Transconjunctival Approach Blepharoplasty

Updated: Nov 30, 2021
Author: Suzanne K Doud Galli, MD, PhD; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

Lower eyelid blepharoplasty is often the treatment for patients who have bags or puffiness under the eyes. This deformity is frequently a result of pseudoherniation of the orbital fat. Skin laxity and rhytides may contribute to the overall perception of the deformity. Blepharoplasty rejuvenates and restores the lower lid area. Traditionally, the anterior transcutaneous approach is used for this procedure. This technique provides excellent exposure to the orbital fat, and the resultant scar is minimal. Unfortunately, the approach is associated with many complications.[1, 2, 3]

Lower eyelid malposition is a feared complication after lower lid blepharoplasty and may be associated with scleral show and ectropion of various degrees. These complications tend to limit the success of the transcutaneous blepharoplasty technique. To this end, the use of a posterior transconjunctival technique has been explored. By avoiding scarring at the anterior lamella and lower eyelid septum, retraction of the eyelid and ectropion can be avoided. Accordingly, the posterior transconjunctival approach has gained in popularity and acceptance. The transconjunctival incision through the fornix seems to offer less risk for postoperative lid malposition and provides for the best exposure to the orbital fat.[4]

Images depicting preoperative and postoperative blepharoplasty can be seen below.

Preoperative photograph of the right eye. Preoperative photograph of the right eye.
Postoperative photograph of the right eye. Postoperative photograph of the right eye.

History of the Procedure

Tessier reported his use of the transconjunctival approach for craniofacial procedures in the 1970s.[5] He had been applying this approach for congenital abnormalities and trauma for almost 20 years when he presented his findings. In the 1920s, Bourget first described the transconjunctival approach in the French literature as a method for removing herniated orbital fat.[6] Tessier adapted the technique to approach the orbital floor without leaving a visible scar. He found the standard periorbital incisions to be limited to specific maneuvers and theorized that the transconjunctival technique was truly the most logical approach to the orbital walls.

Transconjunctival approaches to the lower eyelid have become very popular. In combination with other techniques, the application can be expanded to address skin laxity and rhytides as well as pseudoherniated fat.

Problem

The goal of blepharoplasty of the lower lid is to rejuvenate and thus restore the eyelid. This is achieved with special attention to lateral canthus definition and to eyelid position and function. Excess fat (pseudoherniated orbital fat) is removed, and excess skin is then addressed. Excess fat in this region may arise from a hereditary pseudoherniation of the fat or from the effects of aging. Additionally, systemic diseases, including allergies, cardiac or renal disease, liver cirrhosis, and hyperthyroidism, may contribute to puffiness around the lower eyelid.

A genetic condition known as blepharochalasis is another potential disorder leading to this deformity. Blepharochalasis is a familial disorder that results in chronic eyelid edema, which can progress to localized tissue breakdown and fat herniation. Clearly, these conditions are separate from the pseudoherniation observed in the typical patient evaluated for cosmetic blepharoplasty, and they must therefore be excluded.

The ideal patient is young and has excess pseudoherniated fat but minimal skin laxity. Older patients may benefit from the transconjunctival approach combined with a pinch excision of excess skin or a resurfacing technique such as laser resurfacing or deep chemical peel.

Pathophysiology

As humans age, the orbital septum loses its structural integrity and consequently fails to contain the orbital fat. The supporting structures of the orbit also become lax, allowing settling of the globe, which contributes to fat protrusion. Although the fat remains posterior to the orbital septum, the septum/fat complex bulges forward, giving the illusion of herniated fat (hence the term pseudoherniation). The transconjunctival approach delivers the fat without disrupting the orbital septum and removes the excess fat.

Presentation

Candidates for blepharoplasty typically present with fat herniation and are unhappy with the bags, puffiness, or dark circles under their eyes.

Indications

Assess candidates for blepharoplasty by evaluating pseudoherniated fat, excess eyelid skin, skin laxity, and rhytides. Because the transconjunctival approach is best for removal of pseudoherniated fat, patients who have fat pseudoherniation without additional skin laxity or orbicularis oculi hypertrophy are the best candidates.[2]

Because the technique has a lower risk of resultant scleral show and eyelid retraction (as with the transcutaneous approach), patients with pseudoproptosis and lower eyelid bulges are eligible for the transconjunctival approach. Additionally, patients with retracted eyelids from Graves disease are also good candidates for transconjunctival blepharoplasty.

The transconjunctival approach is a better option in patients who express concerns about scarring with the transcutaneous approach. Although the resultant transcutaneous scar is almost imperceptible, depigmentation at the scar line sometimes occurs in darker-skinned individuals. The transconjunctival approach obviates this possibility.

