Purpose

The deep plane facelift has gained attention for more durable and natural results compared to skin-only techniques. Traditional lower blepharoplasty emphasizes fat repositioning—often transconjunctival—and skin resection via skin pinch. These approaches have 15-20% eyelid retraction rates and limited durability. We describe a deep plane trans-eyelid midface lift technique, highlighting conceptual parallels to deep plane facelifting and evaluating aesthetic outcomes, durability, and safety.

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Methods

A large retrospective 15-year series of deep plane trans-eyelid midface lift for aesthetic concerns at two centers. Outcomes included aesthetic measures and functional results. Surgical Technique: A subciliary lower eyelid incision was made, with release of arcus marginalis and orbitomalar ligament to mobilize the midface. Prolapsed orbital fat was redraped. A composite deep plane flap from skin to periosteum was developed, with the edge of orbicularis secured to lateral rim periosteum. Some redundant skin from the underlying muscle flap is resected past the lateral canthus, with minimal or no subciliary skin excision.

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Results

A total of 983 patients were included: 69% female, age 71.4 ± 9.4 years. Improvements were consistently observed in tear trough deformity, lower eyelid position, midface descent, and skin elasticity. Overall revision rate was 7.3%, mostly for minor lateral scar revision, trichiasis, cysts, or granulomas (4.4%). Revision for lower lid retraction was rare (0.55%) via lateral tarsoconjunctival suspension flap. Repeat surgery for cosmetic indications occurred in 2% of cases.

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Conclusion

Skin-sparing deep plane lower eyelid blepharoplasty and midface lift was safe and durable with favorable aesthetic and functional outcomes and low complication rates in this large series. Postoperative retraction rates were lower than skin-pinch blepharoplasty. By elevating and suspending a composite midface flap, this technique shares key principles with deep plane facelift and may similarly enhance eyelid aesthetics, safety, and durability.

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Additional Authors

First name	Last name	Base Hospital / Institution
Emily	Tom	Gavin Herbert Eye Institute, University of California, Irvine
Roberto	Limongi	Universidade Federal de Goiás
Jeremiah	Tao	Gavin Herbert Eye Institute, University of California, Irvine

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