The goals of lower eyelid blepharoplasty are to correct the characteristic signs of aging that occur in the periorbital region, including excess eyelid skin, lid laxity, and orbital fat malposition. In general, two basic blepharoplasty approaches exist—the transcutaneous and transconjunctival approaches. This activity discusses the nuances of the transconjunctival lower lid blepharoplasty approach, an effective and reliable technique ideal for patients with pseudoherniated orbital fat and good skin elasticity. The modern-day aesthetic surgeon must understand the indications, preoperative considerations, operative techniques, and complications associated with transconjunctival lower lid blepharoplasty to maximize outcomes and improve patient satisfaction.
The transconjunctival lower lid blepharoplasty approach is best suited for the patient with steatoblepharon with minimal to moderate lower eyelid laxity. Fat repositioning can also address a prominent tear trough deformity. While modern-day periorbital rejuvenation principles emphasize orbital fat preservation during blepharoplasty (with either fat repositioning or augmentation); nevertheless, fat resection may be suitable for patients with steatoblepharon and no tear trough deformity.
Other indications for a transconjunctival approach include patients with a history of hypertrophic scarring, history of blepharoplasty, or a pre-existing pseudoproptosis (at risk for lower eyelid retraction and further scleral show).
Photographic views should be obtained using a 5-view head series with the patient in a seated and upright position with no facial animation. There should be documentation with close-up views of the eyes (closed/open/upward gaze/lateral gaze).
The infraorbital fat pads, tear trough, and site of the infraorbital nerve are marked. If a performing a concomitant skin pinch, this can be marked out with a conservative (2 to 3 mm) skin pinch along the subciliary margin.
Although the transconjunctival blepharoplasty may be performed entirely under local anesthesia, nevertheless general anesthesia or intravenous (IV) techniques are advisable to ensure patient comfort.
A single dose of intravenous antibiotics should be administered before the start of the procedure.
Local anesthesia should infiltrate along the inferior orbital rim, tear trough, and conjunctiva.
Eye shields can are an option per surgeon preference.
First, the surgeon incises the lower conjunctiva. If a pre-septal approach is utilized, the conjunctival incision is made 4 mm inferior to the tarsus with dissection proceeding anterior to the septum. Alternatively, a post-septal approach requires an incision made 6 to 7.5 mm inferior to the tarsus, with dissection following posterior to the orbital septum (middle lamella). Although the theoretical benefit to the post-septal approach is the preservation of the orbital septum, either approach may be used as they both posess similar risk profiles.
In order to protect the cornea and maximize exposure of the fat pads, the posterior conjunctival flap is secured cephalad with a traction suture, while the anterior edge of the divided conjunctiva is retracted caudally using a small retractor.
Before dissecting the orbital fat, a subperiosteal pocket for fat transposition is created by making a periosteal incision through the arcus marginalis just below the inferior orbital. An elevator is used to raise the periosteum over the upper maxilla for approximately 15 mm, with care not to injure the infraorbital nerve. Depending on the extent of fat repositioning, dissection may be carried laterally to release the orbital retaining ligament. As an alternative to the subperiosteal technique, a supraperiosteal pocket may be used for fat repositioning; both have similar clinical outcomes and high patient satisfaction.
The orbital fat is then dissected. If a pre-septal approach was used, the inferior edge of the septum is incised to expose the medial and central fat pads. The extruded fat is then carefully dissected and made into a pedicle with care to prevent devascularization and to avoid injury to the inferior oblique muscle.
Transposition of the orbital fat into the subperiosteal or subperiosteal pocket is done with a series of transcutaneous horizontal mattress retention sutures placed beyond the marked tear trough. The suture is then secured using a bolster or fixed in place using adhesive tape.
The conjunctival incision may be left to heal secondarily or closed loosely with buried 6-0 fast-absorbable gut sutures.
A major advantage of the transconjunctival approach compared to the transcutaneous approach is the decreased incidence of complications, namely lid malposition, and external scarring. Nevertheless, the blepharoplasty surgeon must possess a thorough knowledge of the potential complications of the transconjunctival lower lid approach.
A transconjunctival lower lid blepharoplasty aims to restore a more youthful and rested appearance to the periorbita with removal or relocation of pseudoherniated fat. When performing a transconjunctival blepharoplasty, proper patient evaluation, and development of a thorough, anatomic-based treatment plan can produce safe, reliable, and satisfactory outcomes.
It remains imperative to identify the risk factors and perform a thorough assessment of the patient before transconjunctival blepharoplasty. A team approach is an ideal way to limit the complications of this procedure. Before surgery, the patient should have the following done:
an interprofessional team of an experienced surgeon, anesthesiologist, and surgical assistants and operative nurses should perform the transconjunctival blepharoplasty for the best outcomes. Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the post-operative care of transconjunctival blepharoplasty should monitor the patient for possible complications, including any visual deficits. It is also critical to counsel the patient on avoiding strenuous activity, heavy lifting, or bending over during the first several days post-operatively to prevent such complications. This type of interprofessional team approach will lead to optimal patient outcomes in transconjunctival blepharoplasty cases. [Level 5]
Adequate pain medication is given, as patients often report mild peri-incisional pain for 1-2 days post-operatively. In order to minimize edema and ecchymosis, the patient should place ice packs around the eyes intermittently for the first 24 hours, sleep with the head elevated for 1 week, and avoid rigorous activity for 2 weeks. A low dose corticosteroid taper may help lessen bruising and swelling as well. Patients are asked to return at 1 week for wound assessment with or without suture removal. Photographic documentation should occur at around 6 months postoperatively.
Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the post-operative care of transconjunctival blepharoplasty, should monitor the patient for possible complications including acute visual disturbances.
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