Lower Lid Transconjunctival Blepharoplasty Treatment & Management
- Author: Christian N Kirman, MD; Chief Editor: James Neal Long, MD, FACS more...
Transconjunctival blepharoplasty is easily performed with local or general anesthesia. When performed as an isolated procedure, local anesthesia is often preferred with or without intravenous sedation. This can be performed in an office operating room setting.
The conjunctiva and cornea are anesthetized with 2 drops of 0.5% tetracaine hydrochloride ophthalmic solution instilled into the lower fornix of each eye. This is followed with a transconjunctival injection of local anesthetic solution (consisting of 0.5% lidocaine with 1:200,000 epinephrine containing 150 U hyaluronidase additive) into the lower fornix using a 30-gauge needle. To limit patient discomfort during fat excision, the fat pads should be individually anesthetized, as they are exposed during the dissection.
Many surgeons routinely use corneal protectors. However, stay sutures placed through the medial and lateral conjunctival surfaces of the inferior fornix may be used to retract the inferior conjunctiva superiorly, which protects the cornea and gives wide access to the orbital fat once an incision is made. A small double skin hook or traction suture in the lower lid margin exposes the inferior fornix maximally for safe dissection.
A retrospective study by Undavia et al indicated that in performing lower lid transconjunctival blepharoplasty, postseptal access to the patient’s orbital fat can be optimized by making the conjunctival incision 0.5 mm posterior to the most superior tip of clinically visible fat, using globe retropulsion and lower eyelid inferior displacement to balloon the conjunctiva forward. The study involved 66 patients, with the described incision placement allowing direct access to the postseptal space in 54 of them (82%).
Orbital fat excision
One or 2 incisions in the lower lid conjunctiva are made at least 4 mm below the tarsus, using a Colorado tip monopolar cautery or radiofrequency device. When 2 incisions are made, they should overlap, allowing the preservation of a conjunctival bridge over the inferior oblique muscle in an effort to safeguard this muscle during dissection. The muscle often is visualized clearly in the depths of the wound. Pechter has recently suggested that 3 separate incisions be made to address each of the 3 fat compartments.
Once the orbital fat compartments are entered, gentle pressure on the globe provides a guide to the level of fat resection. Avoiding overresection is important. The quantity of fat resection is more difficult to assess via the transconjunctival approach than with the transcutaneous technique. In the latter approach, the orbital rim provides a useful guide in evaluating the amount of fat to resect; with the transconjunctival approach, this anatomic landmark is not seen as easily.
Hemostasis is assured at the vascular pedicle of each fat pad, with either Colorado tip unipolar cautery or bipolar cautery. The residual fat is returned to its anatomic location, and the conjunctiva is allowed to redrape naturally. No sutures are required to close the inferior conjunctival incisions.
Tear trough correction
Two operative methods of addressing the tear trough deformity have been demonstrated to effectively augment the tear trough, resulting in an improved contour of the area without resecting inferior orbital fat. This is accomplished by redraping or repositioning the orbital fat to augment the tear trough.
The first method is to redrape the nasal and central fat pads individually to augment the tear trough. This is accomplished by making an incision 5 mm below the inferior tarsus through the conjunctiva and the lower eyelid retractors. The nasal and medial fat pads are then identified, with the inferior oblique muscle preserved between the two. The fat pads are then mobilized as pedicles and can then be transposed either in the subperiosteal or the supraperiosteal plane. For subperiosteal redraping, an incision is made through the arcus marginalis below the inferior orbital rim, with the periosteum elevated to redrape the orbital fat pads. In supraperiosteal redraping, the suborbicularis oculi fat (SOOF) is identified and blunt dissection is used to create a pocket for redraping. Absorbable sutures are often used to secure the orbital fat in position.
A retrospective study by Yoo et al indicated that in transconjunctival lower lid blepharoplasty, the ultimate aesthetic results of fat transposition to either the subperiosteal or supraperiosteal plane are comparable. However, the study, which involved 40 patients and had a mean follow-up period of 10 months, did find that supraperiosteal transposition, while faster than the subperiosteal procedure, caused greater trauma, including more bruising and swelling.
