were all improved.There were no cases of lower lid malposition.Conclusions: Aesthetic outcomes in lower lid blepharoplasty can be im-proved using a five-step technical sequence that addresses all of the ana-tomical findings. Lower lid blepharoplasty results are improved when (1) thesupportive deep malar fat compartment is augmented; (2) lower lid orbic-ularis oculi muscle is preserved with minimal fat removal (if at all); (3) themain retaining structure (orbicularis retaining ligament) is selectively re-leased; (4) lateral canthal support is established or strengthened (lateralretinacular suspension); and (5) minimal skin is removed. (Plast. Reconstr.Surg. 128: 775, 2011.)CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The history of surgical advances in lower lidblepharoplasty is perplexing, as many con-flicting opinions exist regarding the most

effective, safest surgical approach with the fewestrisks and long-term complications. Recent para-digm shifts in concepts regarding lower lid surgeryhave been beneficial in decreasing aesthetic andsurgical complications (Table 1).

A wide spectrum of surgical techniques havebeen described and are often used in combina-tion to improve the aesthetic results and to pre-vent postoperative complications. The myriad of

techniques include simple fat removal, usuallywith lower lid skin excision1–5; combined muscle-skin flap techniques6,7; emphasis on lateral canthalsuspension and/or tightening8–13 with simplifiedfat/skin removal; laterally based muscle pen-nants7,14,15; fat transposition14–17 and release of re-taining structures14–16, 18–20; tightening of the or-bital septum21–23; or lower lid bony augmentationby means of implantation.24–26

A common thread of all these techniques isthat many are aimed at improving the aestheticoutcomes while attempting to prevent postoper-ative complications such as lower lid malposition,scleral show, dry eyes, and frank lower lid ectro-pion. The prevailing fears among plastic surgeonsFrom the Department of Plastic Surgery, University of Texas

Southwestern Medical Center; private practice; and the De-partment of Plastic Surgery, University of Lyon.Received for publication October 10, 2010; accepted January18, 2011.Copyright ©2011 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3182121618

Disclosure: The authors have no financial interestto declare in relation to the content of this article.

www.PRSJournal.com 775

regarding the lower lid may inhibit patients fromachieving the necessary aesthetic improvements.Some surgeons avoid the lower lid altogether. Un-desirable postoperative sequelae exist along a con-tinuum, and their prevention is critical becausecorrective lower lid surgery is often more invasiveand complicated. Many surgeons have attemptedto improve outcomes by advocating a combinationof techniques that have each been shown to beindividually effective. However, the various com-binations have caused some confusion and out-comes have not been evaluated objectively.

The individual components (cheek and or-bital fat preservation/augmentation, muscle/lig-amentous attachments, canthal supporting struc-tures, and lower lid skin) vital to successful lowerlid operations have all been described previously.Loeb16 was instrumental in addressing the impor-tant concept of lower lid fat preservation throughtransposition of pedicled fat rather than excision.As a key part of his technique, release of the lowerlid attachments was necessary to allow for fat coales-cence with the cheek fat and a smoother lid-cheekcontour. Later, both Hamra14 and Barton et al.15

reaffirmed this important contribution throughtheir studies on “resetting” this inferior fat and or-bital septum in a new anatomical position. Recentknowledge regarding the topography of facial fatcompartments,27–29 facial soft-tissue deflation withage,30 and details on ligamentous attachments (i.e.,the orbicularis retaining ligament)18–20 have helpedto advance our periorbital and facial rejuvenationtechniques.

In addition to aesthetic benefits, the functionaland supportive role of cheek fat on lower lid shape hasbeenelucidatedbynumerous surgeons.6, 27–34 Whethercheek-lower lid soft tissue is augmented through fatmobilization,6–13,17,35,36 direct injection,31,36 or bymeans of implants,24–26 the goal remains the same.

