Sub-tarsal Capsulopalpebral Fascia Incision: A New Paradigm for Ectropion-Free Transcutaneous Lower Blepharoplasty

Lower-eyelid surgery via the transcutaneous approach is challenging due to common complications such as ectropion and scleral show. We devised a transcutaneous lower-eyelid technique that incorporates four modifications that greatly reduce these complications, namely, tension-reducing incision of the capsulopalpebral fascia to prevent ectropion and preserve the tear bags; selective omission of lateral canthoplasty; universal application of arcuate expansion cuts to prevent lateral compartment bulging; and reattachment of the tear-trough and orbital-retaining ligaments to the orbital septum. A prospective cohort study was conducted on all consecutive patients who underwent the technique in January 2020-March 2023. All complications were reviewed. The 50 most recent patients were assessed objectively by three independent plastic surgeons with regard to patient preoperative and 3- and 6-month postoperative tear trough, lid-cheek groove, eye bag, and fine lines. Each variable was scored on a 5-point scale. In total, 340 patients underwent the procedure. No major complications, including ectropion, were observed. All four esthetic variables improved significantly at 3 and 6 months relative to preoperative baseline. This new approach significantly mitigates common complications of transcutaneous lower-eyelid surgeries, including persistent postoperative ectropion. Thus, it may be a promising advance in surgical correction of lower-eyelid esthetics.