Fat removal in the lower eyelid may be accomplished via either of two basic approaches -- an incision made along the inside surface of the eyelid (transconjunctival) or an incision placed through the skin just below the lashes (transcutaneous):
Transcutaneous lower blepharoplasty is also known as the anterior approach, skin approach, subciliary approach, and skin flap blepharoplasty
|Before and After Transcutaneous Lower
Blepharoplasty with Canthoplasty
(with upper blepharoplasty)
Removal of excess skin, orbicularis muscle, and/or fat
Local anesthesia with oral or intravenous sedation is generally sufficient, although some surgeons prefer general anesthesia.
The skin is incised just below the eyelid margin along its full length and slightly beyond into the lateral canthus.
The exposed orbicularis muscle is incised along its length in a similar fashion. A skin-muscle "flap" is lifted off of the underlying orbital septum using blunt dissection with cotton-tipped applicators and sharp dissection with scissors. The skin-muscle flap dissection extends downward over the entire lower eyelid to a level approximately even with the orbital bony rim. The orbital septum is incised to expose the three fat pockets of the lower eyelid. Excess fat is teased free and clamped. The fat is removed with scissors, and each "stump" is cauterized before allowing it to retract back into the orbit. The patient is asked to open his or her mouth and look upward towards the forehead while the surgeon drapes the skin-muscle flap over the initial incision to determine the amount of "extra" tissue (generally, only a small amount). Any excess tissue is trimmed. The skin edges are closed using sutures.
Transcutaneous blepharoplasty surgery photos step-by-step >
Many variations have been suggested, most of which have to do with placement of incisions or level of penetration from one tissue layer to the next. While all such adaptations are attempts to overcome the basic insufficiency of this operation (extensive internal disruption of the eyelid, which is, in effect, filleted), none, in our opinion, make any sort of startling difference. If the orbicularis muscle is "hypertrophic" (and bunches into a "roll" just below the lashes when smiling), a thin strip of extra muscle may be removed. In patients with markedly excessive skin, only a skin flap may be dissected (rather than skin-muscle), and the orbicularis muscle then entered lower down near the bone (which allows for more skin relative to muscle to be removed when the flap is trimmed).
In addition to fat removal or repositioning, excess skin and orbicularis muscle may be removed (which is not possible in transconjunctival blepharoplasty without making a second skin incision). Doing so, however, adds substantial risk.
There are many problems with this operation, as discussed below and in Lower Blepharoplasty Complications. Its "fatal flaw" is its overly invasive nature that creates a band of skin/muscle/orbital septum scar tissue inside of the lid that almost always alters the shape of the eyelid opening. Accompanied by "reinforcement" procedures at the lateral canthus (canthopexy), this operation has remained popular with some practitioners, although we disagree that canthopexy is protective over the long-term.
Risks and complications
As discussed in Eyelid Surgery Risks and Complications, the risk of eyelid malposition (retraction, ectropion) following lower blepharoplasty undertaken from a skin approach is substantial, while the similar risk with transconjunctival eyelid surgery is much less. More bruising, more swelling, and slower healing are to be expected. Uncommonly, eyelashes may be lost.
Pros and Cons
For a more complete discussion of transcutaneous blepharoplasty pros and cons >
Before and After Photos
Patient before and after blepharoplasty photos >
"Pure" transcutaneous lower blepharoplasty (that is, without adjunctive procedures such as lateral canthal reinforcement or midface resuspension) has been called a "discredited operation" and has, in our opinion, seen its day. Even when well-performed and accompanied by other procedures, this operation not infrequently results in an unnatural "surgical look." If complicated by lid retraction, the abnormal exposure and poor closure can cause major eye problems for those with ocular disease, dry eyes, contact lenses, or refractive eye surgery.