The lower lid requires malar support for establish-ing and maintaining appropriate postoperativecontour and position. This point was clearly madeby Rees and LaTrenta,32 later Jelks and Jelks,33 andHirmand et al.34

Further support to the lower lid is requiredand involves some form of lateral canthal strength-ening and/or repositioning. Patipa’s13 treatise onthe subject involves an appropriate “tripartite” ap-proach in both primary and secondary lower lidsurgery. The three-part technique involves lateralcanthal support, cheek suspension, and orbicularisoculi muscle-cheek fat elevation. Since Flowers8 sug-gested “routine canthopexy” with blepharoplasty,the importance of canthal repositioning and/ortightening has been widely adopted. Specific lowerlid morphologies such as a negative vector globe33 orinsufficient skeletal (malar) support13,32 mandatecanthal treatment. However, canthal fixation/repo-sitioning benefits most if not all lower lid blepharo-plasty techniques.8

Lastly, excision of skin excess is the oldest tech-nique and, when indicated, provides for a clean,smooth lower lid contour. The simplest form,“pinch blepharoplasty” has been revisited byRosenfield4 and, in some clinical situations, maybe all that is needed, along with safe conservativefat removal. On the other end of the spectrum,aggressive skin removal can result in severe ectro-pion and other negative outcomes.

We present a simplified, five-step approachthat safely addresses all the above componentswhile producing successful aesthetic results. Thisis based on the senior author’s (R.J.R.) clinicalexperience, previous knowledge on lower lid sur-gery, and recent anatomical details regarding thedeep cheek fat compartments. In the senior sur-geon’s practice, it is common that lower lid bleph-aroplasty is combined with a concomitant face lift.We feel strongly that this does not affect the spe-cific outcomes measured for the five-step lower lidblepharoplasty, as the aesthetic units measuredare not affected by the type of face-lift techniqueused.36 Aesthetic results are measured using spe-cific data points to objectively evaluate the syner-gistic affects of the five-step combination.

PATIENTS AND METHODSA review of the senior author’s (R.J.R.) clinical

experience with the five-step blepharoplasty wasconducted. Fifty consecutive lower lid blepharo-plasties that used the five-step sequence were an-alyzed using a computer-based system that mea-sured relevant data points. The five-step lower lid

Table 1. Changing Concepts in LowerBlepharoplasty

Old New

Intraoperative planning Proper preoperative analysisand planning

Maximal muscle resection(composite)

Orbicularis oculi musclepreservation

Emphasis on fat removal Shift toward eyelid “shaping”and periorbital contouringand blending lid-cheekjunction

Long-term “hollowed”appearance

Natural appearing and fullerlower eyelids that blendwith overall facial shape

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blepharoplasty technique includes the following:step 1, deep malar fat compartment augmentationusing injected fat; step 2, transconjunctival ap-proach/removal of lower lid fat (if indicated basedon preoperative assessment); step 3, orbicularisretaining ligament release; step 4, lateral retinacu-lar canthopexy; and step 5, skin pinch removal orskin flap (Figs. 1 and 2).

Complication rates were also assessed. Thepostoperative outcomes were evaluated using con-tour ratios of specific morphologic facial points.Patient case examples are used to illustrate typicalaesthetic outcomes of this technique.

The measurements include the following: dis-tance A, the distance from the pupil to the lowereyelid margin; distance B, the distance from thepupil to the tear trough; distance C, the width of thetear trough; and distance D, the intercanthal angle.The horizontal axis was corrected for head tilt biasby including only patients who had pupil flash reflexaligned and in the center of both pupils.

Computer Program for Outcome AnalysisA computer software program was developed

to quantify variations in specific topographic faciallandmarks. Data from preoperative and postop-erative digital images were analyzed based on thefollowing three variables: x axis, y axis, and inter-pupillary distance. Specifically, primary pointswere marked on the medial canthi. A horizontalline intersecting both points generated the x axis.A second set of points were marked at the middleof the brows and at the middle on the upper lipto generate the y axis. The standardized measure-ments avoided inaccuracies caused by head tilting.A third set of points in the middle of each pupilwas marked to define the interpupillary distance.This served as the denominator to analyze all mea-surements as a ratio to eliminate the risk of errorattributable to variations in the size of the images.Using a ratio for each subject also allows the anal-ysis of measurements among all subject data sets.Next, one point was placed at the lower eyelidmargin, a second one at the upper border of the

Fig. 1. The five-step lower lid blepharoplasty: step 1, fat augmentation to the deep malar fat compartment;step 2, conservative fat removal; step 3, orbicularis retaining ligament selective release; step 4, lateral reti-nacular canthopexy; and step 5, skin pinch and excision.

