eMedicine Specialties > Plastic Surgery > Eyelids

Blepharoplasty, Lower Lid Transconjunctival

Author: D Glynn Bolitho, MD, PhD, FACS, FRCSC, FCS(SA), Associate Clinical Professor, Department of Plastic Surgery, University of California at San Diego; Private Practice, LaJolla, California
Coauthor(s): Foad Nahai, MD, Professor, Department of Surgery, Emory University
Contributor Information and Disclosures

Updated: Oct 3, 2006

Introduction

The transconjunctival blepharoplasty is receiving increasing attention as an alternate technique to traditional transcutaneous blepharoplasty. Many of the lower lid malpositions appear to be obviated by the use of this technique (Silkiss, 1992; Zarem, 1993). Transcutaneous blepharoplasty has been associated with the round eye appearance, inferior scleral show, and frank ectropion, which is the invariable consequence of overgenerous skin resection.

More conservative skin resection obviates some of these complications, particularly when a lower lid tightening procedure is added. These techniques include wedge excision, lateral canthoplasty or canthopexy, and periosteal flap fixation based on the lateral orbital margin. Transconjunctival blepharoplasty has been advocated to limit the incidence of these complications, particularly in patients with minimal skin laxity or predominant fat herniation who otherwise would not require skin excision.

This article reports the authors' experience with consecutive transconjunctival blepharoplasty performed by the senior author (FN) and compares the results with those achieved using conventional transcutaneous blepharoplasty techniques. A total of 177 patients were operated on over a 34-month period with a mean follow-up time of 2.4 months (range 1-18 mo). This experience suggests that the transconjunctival approach is a safe, effective procedure with minimal complications and is useful in the younger patient with isolated fat excess as well as in the older patient with manifestations of mild-to-moderate skin redundancy.

History of the Procedure

This technique has been practiced in Europe for almost 70 years. The first description by Bourget in 1928 was followed by the account of Tessier in 1973 of this approach for blepharoplasty, trauma, and congenital deformities. Isolated reports of this technique for blepharoplasty began appearing in the North American literature during the 1970s and early 1980s (Tomlinson, 1975; Baylis, 1989) but the landmark contribution by Zarem and Resnick (1991) propelled this procedure into more widespread acceptance.

Although earlier studies focused on the young patient with isolated fat excess, these authors expanded the indications to include older patients with some degree of cutaneous redundancy. They reported excellent results and a reduced incidence of postoperative lower lid complications. The authors' experience with this technique has been highly favorable, with fewer complications and less apparent morbidity than with the transcutaneous approach.

Presentation

History and physical examination

Preoperative evaluation includes a thorough history and physical examination. Identify herniated fat pads and note the degree of skin laxity. Carefully assess lower lid tone in all patients. Test visual acuity and perform an unanesthetized Schirmer test in selected patients. As several authors have observed, fat pad herniation is best tested with the patient's eyes in an upward gaze (Soll, 1993). Evaluate lower lid laxity by elevating the central lid with the examining forefinger or thumb and by testing lid return using the lower lid snap test. A lax lower lid may be an indication for lateral canthopexy or wedge excision in some patients.

Indications

Although initial reports focused on the young patient with isolated fat herniation, the indications have been broadened somewhat to include patients with modest skin laxity (Zarem, 1991). Further experience with this technique has resulted in expansion of the indications for its use. Transconjunctival blepharoplasty has been recognized as useful in patients with fat excess and fine skin wrinkling and in those with apparent skin and fat excess in whom fat excision alone allows for redraping of the lower lid skin into an acceptable contour with elimination of the skin laxity.

Lower lid blepharoplasty does not eradicate fine skin wrinkling regardless of which technique is used. This issue is better addressed with either chemical peels or laser resurfacing. Use of transconjunctival upper blepharoplasty may be reserved for the patient with a high tarsal crease with no central or lateral fat pad herniation and minimally redundant upper eyelid skin and for patients who present with residual fullness of the upper eyelid following prior blepharoplasty.

Relevant Anatomy

Inferior periorbital fat is contained posteriorly by the capsulopalpebral fascia and overlying conjunctiva of the posterior fornix (see Image 1). The capsulopalpebral fascia fuses superiorly with the inferior tarsal muscle, which inserts into the lower border of the tarsal plate. Anteriorly, the fat is bounded by the orbital septum, which separates it from the overlying orbicularis oculi muscle and lower lid skin.

Transconjunctival blepharoplasty permits access to the orbital fat by an incision through the inferior fornical conjunctiva and capsulopalpebral fascia without any disruption of the skin and muscle of the lower lid. This results in a reduction in the risk of ectropion and round eye syndrome, which may complicate the transcutaneous approach.

The inferior oblique muscle is an important anatomic landmark. It arises from the anteromedial portion of the orbital floor and passes posterolaterally, separating the medial and central fat compartments during its course. The lateral and central fat compartments are separated by the arcuate expansion of the inferior oblique muscle. This diaphanous structure inserts into the orbital rim anterolaterally.

The upper lid classically is divided into an anterior (skin and orbicularis) and a posterior (tarsus and conjunctiva) lamella. The supratarsal fold results from a fusion of levator aponeurosis, orbital septum, and fascia on the deep surface of the orbicularis muscle. The fused layer acts as a sling for the periorbital fat and is higher medially than laterally. In an attempt to divide the orbital septum medially in a conventional blepharoplasty, this fused layer may be damaged inadvertently.

Generally, the presence of either 2 or 3 upper lid fat pads is accepted (Januskiewicz, 1999). The medial fat pad is typically pale yellow or white and lies medial to the levator aponeurosis at the root of the nose. It has a greater connective tissue component and is innervated by the supratrochlear nerve. The middle and lateral fat pads lie on the levator and are a rich butter yellow color. They are innervated by the supraorbital nerve.

Contraindications

Contraindications for those procedure include patients with significant lower eyelid skin laxity, patients with overt festoon formation, and those who are elderly.

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