PREMIUM ARTICLE PREVIEW
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 (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").
• Anesthesia: Local anesthesia with oral or intravenous sedation
• 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
• 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 . . .