NORTHEASTERN SOCIETY OF PLASTIC SURGEONS
Power of the Pinch
Pinch Lower Lid Blepharoplasty
Elizabeth M. Kim, MD, and Louis P. Bucky, MD, FACS
Abstract: Lower lid blepharoplasty is performed with great varia-
tion in technique. Conventional lower lid blepharoplasty with ante-
rior fat removal via the orbital septum has a potential lower lid
malposition rate of 15% to 20%. Lower lid malposition and the
stigma of obvious lower lid surgery have led plastic surgeons to
continue to change their approach to lower lid rejuvenation. In
recent years, some surgeons have come to rely on alternative
procedures like laser resurfacing alone or in conjunction with
transconjunctival fat removal and canthopexy in an effort to avoid
such complications. The pinch blepharoplasty technique removes
redundant skin without undermining. This allows for more con-
trolled wound healing, predictable recovery, and potential for simul-
taneous laser resurfacing. The combination of pinch blepharoplasty
with transconjunctival fat removal leaves the middle lamella intact
and reduces the chance of scleral show or ectropion. The purpose of
this series is to demonstrate that pinch excision of redundant lower
eyelid skin can be safely performed and that it can be used with laser
resurfacing and/or transconjunctival fat removal for optimal treat-
ment of the aging eye. A retrospective review of 46 consecutive
patients who underwent pinch blepharoplasty, either in isolation or
with other periorbital procedures was performed. Follow-up was at
least 4 months (range of 4 –24 months). In addition, we performed a
prospective study of 25 consecutive patients to quantify the amount
of skin removed and evaluate results and complications. An average
of 8 mm of skin was resected (range of 4 –12 mm) with the pinch
blepharoplasty technique. Of these patients, 5.6% also underwent
transconjunctival blepharoplasty, laser resurfacing, and/or fat graft-
ing of the nasojugal groove. Despite the addition of simultaneous
laser resurfacing, we did not see an increase in lower lid malposi-
tion. Three of the 71 patients had temporary scleral show that
resolved with lower lid massage. In total, only 4 patients had
isolated pinch lower lid blepharoplasty. Twelve patients had orbic-
ularis suspension and 15 had either canthopexy or canthoplasty. Five
patients who had orbicularis suspension, canthopexy, or canthop-
lasty had periorbital edema. Two also had pronounced chemosis.
Four patients had mild rounding of the lower lid. Pinch blepharo-
plasty is a versatile technique that produces consistent results. This
study confirms that more skin from the lower lid can be resected than
Received March 5, 2008 and accepted for publication March 5, 2008.
From the Division of Plastic Surgery, Department of Surgery, University of
Pennsylvania, Philadelphia, PA.
Reprints: Louis P. Bucky, MD, FACS, 2300 West Washington Square, Suite
101, Philadelphia, PA 19106. E-mail: elizabeth.kim@uphs.upenn.edu.
Copyright © 2008 by Lippincott Williams & Wilkins
ISSN: 0148-7043/08/6005-0532
DOI: 10.1097/SAP.0b013e318172f60e
532
classically described. Pinch blepharoplasty can be performed safely in
combination with other procedures to enhance lower lid appearance.
The absence of skin undermining allows for safe simultaneous laser
resurfacing. Preserving the middle lamella and supporting it when
necessary allows one to resect significant amounts of lower lid skin
without significant risk of scleral show, lower lid rounding, and ectro-
pion. Patients with poor lid tone or laxity may benefit from supportive
procedures such as the canthopexy or canthoplasty.
Key Words: lower lid blepharoplasty, pinch lower lid blepharoplasty
(Ann Plast Surg 2008;60: 532–537)
T he incidence of postoperative lower lid malposition after
conventional lower lid blepharoplasty is estimated to be 15%
to 20%.1,2 Reports of frank ectropion are approximately 1%.1
Complications associated with lower lid malposition can range
from a poor esthetic result, to persistent keratoconjunctivitis with
corneal exposure.3 Often times this requires prolonged postop-
erative management and/or revisional surgery. To avoid the
potential undesirable sequelae of lower lid surgery while pro-
viding a natural and refreshed look, the ideal approach to lower
eyelid rejuvenation continues to evolve.
Although the concept of the pinch lower lid blepharo-
plasty is not new, its use in comprehensive lower lid rejuve-
nation has been refined in the last 3 decades. Rosenfield4
reported routine excision of 8 to 12 mm of lower lid skin
without an increase in complication. Glat et al5 reports the use
of the pinch technique in combination with transconjunctival
blephroplasty and inferior retinacular lateral canthoplasty as
part of his “no touch” technique.
