Lower Lid Transconjunctival Blepharoplasty 

Updated: Feb 19, 2021
Author: Christian N Kirman, MD; Chief Editor: James Neal Long, MD, FACS 

Overview

Background

Initially titled in 1818 by Graefe, blepharoplasty is currently one of the most commonly performed aesthetic procedures but is still regarded as a technically challenging operation that requires a thorough understanding of the anatomy and function of the eyelids.[1, 2]

As the lower eyelid ages, excess skin, muscle, and fat cause an unattractive bulge to develop below the eye. The orbital septum becomes lax with aging, and this can lead to bulging of the orbital fat through the weak septum. Traditionally, these problems have been addressed by a transcutaneous blepharoplasty, where an incision is made through the skin to resect excessive orbital fat, redundant muscle, and skin if needed. The transconjunctival blepharoplasty is receiving increasing attention as an alternate technique to traditional transcutaneous blepharoplasty. With the transconjunctival technique, an incision is made through the lower lid conjunctiva, thereby avoiding an external incision through the skin and leaving no obvious scar. Many of the lower lid malpositions appear to be obviated by the use of this technique.[3, 4]

Potential complications that may occur after a classic transcutaneous blepharoplasty have been well described, including a postoperative change in the shape of the aperture, inferior scleral show, and malposition of the lower eyelid. Transconjunctival blepharoplasty has been advocated to limit the incidence of these complications, particularly in patients with minimal skin and muscle laxity or predominant fat herniation who otherwise would not require skin excision.[5]

As the transconjunctival technique of lower lid blepharoplasty is more widely used and reported, experience suggests that the transconjunctival approach is a safe and effective procedure with minimal complications. Specifically, this approach avoids violation of the orbital septum, which may lead to less eyelid malposition postoperatively. This technique is useful in the younger patient with isolated fat excess who does not need skin excision, as well as in the older patient with manifestations of mild-to-moderate skin redundancy. This approach can be used for lower lid fat removal, fat redraping and redistribution, and as an access point to the midface.[1]

History of the Procedure

This technique has been practiced in Europe for nearly 80 years. The first description by Bourget in 1928[6] was followed by the account of Tessier in 1973[7] 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[8] and 1980s[9] , but the landmark contribution by Zarem and Resnick in 1991[10] propelled this procedure into more widespread acceptance.

Although earlier studies focused on the young patient with isolated fat excess, indications for the procedure may be expanded to include older patients with some degree of cutaneous redundancy. Many studies now report excellent results and a reduced incidence of postoperative lower lid complications. As more experience with this technique is shared and results reviewed, reports have shown fewer complications and less apparent morbidity than with the transcutaneous approach.

Presentation

Preoperative evaluation

Preoperative evaluation includes a thorough history and physical examination. Careful attention to medical history regarding presence of hypertension, current medications, history of bleeding diathesis, and history of dry eyes or eye surgeries. The physical examination must be performed in a complete and sequential manner to assess periorbital anatomy. Eyelids are evaluated for shape and function. In addition, the eyebrows should be evaluated for ptosis and symmetry.[1] Visual acuity as well as field of vision should be evaluated in all patients. Any evidence of herniated fat pads as well as the degree of skin laxity of the lower lid should be noted. As several authors have observed, fat pad herniation is best tested with the patient's eyes in an upward gaze.[11]

The finding of scleral show on preoperative evaluation can be caused by a prominent eye, excess lower lid laxity, and poor infraorbital support. Lower lid tone should be assessed via the lower lid "snap back" test in all patients. In this test, the central lower lid is pulled gently away from the eye and is then observed as it returns to its normal resting position. These findings often require lateral canthopexy, wedge excision of redundant tissue, possible midface lift, or orbital rim augmentation.[1]

A: The lower eyelid is evaluated for the presence A: The lower eyelid is evaluated for the presence or absence of adequate tone. The snap test is shown. This involves pulling the lower eyelid skin away from the globe with the thumb and index fingers. B: This photograph demonstrates the lid retraction test, which involves displacing the lower eyelid inferiorly in order to evaluate lower eyelid tone. C: This is a preoperative oblique view. Note the brow position in relation to the orbital rim. Note also the excessive eyelid skin and crow's feet in this particular patient. D: Preoperative frontal view of the same patient. Note the lower position of the left brow, the redundancy and asymmetry of the upper eyelid skin, and the crow's feet in the lateral orbital areas.

