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? . . .