blepharoplasty guide

Insider's Guide to

Chapter 17

Lower Eyelid Fat Removal:
Transconjunctival and Transcutaneous Blepharoplasty


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):

Transconjunctival Lower Blepharoplasty

Other names: Posterior approach lower blepharoplasty

Primary goal: Removal of bulging fat

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, we no longer favor this procedure.

Advantages: The advantages of the transconjunctival approach 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 this operation 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 Eyelid Surgery 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, we continue tol recommend transconjunctival blepharoplasty with or without skin pinch or chemical peel as our procedure of choice.

Transcutaneous Lower Eyelid Blepharoplasty

Note: While still in wide use elsewhere, Dr. Meronk has not offered this procedure for over a decade.

Other names: Anterior approach lower blepharoplasty, skin approach lower blepharoplasty

Primary goal: Removal of excess skin, orbicularis muscle, and fat

Secondary goals: May be combined with adjunctive procedures described in subsequent chapters, particularly lateral canthal reinforcement and SOOF lift.

Anesthesia: Local anesthesia with oral or intravenous sedation

Operative technique: 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. Step-by-step photos

Variations: 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 (surgery photos). 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).

Advantages: 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).

Limitations: There are many problems with this operation, as discussed below and in Chapter 30: Lower Blepharoplasty Complications. Its "fatal flaw" is its overly invasive nature that creates a sheet of 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.

Care and recovery: As noted in Section Four

Risks and complications: As in Chapter 28: 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.

• Comments: "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 LASIK.

Next: Tissue-sparing
lower blepharoplasty


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