Patients should also be evaluated for the presence of Bell phenomenon, as patients with poor response may have increased postoperative corneal dryness. These patients and any patient with a history of dry eyes require preoperative tear film evaluation, including a Schirmer test. The Schirmer test uses paper strips inserted into the eye for several minutes to measure the production of tears.[1]

Indications

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. 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.[10] Furthermore, the lower lid transconjunctival blepharoplasty has been shown to be safe and effective along with resecting a pinch of excessive skin to address skin laxity.[5]

In the aging face the nasojugal groove, or tear trough, can become a significant cosmetic issue resulting from changes in the infraorbital region causing the tear trough deformity. This deformity can occur along with excessive lower eyelid fat herniation or alone.[12] Multiple options for correction of the tear trough deformity have become available and are often considered a part of the blepharoplasty procedure.

Lower lid blepharoplasty (transcutaneous or transconjunctival) is not meant to address fine skin wrinkling. This issue may be better addressed with either chemical peels or laser/mechanical resurfacing.

Relevant Anatomy

Inferior periorbital fat is contained posteriorly by the capsulopalpebral fascia and overlying conjunctiva of the posterior fornix.

Surgical anatomy of upper and lower eyelids. Surgical anatomy of upper and lower eyelids.

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 (see the images below). With age, these tissues may relax, and the orbital fat may herniate forward, which presents as unnatural fullness of the lower lid. This bulging of the lower lid can also cause a hollowed look of the upper lid, as the entire orbital contents drop.

Cross-sectional anatomy of the mid face. Cross-sectional anatomy of the mid face.
Cross-sectional anatomy of the mid face. SOOF indi Cross-sectional anatomy of the mid face. SOOF indicates suborbicularis oculi fat; SMAS indicates superficial musculoaponeurotic system.

Transconjunctival blepharoplasty permits access to the orbital fat by an incision through the inferior conjunctiva and capsulopalpebral fascia without any disruption of the skin and orbicularis muscle of the lower lid. This approach avoids violating the inferior orbital septum, which may result in less postoperative eyelid retraction, scleral show, and changes in the shape of the aperture, 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.[13] 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

Dry eye exposure is a risk of any surgical manipulation of the upper or lower lids. Patients who have undergone corrective vision procedures such as laser in situ keratomileusis (LASIK) or keratotomy have an increased risk of dry eye problems and should be cleared for further surgery by their refractive eye surgeon.

Patients wearing contact lenses pose a particular risk when blepharoplasty is considered. Eyes may dry out as a patient ages, and this process is often hastened by chronic contact lens use. Additionally, eyelid surgery such as blepharoplasty, canthopexy, or other lid altering procedures may subtly affect the curvature of the cornea, making use of contact lenses uncomfortable or even dangerous. Patients should discontinue the use of contact lenses weeks before surgery and not restart use for several weeks postoperatively to allow healing without any eyelid manipulation.

 

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.

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%).[14]

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.[15]

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.[16] 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.[17] 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 lower lid transconjunctival 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.[18]

A study by Ramesh et al indicated that in lower lid transconjunctival blepharoplasty, patients in whom the fat is excised have a shorter lower eyelid than those in whom the fat is transposed into a preperiosteal plane (13.5 mm vs 16.1 mm, respectively), while in the fat transposition patients, the nasojugal fold is effaced to a greater degree.[19]

An alternative method for repositioning the inferior orbital fat involves a septal reset.[16] 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.

A study by Majidian Ba et al indicated that in patients undergoing lower lid transconjunctival blepharoplasty, fat pedicle transposition above the orbicularis muscle is a safe and effective alternative to repositioning fat into the subperiosteal or submuscular plane. Long-term improvement in tear trough abnormalities was reported with this technique, and patients in the study experienced no major complications.[20]

 

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 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.[21, 22, 15, 5]

Outcome

A study by Segal et al of patients who underwent lower lid transconjunctival blepharoplasty found that the procedure did not lead to lid retraction but did, in most patients, elevate the lower lid. (Postoperative photos were taken an average of 4.6 months after surgery.) Such height increase can prove an aesthetic advantage by reducing or eliminating inferior scleral show. The investigators suggested that the elevation resulted from “partial recession of the lower lid retractors during the surgical approach to the fat pockets.”[23]

A study by Lee et al indicated that in lower lid blepharoplasty, in accordance with patient characteristics, both the transcutaneous and transconjunctival approaches can significantly restore the tear meniscus height.[24]

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.[9] 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.[25]

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.