title: Decreasing complications in lower lid and midface rejuvenation: the importance of orbital morphology, horizontal lower lid laxity, history of previous surgery, and minimizing trauma to the orbital septum: a critical review of 269 consecutive cases.
abstract: BACKGROUND
  Minimizing complications following surgical rejuvenation of the lower lid and midface continues to challenge plastic surgeons. The evolution of refinements of the authors' technique designed to identify high-risk patients and minimize morbidity is described.
  
  
  METHODS
  The records of 269 patients having consecutive transorbital, endoscope-assisted lower lid and midface rejuvenation were reviewed and complications identified. High-risk patients were defined based on orbital morphology, degree of horizontal lower lid laxity, and history of previous lower lid or midface surgery.
  
  
  RESULTS
  The authors found that patients with enophthalmic orbits and significant horizontal lower lid laxity were at increased risk of postoperative lower lid malposition. They found that identifying these patients preoperatively, combined with intraoperative correction of laxity when indicated, minimized the risk. They also confirmed that patients with a previous history of lower lid manipulation were at increased risk.
  
  
  CONCLUSIONS
  Minimizing trauma to the orbital septum of the lower lid and correction of horizontal lower lid laxity when present are effective techniques in lowering the risk of postoperative lower lid complications. Trauma is minimized by eliminating dissection in the plane between the orbicularis muscle and orbital septum. The passive septal tightening that occurs with this technique combined with fat micrographs to the tear trough and over the inferior orbital rim has rendered more traumatic open surgical manipulation of the septum or postseptal fat almost universally unnecessary.
authors.affiliation: Atlanta, Ga. From Paces Plastic Surgery.
authors.forename: T Roderick
authors.initials: TR
authors.lastname: Hester
authors.forename: Trent
authors.initials: T
authors.lastname: Douglas
authors.forename: Steven
authors.initials: S
authors.lastname: Szczerba