Study Maps Lower Eyelid Asymmetry to Midfacial Skeletal Differences
Key Takeaways
- A prospective study of 267 patients undergoing primary lower blepharoplasty classified lower eyelid asymmetry into 3 major morphologic types and 5 subtypes.
- The left inferior orbital rim was positioned more posteriorly than the right in 96% of patients, indicating that clinically visible eyelid asymmetry frequently accompanied underlying skeletal differences.
- An algorithm using sub-orbicularis oculi fat (SOOF) advancement and orbicularis oculi muscle suspension was associated with satisfactory correction in 94% of patients.
Lower eyelid asymmetry may reflect underlying differences in midfacial skeletal anatomy that warrant assessment before primary lower blepharoplasty, according to a prospective study published in Plastic and Reconstructive Surgery – Global Open.
Kenneth K. Kim and Jin Suk Byun proposed a morphologic classification and corresponding surgical algorithm based on palpebro-malar groove width, anterior-posterior displacement of the inferior orbital rim, and lower eyelid vertical length.
Classification Links Lower Eyelid Asymmetry With Midfacial Anatomy
The investigators prospectively evaluated 267 patients who underwent primary lower blepharoplasty from June 2023 through May 2025. The cohort had a mean age of 56.8 years and included 227 women and 40 men.
Patients were divided into 3 major types and 5 subtypes, with surgical techniques customized according to morphologic classification. The approach incorporated sub-orbicularis oculi fat (SOOF) advancement and orbicularis oculi muscle suspension. Outcomes were evaluated using standardized clinical photography, independent assessment, and patient-reported satisfaction.
Of the 267 patients, 127 (48%) had type I, or mild, asymmetry; 134 (50%) had type II, or severe, asymmetry; and 6 (2%) had type III, characterized as right-side dominant. The left inferior orbital rim was positioned more posteriorly than the right in 259 patients (96%). The left palpebro-malar groove was wider in 38% of patients, compared with 2% who had a wider right groove.
Following surgery, 251 patients (94%) reported satisfactory correction, while 16 (6%) were partially satisfied, primarily because of inadequate lateral SOOF advancement. Independent evaluators also identified symmetry in 251 cases.
“Lower eyelid asymmetry reflects underlying midfacial skeletal discrepancies between the maxilla and zygoma,” the authors concluded. “The proposed classification facilitates preoperative assessment and surgical planning. Algorithm-based SOOF advancement and orbicularis oculi muscle suspension were associated with improvement in lower eyelid symmetry in most patients.”