Fat removal or repositioning in the lower eyelid may be accomplished via either of two basic approaches to the lid's interior -- a hidden incision made along the inside surface of the eyelid (transconjunctival blepharoplasty) or an external incision placed just below the lashes (transcutaneous blepharoplasty). Also known as "posterior approach lower blepharoplasty," the primary goal of transconjunctival surgery is to allow thinning or relocation of bulging lower fat without damaging the eyelid's skin and closing muscle.
While transconjunctival fat removal in the upper eyelid has also been described, the operation is seldom employed.
|Before & After Photos
As illustrated in Eyelid Anatomy, the "conjunctiva" is the thin membrane of tissue that lines the back of the eyelid and then reflects onto the front surface of the eyeball to cover the white of the eye ("sclera").
Compared with other surgery on the lower eyelid, transconjunctival blepharoplasty is less invasive. Most commonly, local anesthesia with oral or intravenous sedation is employed.
The lower eyelid is gently pulled down and away from the eyeball using a blunt retractor, while the eyeball surface is protected with a plastic plate. An electric cautery or surgical blade is used to sweep across the conjunctiva (back side of the eyelid) along most of its length near its junction with the eyeball. The orbital fat presents itself through this incision almost immediately. The incision may be enlarged using scissors, and the three internal fat pockets individually teased out of their capsules and into the surgical field.
Most commonly, clearly excess fat is 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 enhancing the operation's 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.
Transconjunctival blepharoplasty 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 (Arcus marginalis fat repositioning). Because of the risk of orbital hollowing, we no longer favor this procedure.
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 second operations in patients who have undergone previous lower eyelid surgery
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.
PROS AND CONS
Review a more detailed discussion of transconjunctival blepharoplasty pros and cons >
CARE AND RECOVERY
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.
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 to recommend transconjunctival blepharoplasty with or without skin pinch or chemical peel as our procedure of choice.