Fig. 2. Image showing distance points A, B, C, and the angle ofinclination. A, Pupil to eyelid margin distance; B, Pupil to teartrough distance; C, tear trough width.

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tear trough, and a third one at the lower borderof the tear trough. The location of each point isdefined as an x and y axis value by the program.

Quantitative Outcome AssessmentQuantitative assessments included evaluation

of preoperative and postoperative symmetry be-tween these anatomical landmarks. All variation interms of modification of landmarks location werecalculated (i.e., postoperative – preoperative/pre-operative) and presented as a percentage. For dis-tances (A, B, and C), a negative variation (a de-crease of the distance) corresponds clinically to adecrease of the lower eyelid height and has a fa-vorable rejuvenation effect.

Intercanthal angle variation represents an up-per displacement if the angle is positive and alower displacement if the angle is negative. Resultsare presented as the variation of the postoperativeangle minus the preoperative angle.

RESULTSSubjects

The mean age of the patients was 51.3 years(range, 39 to 65 years) in the 50 subjects exam-ined. The average follow-up examination oc-curred at 17.9 months, with a range of 14 to 36months. All patients, except three, had a concom-itant individualized component face lift.36 Resultsare shown in Tables 2 and 3. These three patientshave been chosen as case examples below.

Pupil to Eyelid Margin (Distance A)Among 100 lower blepharoplasties analyzed,

64 had a decrease of this distance, with an averagedecrease of –18.1 � 2.1 percent. In 34 cases, thepupil to eyelid margin distance was increased byan average of 12.3 � 1.9 percent. The overallanalyses showed a decrease of the pupil to margindistance of –7.17 � 2.4 percent.

Pupil to Tear Trough (Distance B)Of 100 lower blepharoplasties analyzed, 80

had a decrease of this distance, with an averagedecrease of –21.2 � 5.1 percent. In 20 cases, thepupil to tear trough distance was increased by anaverage of 6.2 � 1.2 percent. The overall analysesshowed a decrease of the pupil to margin distanceof –15.7 � 4.3 percent.

Tear Trough Width (Distance C)Of the 100 lower blepharoplasties analyzed,

79 had a decrease of this distance, with an av-erage decrease of –35.5 � 3.4 percent. In 21cases, the tear trough width was increased by anaverage of 16.6 � 1.5 percent. The overall anal-yses showed a decrease of the pupil to margindistance of –24.6 � 3.3 percent.

Intercanthal AngleAmong 100 lower blepharoplasties analyzed,

36 had a decrease of this angle, with an averagedecrease of –1.1 � 1.0 degrees. In 64 cases, theintercanthal angle was increased by an average of1.4 � 1.3 degrees. The overall analyses showed anincrease of the intercanthal angle of 0.5 � 1.7degrees.

The five-step blepharoplasty is an efficacioustechnique in periorbital rejuvenation. The five-step lower lid blepharoplasty technique addresseseach component of lower lid shape and aging. Insummary, the position of the lower lid margin andwidth (severity) of the tear trough were both im-proved. In addition, a slight increase in the inter-canthal angle was noted.

There were no major complications notedpostoperatively, defined as those that wouldhave otherwise required surgical interventionfor correction. Although not all patient resultswere optimal, lower lid malposition requiringrevision was not seen in any of the patients.There was one case of scleral show that im-proved with taping and massage, two cases ofslight chemosis that were managed conserva-tively, no cases of canthal distortion, and nocases requiring suture removal.

Table 2. Average Percentage Change in Angle ofInclination and Data Points A, B, and C*

Distance

Angle (degrees) A (%) B (%) C (%)

Average 0.49 �7.17 �15.70 �24.59SD 1.708 2.38 4.26 3.27*Results of 100 eyelids measured.

