Fat removal in the lower eyelid may be accomplished via either of two basic blepharoplasty approaches -- an incision made along the inside surface of the eyelid (tranconjunctival) or a skin incision placed just below the lashes (transcutaneous):
• Other names: Posterior approach lower blepharoplasty
• Primary goal: Removal of bulging lower fat without a skin incision
|Young Female Before & After
Transconjunctival Fat Thinning
• Special anatomy: As noted in Chapter 4: Eyelid Anatomy. The "conjunctiva" is the thin clear membrane of tissue that lines the back of the eyelid and then reflects onto the front surface of the eyeball to cover the sclera (the "white").
• Blepharoplasty anesthesia: Local anesthesia with oral or intravenous sedation
• Sample operative technique: The lower eyelid is gently pulled away from the eyeball using a blunt retractor, while the eyeball is protected with a plastic plate. An electrocautery is used to sweep across the conjunctiva (back side of the eyelid) along most of its length near its junction with the eyeball. The eyelid fat presents itself through the incision almost immediately. The incision may be enlarged using scissors, and the three fat pockets individually teased out of their capsules and into the surgical field. Most commonly, clearly excess fat is then clamped, excised, and cauterized in a conservative piecemeal fashion from each pocket. The surgeon may stop at any time, return the eyelid to its normal position, and evaluate the result in progress, thus allowing for excellent precision. At the conclusion of the procedure, the surgeon may choose to close the wound with one or two dissolving sutures, but more commonly no stitches are used. Step-by-Step Photos
• Blepharoplasty variations: The surgery may be accomplished with the laser or any other cutting tool. An optional "skin pinch" excision may be added (see below), and, if indicated, the supporting orbicularis muscle and canthal tendon may be tightened through this same skin incision.
Alternatively, fat may be reflected over the rim of bone to fill in slight depressions on the upper cheek (see Chapter 20: Fat Repositioning). Because of the risk of orbital hollowing, we no longer favor this procedure.
• Advantages: The advantages of the transconjunctival approach to lower blepharoplasty include:
• no external scar
• less invasive to the middle layers of the eyelid
• less chance of lower eyelid ectropion (lower eyelid pulled away from eye)
• more precise fat sculpting
• less bruising and swelling
• safer for reoperations in patients who have had previous lid surgery
• Limitations: One big question to ask about lower blepharoplasty is obvious: if only the fat is addressed, what happens to the skin? In patients with minimal or no excessive skin (the majority), the skin and muscle layers previously extended out over the bulges simply returns to a more normal position with little or no evidence of redundancy or wrinkling. In patients with more significant skin excess or festoons (skin pouches), a strip of skin just below the lashes can be pinched and excised ("skin pinch blepharoplasty", with or without canthopexy) or the skin can be tightened very slightly using chemical peel - laser resurfacing over the lower eyelid and upper cheek.
A reasonable expectation for lower eyelid blepharoplasty is that you will obtain about a 70-80% improvement.
• Care and recovery: As noted in Section Four. In general, bruising and swelling are less than with other types of eyelid surgery, and recovery is rapid. A small amount of residual swelling, however, will persist for some months and resolve very gradually.
• Risks and complications: As noted in Blepharoplasty Risks. In addition, there is a risk of temporary conjunctival swelling ("chemosis"), which can make the thin membrane of tissue over the white of the eye look slightly blistery for several weeks. As with any form of blepharoplasty based upon fat removal, the eyelid may become hollowed.
• Comments: The introduction of transconjunctival blepharoplasty twenty years ago represented a major stride forward in the field of eyelid surgery. The procedure remains technically more difficult for the "occasional blepharoplasty surgeon" and even today is not embraced by all cosmetic surgeons, some of whom still routinely use the much older skin approach to remove orbital fat.
Newer tissue-sparing techniques allow bulging fat to be returned to the orbit without removal, thus reducing the chance of immediate or late-term hollowness. Until tissue-sparing techniques have been studied more thoroughly, however, many surgeons continue to recommend transconjunctival lower blepharoplasty with or without skin pinch or chemical peel as their procedures of choice.