Pinch lower lid skin excision has the advantage of no
skin undermining. Therefore, wound contraction is mini-
TABLE 1. Procedures Performed With Pinch Blepharoplasty
for Lower Lid Rejuvenation in 71 Patients
Procedure Number of Patients
Pinch only 4
Laser 60
Fat grafting 21
Transconjunctival fat removal 30
Orbicularis suspension 12
Canthopexy or canthoplasty 15
Facelift 22
Annals of Plastic Surgery • Volume 60, Number 5, May 2008
Annals of Plastic Surgery • Volume 60, Number 5, May 2008 Pinch Blepharoplasty

FIGURE 1. A, Lower lid skin is recruited

by placing gentle traction in a cephalad
direction using Brown-Adson forceps. B,
The lower lid skin is “pinched” between
the two adsons, making sure to stay
close to the ciliary margin. C, This results
in an upright, folded segment of skin
only. D, The skin is excised with curved
iris scissors, making sure to place tension
laterally and not anterior to the face to
avoid excising too much skin or inadvert-
antly including the underlying orbicularis
oculi muscle. E, When performed prop-
erly, the remaining skin edges should be
abutting without tension.

FIGURE 2. A 42-year-old woman with

significant skin excess and fine wrinkling
who underwent pinch excision of 10 mm
of skin with laser resurfacing and percu-
taneous fat grafting of the nasojugal
grooves. Preoperative (A and B) and 6
months postoperative (C and D).

© 2008 Lippincott Williams & Wilkins 533

Kim and Bucky
FIGURE 3. A 53-year-old woman with
significant lower lid skin excess, fine
lines, and infraorbital fat underwent
pinch lower lid skin excision of 11 mm
on the right and 8 mm on the left. She
also had transconjunctival removal of in-
fraorbital fat, as well as laser resurfacing.
A, Preoperative and, B, 6 months postop-
erative.
mized, subcutaneous hematoma is avoided, and simultaneous
laser resurfacing can be used safely. Over the last 10 years,
we have used laser resurfacing as a key component of lower
lid rejuvenation. Laser resurfacing’s ability to improve the
textural changes of lower lid skin is most beneficial. Based on
previous authors’ reports of the benefits of the pinch tech-
nique, we felt that this would be an ideal addition to our
approach to lower lid rejuvenation. Therefore, we opted to
study pinch blepharoplasty in isolation and in conjunction
with transconjunctival fat removal and laser resurfacing.
PATIENTS AND METHODS
Patients
We reviewed a single surgeon’s experience with 71
patients that underwent lower lid blepharoplasty from Janu-
FIGURE 4. The average amount of skin excised by the pinch
lower lid blepharoplasty method was 8 mm (range of 4–12 mm).
This patient had nearly 1 cm of lower lid skin removed.
534
Annals of Plastic Surgery • Volume 60, Number 5, May 2008
ary 2006 to July 2007. Ages ranged from 41 to 72 years old.
Follow-up ranged from 4 months to 2 years.
A subgroup of 25 patients was followed prospectively,
to accurately quantify the amount of skin excised and docu-
ment photographically their healing process. Photographs
were taken at 2 weeks, 3 months, and 6 months in the
prospective group. The retrospective review of all patients
was performed to determine esthetic results via photographs,
complication rate, and revision rate. In addition, the number
of combination lower lid treatments and pan-facial rejuvena-
tion procedures were recorded (Table 1). Results were re-
viewed independently by the senior author, a plastic surgery
resident, and a registered plastic surgery nurse.
Preoperative evaluation included a thorough ophthalmo-
logic history including previous ocular or periorbital surgery,
history of dry eyes and/or visual disturbance, and any relevant
medical conditions. Preoperative photographs were taken of
every patient. The determination of surgical approach and sub-
sequent procedures were determined by evaluation of lower lid
fat pockets, depth of nasojugal grooves, evaluation of lid tone
(with snap test), and vector analysis. In addition, skin pigment,
texture, and degree of wrinkles were assessed.