Table 3. Positive and Negative Percentage Changesfrom Preoperatively to Postoperatively*

Distance

Angle A B C

NegativeNo. 36 64 80 79Average �1.09 degrees �18.10% �21.16% �35.53%SD 1.037 degrees 2.09% 5.51% 3.42%

PositiveNo. 64 34 20 21Average 1.38 degrees 12.25% 6.16% 16.55%SD 1.323 degrees 1.85% 1.23% 1.53%

*Results represented by subgroups of positive or negative variations.Ratio presented as a percentage.

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DISCUSSIONSurgical rejuvenation of the lower eyelid

continues to be a controversial topic in aestheticplastic surgery. Many of the conflicts arise fromfrustration regarding the propensity of this an-atomical site toward postoperative complica-tions along with less than optimal aesthetic im-provements. Extensive maneuvers have a steeplearning curve and can have devastating re-sults. Recent techniques have focused more oncomplication prevention, and most include somecombination of surgical maneuvers such as can-thopexy and minimal fat removal. Bolder tech-niques have also been described, such as the “sep-tal reset,”14,15 subperiosteal muscle, and cheek fatsuspension.6,14 All require careful patient selectionand have a steep learning curve.

Cumulative anatomical understanding andadvances have helped guide our technical exe-cution, improve surgical results, and reducedthe dreaded postoperative complication rates.Recent advances in our anatomical knowledgeof the periorbital region, especially in definingthe clinical applications of the fat compartmentsof the face, formed the basis for the five-steplower lid blepharoplasty. The recent detailedevaluation of the deep malar fat and other fatcompartments of the face have provided theknowledge with which to optimize the efficacy oflower lid and cheek balance. This may be themissing link in safely and effectively blendingthe eyelid and cheek junction.27–29

Preservation of lower lid fat and minimal ifany skin removal have gained widespread accep-tance. In addition, performing some form ofcanthal strengthening or support has become amainstay of lower lid surgery, as advocated longago by Flowers.8 Muscle preservation may alsohelp retain lower lid shape and support longterm. Current aesthetic goals now center moreon enhancing lower lid– cheek shape and con-tour rather than simple elevation and tissueremoval. This paradigm shift has become prev-alent in concepts of facial rejuvenation as awhole.30,35–37

In concert with these changing concepts,recent anatomical knowledge regarding the fa-cial fat compartments has shown that to coun-teract facial fat deflation caused by age, precisefilling of these compartments is required.27–29,36

As facial aging progresses, the fat compartmentsdeflate and separations (appearing as depres-sions and folds) form between them, accentu-

ating specific transition zones, such as the lowerlid– cheek junction.

The orbicularis retaining ligament is locatedat this junction, and selective release (based onextent of tear trough formation) of the orbicularisretaining ligament along with deep cheek fat aug-mentation effectively blends this transitionzone, simultaneously providing support to thelower lid and maintaining lower lid position andshape (Fig. 3). Although the attachments of theorbicularis retaining ligament require release,“resetting” them may not be necessary becausethe orbicularis retaining ligament has not dem-onstrated a reattachment in any cases. The arcusmarginalis (which is a periosteal adhesion line)is not directly released because the orbicularisretaining ligament “disinsertion” is performedbluntly in a supraperiosteal plane. This allowsthe more caudal, more mobile fat lobules toslide and coalesce with the cheek fat. We notedan 80 percent reduction in pupil to tear troughdistance along with a 79 percent reduction intear trough width without orbicularis retainingligament resetting. Direct fat is never injectedinto the region of the tear trough itself. Fatvolumes in the malar region range between 6and 12 cc each. Lambros recently noted that thelid-cheek junction does not change positionwith age.39 However, surgical correction willproduce a change in both position and width ofthis region. This change may be an inevitableresult of effective lower lid rejuvenation tech-niques. Furthermore, ethnic variations in lateralcanthal angle changes have been appreciated byOdunze et al.40

