Subcutaneous blepharoplasty is a minimally invasive technic with amazing results.  For twenty years, we performed this procedure at the Saint Louis hospital in Paris, and at the Columbus clinic in Milan, on 846 patients: 439 men and 407 women.

This technic requires a sub-cutaneous dissection, which is then infiltrated with 1% carbocaine-adrenaline. The muscle is not detached at all. Two holes are then created in the orbicular oris muscle to trim the fat. One external for external fat, and one medial for the medial and internal fat. The skin is lifted in this way 7 times more than in the habitual technic.

The indication is particularly important in men, as the inferior eyelids are too heavy. With the classic technic, every now and again there is not enough skin removed, resulting in a poor effect or even ectropion. This technique is also applied to women, as the result is much better as the muscle is not touched (just two 1/2 mm holes). The amount of skin trimmed creates fantastic results.

In young patients, the indication is still very good as they have great skin elasticity. On the other hand, in old patients it is necessary to evaluate the loss of elasticity, and to pay particular attention to the quantity of skin to be removed.  It is better to trim less skin and to complete the intervention a second time, which usually take just 10 minutes under local anaesthesia. The target of this technic is to remove a greater amount of skin in a shorter period of time; therefore an astute surgeon, especially concerning the internal sections, must perform it.

Ectropion is often present after the first week, and last for some weeks. Patients who present these results must consult a surgeon with experience in orbit reconstruction, where the elasticity of the skin is the most important point to evaluate.  When there is a persistent ectropion that doesn't improve after a couple of month of massage and tension of the inferior eyelid, reconstruction is required.

For many years, how to reconstruct the inferior eyelid was a great topic of discussion for plastic and reconstructive surgeons. It is not necessary to set the skin graft up to the temporal region. But it is mandatory to distend the orbicular oris muscle fibres with the tip of scissors before fixing the skin graft from the opposite superior eyelid, if possible. In some extreme complications, it is necessary to apply an alar rim cartilage through an alar rim incision, where the auricular cartilage must always be carved following the convexity of the orbit, and closed with a dissection of the mucosa and eyelid skin, or with superior eyelid flaps from the same side, or even with frontal flaps (rare) which need two operations.

The technic is as follows:

A) Under local anaesthesia with 1% carbocaine-adrenaline (insulin needle)   B) An external incision with an 11/15 knife followed with little scissors, over the muscle/under the skin. C) A dissection just to the edge of the orbit bone, even if it could possibly go further. D) The quantity of skin to trim is evaluated and then removed. E) Two holes of about 2mm are pierced into the orbicular muscle, one for the internal and medial fat hernia and trim, and a second external one for the external fat. F) An accurate haemostasis is performed  G) Closure with a 5/0 intradermic Ethicon.  H) Bandaged with a compressive gauze and ice.

In conclusion, this is the best technic for blepharoplasty, particularly in men but also for women. Younger patients are the best candidates as their elasticity is great. Older patients could be good candidates, but careful attention must be paid to the quality of their skin. It is possible to remove seven times more skin than the classic techniques.  In men it is usually hard to remove the skin necessary to get good results and there is a high risk of ectropion. For the experienced surgeon, it is the better technic for women too. Fantastic results can be achieved, with more stability due to the muscle not being detached, but a reconstructive surgeon must perform the technique with experience in the orbital area.