Described more than half a century ago, transcutaneous lower blepharoplasty is fraught with potential problems that can be almost entirely avoided by employing the less invasive transconjunctival approach with or without skin pinch and resurfacing. Disadvantages include:
1. Lower Eyelid Retraction Now
Because of anatomical disruption related to a long dissection, internal scarring of skin, muscle, and orbital septum can be extensive. If contracture ensues, the eyelid may be pulled downward, become rounded, and the white of the eye may become exposed.
2. Lower Eyelid Retraction Later
Since a plane of scar is created in the normally flexible interior of the eyelid and the orbicularis muscle is weakened by cutting through it, retraction may first appear or, if already present, worsen with advancing age as the lid's support system loses some of its natural strength and a descending middle face transmits more force than the lid can handle.
3. Scar Extending Most of the Way Across the Lid
Since a skin incision must be made across the length of the eyelid, an external scar is created, even if only fat needs to be removed. While it eventually fades to white, a slightly pink color may remain for months or sometimes even permanently if the scar has been placed under prolonged tension from lid retraction.
4. Damage to the Orbicularis Muscle and Orbital Septum
For the surgeon to get from the skin surface to the deeper orbital fat requires cutting through assorted eyelid layers located in between, including the orbital septum, a supporting element, and the orbicularis muscle, the eye's closing muscle. Normal tissue is thus converted to scar and function may be compromised.
5. Interference with Closure and the Proper Handling of Tears
If the orbicularis muscle is weakened significantly, the eyelid's position relative to the eyeball may be altered and its closing and pumping function compromised. If eyelid retraction occurs as well, these problems can be aggravated to a point that the health of the eye's surface is threatened.
6. More Bruising and Swelling
The more invasive a procedure, the more bruising and swelling. Healing times can be long, especially if even mild retraction develops.
7. Surgical Look
The long scar, the slightly weakened muscle, and the plane of scar tissue extending throughout the lid's interior can all conspire to make a patient appear "done," even if there are no complications.
Even if coupled with so-called "protective" measures at the lateral canthus, the occurrence of short and long-term functional and aesthetic problems after transcutaneous blepharoplasty is not significantly reduced. In almost all cases, then, it seems safer to consider the transconjunctival approach to remove excess orbital fat and a second skin-only incision to remove excess skin (if needed), thus leaving the eyelid's internal anatomy intact as much as possible.
The main advantages of transcutaneous lower blepharoplasty include:
(No, this is not a glitch.)
Though still in wide use, employing a skin incision to enter the interior of the lower eyelid to remove orbital fat for cosmetic purposes is a procedure that more than a few eyelid specialists strive to avoid.