The lower lid fat and deep medial cheek fattherefore become more confluent, and the con-tribution of the orbicularis retaining ligament tothe overlying skin (tear trough) undergoes an iat-rogenic “dehiscence” by means of its supraperios-teal release. The orbicularis retaining ligamenthas been shown to be present in the upper andlower periorbita, which allows for fine-tuning ofperiorbital shape through release of only the por-tions indicated. In the lower lid, the lateral extentof tear trough formation and the morphology ofthe lid-cheek junction dictate the amount ofrelease required. The lateral orbital thickening,37

which is a periosteal adhesion, is not releasedbecause of the supraperiosteal plane that is main-tained during orbicularis retaining ligament disin-sertion. Extensive dissection this far superolaterallyis almost never indicated. The transconjunctival ap-proach provides adequate access to the entire lengthof the orbicularis retaining ligament in the suprap-

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eriosteal plane. The cumulative effects of lower lidconservative deep cheek medial fat augmentation,minimal lower lid fat removal, and selective orbic-ularis retaining ligament release allows for amore predictable lateral retinacular canthopexyand a safer skin flap elevation or “pinch” skinremoval. The suture for the lateral canthopexyis a dissolvable suture and the effect of this“pexy” is for prevention of scleral show andlower lid malposition, and lasts up to a maxi-mum of 6 months. A more long-lasting sutureeffect is desired in men, revisions, and cases ofdry eyes, and these situations warrant a nonab-sorbable suture.

The facial fat compartments have been de-scribed recently.27–29 In addition to the moresuperficial fat compartments, the deep cheek fatpad has become a critical aspect of facial aging.28

Superficial and deep fat compartments may agein a differential fashion.27 Selective and “site-specific” fat injection to these compartments

and blending of intercompartmental transitionzones improves periorbital and facial rejuvena-tion techniques by addressing one of the rootcause of the deformities (i.e., soft-tissue defla-tion). These suborbicularis fat compartmentsare composed of lateral and medial segments.29

To correct and blend the lower lid fat with thatof the cheek, support of the lower lid fat and lidposition must be maintained by selective filling ofthe deep malar compartment. Fat is injected deepso that lumpiness and irregularities are not seen.Filling of the deep cheek fat plays a key role inour 80 percent improvement of the tear troughdeformity.

The minimal “pinch” removal of skin is dictatedafter all four other steps have been performed. Thesafety of the pinch blepharoplasty has recently beenoutlined elegantly by Rosenfield4 and discussed byRistow,2,38 who was an early advocate of its simpleelegance. Use of the five-step blepharoplasty alsoallows comfort in performing an appropriate

Fig. 3. Selective orbicularis retaining ligament release. Entry is transconjunctival (above, left,and right). After entry through the capsulopalpebral fascia and conservative fat removal, theorbicularis retaining ligament is released using a blunt elevator from medial to lateral. Extent oforbicularis retaining ligament release laterally is based on preoperative lid-cheek contour(below, left).

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face lift without concern for cumulative in-creases in postoperative complications. One ofthe main criticisms of our study may be that allpatients, except three, have had a concomitantface lift. The technique used in all face-lift caseswas an individualized component face lift,36

which incorporates malar soft-tissue augmenta-tion as a critical component, similar to the five-step lid technique. However, because of the typeof superficial musculoaponeurotic system treat-ment in the individualized component face lift,we do not feel that there is any effect or bias onoutcomes in the five-step lower lid study. Malaraugmentation using fat grafting is performed inboth techniques.

In many practices today, lower lid blepharo-plasty is combined with panfacial rejuvenationtechniques. Face-lift techniques other than theindividualized component face lift that involve di-rect malar fat pad elevation or extensive sub–su-perficial musculoaponeurotic system dissectionmay, in theory, affect lower lid position or furtherenhance the benefits of malar fullness and thuslower lid support. However, this is not the casewith the individualized component face lift. Caseexamples are shown of three patients who dem-onstrate the benefits of the five-step lower lidblepharoplasty technique, without having under-gone a face lift.

CASE REPORTSCase 1

A 52-year-old man requested lower eyelid and facial rejuve-nation and was particularly concerned with the aging of hislower eyelids (Fig. 4). He underwent a five-step lower blepha-roplasty and a standard upper blepharoplasty (skin and con-servative fat removal). Note the malar fullness and lid-cheekblending. He underwent full “blunt” release of the orbicularisretaining ligament in a supraperiosteal plane from the nasalinsertions of the orbicularis muscle to the inferior start of thelateral orbital thickening.