If patients had prominent lower lid fat, retroseptal
transconjunctival fat removal was performed first when indi-
cated. Patients with poor lid tone and/or significant negative
vector received canthopexy or canthoplasty depending on the
degree of horizontal lid laxity. The indicated support proce-
dure was performed after fat removal and before pinch skin
excision. In patients with deep nasojugal grooves, arcus
marginalis release was performed if a transconjunctival fat
removal procedure was performed. Fat redistribution or per-
cutaneous fat grafting was performed to fill the nasojugal
groove. In patients that did not have transconjunctival fat
removal, only percutaneous fat grafting was performed to fill
the nasojugal groove. Percutaneous fat grafting was per-
© 2008 Lippincott Williams & Wilkins
Annals of Plastic Surgery • Volume 60, Number 5, May 2008
formed after pinch blepharoplasty. If skin analysis revealed
fine lines or crepe-like skin texture, CO2 laser resurfacing was
performed (1–2 passes, 70 – 80 mJ) after pinch blepharo-
plasty. Flexan topical supportive dressing was applied.
Surgical Technique
Most of operations were performed under general anes-
thesia without local infiltration. Although this operation can be
performed under local anesthesia we found that the infiltration of
local anesthetic to the subdermal region reduced the precision of
skin pinch excision. Preoperative markings are used to deter-
mine the location of lower lid fat pockets, borders for laser
resurfacing, and the lateral extent of the skin excision.
© 2008 Lippincott Williams & Wilkins
Pinch Blepharoplasty
Pinch Lower Lid Blepharoplasty Technique
One should ensure that there is no restrictive traction on
the cheeks from drapes or tape securing the endotracheal
tube. Next, lower lid skin is recruited via superior distraction
using 2 Brown-Adson forceps (see Fig. 1A). The lower lid
skin is “pinched” between the 2 Adsons creating an upright,
folded segment of skin only. It is important to stay close to
the ciliary margin (Fig. 1B, C) and avoid distorting it. The
skin is excised using curved iris scissors, making sure to place
tension laterally and not anterior to the face, so as to avoid
injuring the underlying orbicularis or excising too much skin
(Fig. 1D). The excision extends from 2 to 3 mm lateral to the
FIGURE 5. A 50-year-old woman under-
went pinch excision of 9 mm of skin
from the right lower lid, and 8 mm of
skin from the left lower lid with con-
comitant transconjunctival fat removal,
laser resurfacing, and facelift. Preopera-
tive (A and B) and 3 months postoper-
ative (C and D).
535
Kim and Bucky
FIGURE 6. Immediate postoperative appearence after pinch
lower lid blepharoplasty, skin closure, and simultaneous CO2
laser resurfacing to address the textural irregularities and fine
wrinkles of aging skin. This patient had 8 mm of lower lid
skin excised on the right and 6 mm on the left.
lateral canthus to about the level of the punctum. When per-
formed properly, the remaining skin edges should be abutting
without tension (Fig. 1E). If orbicularis suspension is indicated,
it is performed prior to skin closure.
Postoperatively, patients are instructed to apply opth-
thalmic lubricant 2 to 3 times daily. Suture removal and
flexan dressing removal are performed 5 days postoperative.
RESULTS
Four of the 71 patients had isolated pinch lower lid
blepharoplasty. Sixty also had laser resurfacing in addition to
pinch skin excision. Twenty one had fat grafting of the
nasojugal groove (Fig. 2). Seventeen had pinch blepharo-
plasty with canthal support procedures (orbicularis suspen-
sion, canthopexy, or canthoplasty). Thirty patients had
transconjunctival fat removal (Fig. 3).
FIGURE 7. A 61-year-old woman with
lower lid skin excess, crepe-like skin, mild
lower lid laxity and orbital festoons (left
⬎ right). We performed pinch skin exci-
sion of 11 mm bilaterally, along with or-
bicularis suspension and laser resurfacing.
A, Preoperative and B, 6 months postop-
erative.
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Annals of Plastic Surgery • Volume 60, Number 5, May 2008
The average amount of skin excised by the pinch
lower lid blepharoplasty method was 8 mm (range of 4 –12
mm) (Fig. 4). No patients in this series required “repinch”
or re-excision for inadequate initial removal of skin. One
patient required secondary canthoplasty for lateral lower
lid rounding.
Three of the 71 patients had temporary scleral show at 1
month postoperative that resolved by 2 months postoperative
with lower lid massage. Five patients had persistent periorbital
edema. These same 5 patients also had canthal support proce-
dures or orbicularis suspension. Two patients (2.8%) had tem-
porary chemosis that required treatment with 0.1% fluoro-
metholone eye drops 4 times a day with complete resolution.
Aesthestic evaluation revealed good to excellent results
in 67 of the 71 patients. Four patients had mild rounding of
the lateral lower lid; 3 had complete resolution of the lateral
rounding at 2 months. As expected, patients who had facelifts
in conjunction with lower lid rejuvenation had the most
impressive results (Fig. 5).
