eMedicine Specialties > Plastic Surgery > Eyelids

Blepharoplasty, Lower Lid Transconjunctival: Treatment

Author: Christian N Kirman, MD, Resident Physician, Department of Plastic and Reconstructive Surgery, Wake Forest University Baptist Medical Center
Coauthor(s): Gaurav Bharti, MD, Resident Physician, Department of Plastic and Reconstructive Surgery, Wake Forest University Baptist Medical Center; Joseph A Molnar, MD, PhD, FACS, Associate Director of Burn Unit, Associate Professor, Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine
Contributor Information and Disclosures

Updated: Oct 27, 2009

Treatment

Intraoperative Details

• 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.
• One or two 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.¹²
• 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.

Postoperative Details

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.

Complications

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 eMedicine 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.^13,14,12,4

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