Case 2A 43-year-old woman underwent a five-step blepharoplasty and

upper blepharoplasty (Fig. 5). She felt that her cheeks were veryflat and equated this with appearing as if she had an illness. Herlid-cheek junction and malar fullness have improved through thesynergistic effect of each of the five steps. Fat injection was mod-erately beneficial in balancing her lower lid–cheek contour.

Case 3A 56-year-old woman presented who was very concerned

about the aged appearance of her eyelids (Fig. 6). The seniorauthor performed a five-step blepharoplasty and an upperblepharoplasty. Cheek and lower lids appear more youthful andbalanced without lower lid malposition or an overoperatedappearance to the lid-cheek junction.

CONCLUSIONSThe five-step lower lid blepharoplasty is com-

posed of simple individual technical maneuversthat, when combined, provide a powerful yetreproducible aesthetic eyelid shaping. Although

Fig. 4. Case 1. Anteroposterior views of a 52-year-old man before (above, left) and 1 year after (above, right) five-step lower lidblepharoplasty. (Below, left) Preoperative lateral view. (Below, right) One-year postoperative view.

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many of these techniques have been individuallydescribed in the past, outcomes of a systematic andsynergistic method have not been measured. Quan-tification of specific topographic changes indicatesimprovement in various aspects of lower lid shape

and lid-cheek blending. Emphasis in the field offacial rejuvenation has recently moved toward facialshaping and contouring. Older perceptions regard-ing periorbital and facial rejuvenation focused onlifting, tightening, and excising. Aesthetic paradigm

Fig. 5. Case 2. Anteroposterior views of 43-year-old woman before (above, left) and 1 year after (above, right) five-step lower lidblepharoplasty. (Below, left) Preoperative lateral view. (Below, right) One-year postoperative view.

Fig. 6. Case 3. Anteroposterior views of a 56-year-old woman before (above, left) and 1 year after (above, right) five-step lower lidblepharoplasty. (Below, left) Preoperative lateral view. (Below, right) One-year postoperative view.

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shifts now focus on selective treatment of knownfacial fat compartments, limited release of retainingstructures, and techniques that restore or improveperiorbital “contour.” Future studies with more stan-dardized techniques for analyzing three-dimen-sional images may further improve our understand-ing of the lid-cheek junction.

Rod J. Rohrich, M.D.Department of Plastic Surgery

University of Texas Southwestern Medical Center1801 Inwood Road

Dallas, Texas 75390-9132rod.rohrich@utsouthwestern.edu

PATIENT CONSENTPatients provided written consent for the use of their

images.

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34. Hirmand H, Codner MA, McCord CD, Hester TR Jr, Nahai F.Prominent eye: Operative management in lower lid and mid-facial rejuvenation and the morphological classification system.Plast Reconstr Surg. 2002;110:620–628; discussion 629–634.

35. Stuzin JM. Restoring facial shape in face lifting: The role of skeletalsupport infacialanalysisandmidfacesoft-tissuerepositioning.PlastReconstr Surg. 2007;119:362–376; discussion 377–378.

36. Rohrich RJ, Ghavami A, Lemmon JA, Brown SA. The individ-ualized component face lift: Developing a systematic approachto facial rejuvenation. Plast Reconstr Surg. 2009;123:1050–1063.

37. Lambros V. Changes in eyebrow position and shape withaging (Discussion). Plast Reconstr Surg. 2009;124:1302–1303.

38. Ristow B. The pinch blepharoplasty revisited (Discussion).Plast Reconstr Surg. 2005;115:1413–1414.

39. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of theligamentous attachments in the temple and periorbital re-gions. Plast Reconstr Surg. 2000;105:1475–1490; discussion1491–1498.

40. Odunze M, Rosenberg DS, Dew JW. Periorbital aging andethnic considerations: A focus on the lateral canthal com-plex. Plast Reconstr Surg. 2008;121:1002–1008.

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