One with residual lower lid rounding will require sec-
ondary canthoplasty. No other patients required operative
treatment. No patients had lagophthalmos or ectropion.
DISCUSSION
The limitation of standard lower lid blepharoplasty has
been the inability to remove adequate skin, fat, and improve
appearance of the lower lid-cheek junction without issues of
lower lid malposition. The reasons for lower lid malposition
range from preoperative misdiagnosis of skin tone, vector,
and lower lid morphology,5 as well as surgical techniques that
weaken lower lid support by denervating the orbicularis
muscle, violating the middle lamella,3 or rendering the lower
lid vulnerable to the variability of wound healing.
© 2008 Lippincott Williams & Wilkins
Annals of Plastic Surgery • Volume 60, Number 5, May 2008
Advances in lower lid blepharoplasty have led to very
different approaches to the lower lid. One approach advocates
the use of canthal support procedures in every open lid
surgery. The benefit is increased lower lid support. The
disadvantage is increased operative time and prolonged re-
covery. A second approach avoids orbicularis transection and
middle lamellar violation. However, adequate skin removal
remains questionable. After reviewing the experience of
Rosenfeld4 and Glat et al5 with pinch skin excision, it became
clear that this method has several advantages: 1) it avoids
skin undermining providing less surface area for potential
hematoma and wound contraction and 2) the absence of
undermining allows the addition of simultaneous treatments
to address the surface irregularities of aging skin. Aging
lower lid skin is not limited to redundant skin but is often
associated with textural irregularities as well. Therefore, the
ability to add simultaneous resurfacing procedures can have a
significant improvement on the overall esthetic result (Fig. 5).
This study uses the pinch blepharoplasty as the keystone
for lower lid blepharoplasty. It allows one to avoid middle
lamella transection and orbicularis denervation for fat removal;
however, it does not necessarily mean that one can avoid canthal
support procedures. Patients who are morphologically prone to
lower lid malposition still require canthal support procedures in
addition to the pinch lower lid blepharoplasty. If lower lid laxity
was present, determined by lower lid distraction greater than 7 to
8 mm or a prolonged snap test was present, canthopexy or
canthoplasty was also performed (Fig. 6). If orbital festoons
were present, orbicularis suspension was done (Fig. 7). Addi-
tional indications for lower lid support procedures included
patients with preoperative scleral show, patients with negative
vectors or malar hypoplasia,5 prominent globes, Graves’ oph-
thalmopathy, shallow orbits, and unilateral high myopia.6 Intra-
operatively, the rare patients who showed mild bowing of the
lower lid at the end of the procedure received a temporary
tarsorrhaphy stitch for 3 to 5 days.
We found that the average amount of skin removed with
this technique is significantly more than classically described; 8
to 10 mm was routinely excised without problem. This large
© 2008 Lippincott Williams & Wilkins
Pinch Blepharoplasty
quantity of skin removal may be due to absence of undermining,
or the manner in which the skin was measured. Excised skin was
placed on a flat surface ex vivo, unfurled, and measured with a
ruler. When unfurled in this manner, the skin quantity may
appear larger than in vivo on the lid itself.
The addition of laser resurfacing to significant pinch skin
removal did not result in increased incidence of lower lid
malposition (5.6% in this series). We also found that the post-
operative recovery was shorter and more tolerable for patients.
In general, patients were able to return to work within a week, or
earlier if no laser resurfacing was performed (most patients did
not want to return to work until the Flexan dressing and sutures
were removed). Patients had significantly less periorbital bruis-
ing, swelling, and there were no cases of temporary lid retraction
with early healing.
We have found the pinch lower lid blepharoplasty to be an
exceptionally safe and reliable method for lower lid rejuvena-
tion. Pinch blepharoplasty has become our preferred method for
lower lid skin excision. We believe that it has a benefit over
other skin removal techniques in that it allows laser skin resur-
facing due to the absence of skin undermining, and an intact
orbicularis muscle and middle lamella gives more predictable
recovery and results.
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3. Carraway JH, Mellow CG. The prevention and treatment of lower lid
ectropion following blepharoplasty. Plast Reconstr Surg. 1990;85:971–981.
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Evolution of the lateral canthoplasty: techniques and indications. Plast
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6. Lisman RD, Rees T, Baker D, Smith B. Experience with tarsal
suspension as a factor in lower lid blepharoplasty. Plast Reconstr
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