An alternative method for repositioning the inferior orbital fat involves a septal reset. A similar incision is made in the inferior conjunctiva along the inferior border of the tarsal plate. The incision is then carried through the capsulopalpebral fascia, which exposes the orbital septum. Dissection is continued anterior to the septum and below the orbicularis oculi to the arcus marginalis. A periosteal incision is then made just below the inferior orbital rim and the periosteum is elevated for septal repositioning. The hooded portion of septum and the underlying orbital fat are then pulled down and secured with sutures to the overlying periosteum.
The patient should keep his or her upper body and head elevated for several days, especially when sleeping, to reduce swelling and bruising around the eye. A gentle compressive bandage is applied to the lower lid postoperatively to keep the lower lid suspended and provide pressure to the lower lid while healing. This should remain in place until inflammation of the lower conjunctiva has disappeared, typically 3-5 days.
The intermittent application of cold compresses (eg, iced saline solution–soaked dressings) to the eyes postoperatively assists with reduction of bruising and swelling. When the patient is at home, cold compresses can be continued for the next 24-48 hours. Artificial tears or gel may be used at night to ease ocular discomfort.
The possibility of complications with any surgical procedure should be thoroughly discussed with the patient prior to surgery when obtaining informed consent. Common complications include swelling, ecchymosis, chemosis, and lagophthalmos.
Retrobulbar hemorrhage is a serious complication that results from uncontrolled bleeding within the orbital fat compartment. This results in severe eye pain of sudden onset and can result in bulging of the eye out of the orbit and a decrease in vision. Any severe eye pain in the postoperative period needs to be evaluated emergently, and the patient's head and upper body should be elevated and blood pressure controlled. The bleeding may have to be controlled operatively, with the blood evacuated and bleeding stopped. This may require hospitalization for surgery and medication administration for swelling and blood pressure control. For more information, see Medscape Reference article Lateral Orbital Canthotomy.
The patient’s face may appear asymmetric postoperatively, which may be due to swelling, bruising, or excess fluid in the tissues around the eye. This may take several weeks to resolve. Surgeons and patients should wait a minimum of 2 months for resolution to occur before making any decision to undergo further corrective surgery.
Chemosis, or inflammation of the conjunctiva, is a rare but aggravating complication of any surgery around the eyelid, especially the lower lid. Treatment is conservative, with the use of lubricating eye drops or ointment. Patients may be given a prescription for steroid medication to reduce the inflammation. If chemosis occurs, any further irritation (eg, allergic irritants, contact lenses) to the conjunctiva should be minimized.
Changes in the shape of the eye aperture, increased scleral show, and changes in the position of the lower lid may still occur; however, these complications have been reported to be reduced with the transconjunctival technique.[18, 19, 14, 4]
Future and Controversies
Several reports of transconjunctival approach to lower lid blepharoplasty attest to its efficacy and safety when performed in carefully selected patients. Although some authors have not demonstrated different complication rates between this and the transcutaneous approach, several recent reports and novel modifications of the technique indicate fewer complications from the transconjunctival blepharoplasty provided patients are selected appropriately. Baylis and colleagues in 1989 reported that this approach certainly has reduced the number of cases of lower lid retraction following lower lid blepharoplasty and has minimized dry eye exposure complications. In addition, this approach produces no external lower lid scarring.
A published study describes a more integrated approach to addressing the specific needs of the patient using a combination of techniques with the lower lid transconjunctival blepharoplasty. Preserving the lower orbital fat pads with a more conservative resection and redraping the fat over the bony infraorbital rim will treat a tear trough deformity and blend the lid-cheek junction for a smoother lower lid contour. For patients who exhibit excess lower eyelid skin as well, then skin excision may be added by elevating a skin flap through a subciliary incision, taking care to not violate the underlying orbicularis muscle. This avoids any denervation injury and atrophy of the muscle. Any laxity or malposition of the lower lid may then be addressed by an eyelid support procedure such as lateral canthopexy or canthoplasty. This integrated approach to the lower eyelid blepharoplasty may better address a broader spectrum of anatomic problems specific to each patient.
Patient selection remains an important factor. Good candidates are patients with no excess skin or muscle, while poor candidates have significant skin excess, lid laxity, and muscle redundancy. Patients with lid laxity require lid tightening using other techniques. The transconjunctival approach also is useful for correcting isolated medial fat pad herniation in the upper lid or for revisionary procedures in the lower lids when inadequate fat resection has been performed during a previous blepharoplasty.
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