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Facial paralysis denervates the orbicularis oculi muscle with important functional and cosmetic deficits. When an intact neural circuit between the brainstem and orbicularis oculi cannot be reestablished, nerve transfer techniques are often utilized. The hypoglossal nerve has been the favored donor nerve for the past 40 years. The past 5 years has witnessed an increased interest in using the masseteric nerve due to its lower incidence of donor deficit and excellent static and dynamic results. We describe the surgical technique for end-to-end masseteric to facial nerve transfer and summarize the published results.

The globe retropulsion and eyelid depression (GRED) technique is described. This involves simultaneous unimanual lower lid depression and globe retropulsion (over the closed upper lid) with two fingers of one hand. The maneuver reliably promotes direct entry to the clearly delineated post-septal fat compartment, obviates the need for an assistant to create this exposure, and does not obscure the globe or lower lid from view.

Endoscopic browlifting techniques have been progressively refined through experience and improvements in equipment. In general, the temporal dissection and temporal fixation have been standardized; however, different options for forehead dissection are available. Subperiosteal dissection with release (elevation, incision, and spread) of the periosteum, or subgaleal dissection and release of brow depressor musculature to the supraorbital rim are both effective techniques used in endoscopic browlifts. Methods of bony fixation remain a controversial topic since there are numerous methods. Some of these methods include absorbable and nonabsorbable screws, bone tunnels with sutures, fixation to soft tissue using absorbable attachment devices such as Endotine or Ultratine (MicroAire, Charlottesville, VA), and fibrin glue. In many, particularly younger patients, we advocate deep temporal fixation only (DTFO) without bone fixation.

The title of this chapter is descriptive in that it reviews a posterior eyelid (conjunctival) approach to cosmetic rejuvenation of the lower eyelid. The designation of the procedure as transconjunctival is important in that it differentiates surgery from the more traditional transcutaneous (through the skin) approach. Transconjunctival blepharoplasty has become the most common approach to cosmetic lower lid surgery over the last decade.1 Since I have been in practice, I have only rarely performed transcutaneous lower blepharoplasty, and not at all in the last 7 years. This is because, in my critical evaluation of this surgery and in my hands, the posterior eyelid approach yields excellent results, with high patient satisfaction and fewer complications.