title: Endoscopic management of the difficult lower eyelid:  a review of 300 cases.
abstract: BACKGROUND
  The senior author's (H.S.B.) endoscopic brow and midface lift technique has a series of periorbital suture points. This study evaluated the efficacy of endoscopic treatment of the difficult lower eyelid and identifies the preoperative predictive patterns for additional suture placement and ancillary procedures within this population.
  
  
  METHODS
  Patients who underwent endoscopic brow and midface lift performed by the senior author were stratified into categories of preoperative lower eyelid morphologies, including lower eyelid retraction, negative canthal tilt, negative vector orbit, exorbitism, and a deep tear trough. Intraoperative treatment and postoperative course were recorded and postoperative photographs were evaluated objectively. The data were analyzed to determine preoperative predictive patterns of endoscopic lower eyelid treatment.
  
  
  RESULTS
  Three hundred patients who underwent an endoscopic brow and midface lift between 1999 and 2008 were included in the study, with an average follow-up of 1 year. Most patients were treated with endoscopic orbicularis oculi repositioning combined with midface elevation. Additional suture points were used in 12 percent, with preexisting scleral show being the most common indication for additional endoscopic suture placement. There were no cases of postoperative lower eyelid retraction. Skin resurfacing and volumetric filling were the most common revision procedures.
  
  
  CONCLUSIONS
  The difficult lower eyelid can be treated effectively with endoscopic orbicularis repositioning and midface elevation. This technique preserves the innervation and continuity of the orbicularis oculi muscle, decreasing postoperative complications. Additional suture application is needed in only a minority of patients, and ancillary lower eyelid procedures can be performed safely in the same operative setting.
authors.affiliation: Dallas, Texas From the Department of Plastic Surgery, University of Texas Southwestern Medical Center.
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Trussler
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Schaub
authors.forename: H Steve
authors.initials: HS
authors.lastname: Byrd
mesh_terms: D000328:Adult; D000368:Aged; D019882:Blepharoplasty / Q000379:methods*; D004724:Endoscopy / Q000379:methods*; D005143:Eyelids / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D058629:Plasma Skin Regeneration; D012189:Retrospective Studies; D013536:Suture Techniques; D016896:Treatment Outcome