Relevant Anatomy

The lower eyelid is composed of 3 lamellae. At the level of the tarsus, the posterior lamella consists of the conjunctiva and the tarsus. Inferior to the tarsus, the posterior lamella is composed of conjunctiva, the retractor muscle, and the capsulopalpebral fascia. The middle lamella fuses with the posterior lamella at the tarsal plate and is composed of the orbital septum. The anterior lamella is the orbicularis oculi muscle and overlying skin. The orbital septum is a central component of the lower eyelid. The orbital septum inserts along the inferior aspect of the tarsus and extends inferiorly to its insertion at the arcus marginalis at the orbital rim. The orbital septum confines the fat pads. If the septum is weak, either congenitally or from aging, pseudoherniation of the orbital fat can begin.

Three fat compartments apparently exist: lateral, middle, and medial. Although these compartments are more practical than anatomical, the medial fat pad is separated from the middle pad by the inferior oblique muscle and the arcuate expanse dividing the middle from the lateral fat pad. The medial fat pad is whiter than the middle and lateral pads. The middle fat pad is more yellowish and is often removed in pieces, whereas the medial and lateral pads are often removed intact. In repose, the position of the lower eyelid conjunctiva is vertical at the lid margin and horizontal at the fornix. The average depth of the fornix from the lid margin is 12-14 mm, and the average height of the tarsal plate is approximately 4.5 mm.

Contraindications

Transconjunctival blepharoplasty is a technique that best addresses pseudoherniated orbital fat. In the patient with minimal fat pseudoherniation, this approach may not be best. In patients with significant skin laxity and redundancy, and in patients with hypertrophic orbicularis oculi muscle, the transconjunctival approach can offer little benefit unless combined with an adjunct procedure.

As with all blepharoplasty techniques, transconjunctival blepharoplasty is relatively contraindicated in the patient with severe lower eyelid laxity unless accompanied with lid-tightening procedures.

 

Workup

Laboratory Studies

Laboratory testing should be guided by the type of anesthetic used, the age of the patient, and the medical history.

Other Tests

See the list below:

  • Visual acuity testing is mandatory prior to blepharoplasty because of the rare possibility of blindness, which can occur with any blepharoplasty technique.

  • Tearing adequacy can be confirmed with a Schirmer tear test, but its value is debatable.

 

Treatment

Surgical Therapy

The 2 methods for lower eyelid blepharoplasty differ in their approaches but share the common goal of rejuvenation. The traditional transcutaneous approach is associated with certain complications but may be more appropriate in certain patients. Alternatively, the popularized transconjunctival approach is more appropriate in most blepharoplasty candidates.[7]

Combination procedures involving skin resurfacing or lateral tarsal suspension may be proposed for some patients. Neither blepharoplasty technique addresses the presence of rhytides on the lower eyelids, although the transcutaneous approach can be used to tighten the lower eyelid skin. Rhytides can be managed by chemical peel or laser resurfacing. A lateral tarsal suspension is useful in the patient with preoperative lid laxity or ectropion and is a good technique to treat ectropion as a complication of blepharoplasty.

Simultaneous brow ptosis and upper eyelid redundancy may be indications to perform a brow lift and upper lid blepharoplasty concurrent with lower lid blepharoplasty. An evaluation of these structures is mandatory during preoperative evaluation for lower lid blepharoplasty.

Preoperative Details

Once visual acuity and lacrimal function are established, the eyelids can be examined. Evaluate the eyelids for function, degree of skin laxity, presence of excess skin and rhytides, and condition of the underlying orbicularis oculi muscle. Note the position of the brow and the presence of upper eyelid dysfunction, namely ptosis or lagophthalmos. Finally, evaluate the degree of pseudoherniation of the orbital fat.

This examination must be performed while the patient is in both sitting and supine positions. In the sitting position, the effects of gravity on these tissues manifest. Gravity affects the position of skin as well as the pseudoherniation of fat. See the image below.

Preoperative photograph of the right eye. Preoperative photograph of the right eye.

Intraoperative Details

Several general issues must be considered when performing blepharoplasty. Minimal use of local anesthesia optimizes visualization and prevents distortion of the anatomy.[8] The procedure is most frequently performed with local anesthesia, often supplemented with conscious sedation, but general anesthesia is also appropriate, especially when multiple cosmetic procedures are being performed. Electrocautery provides controlled, pinpoint dissection and works best in the presence of minimal local anesthesia because the injection may increase electrical resistance. Electrocautery provides control over hemostasis, which is of prime concern during blepharoplasty. Prevention of bleeding facilitates better visualization and recognition of closely opposed anatomical structures.

Two approaches to transconjunctival blepharoplasty are used: retroseptal and preseptal. The retroseptal approach is taken by incising from the caruncle to the lateral canthal area at a level 5 mm below the tarsal plate, which is between the inferior margin of the tarsal plate and the fornix of the conjunctiva. This can be accomplished with monopolar cautery on the cutting setting. A traction stitch can be placed through the upper conjunctiva. The fat pads can be assessed. Perform fat amputation until the residual fat pads lie flush with the orbital rim. The fat pads can be clamped and then cut or bipolar cauterized. Meticulous dissection minimizes local tissue trauma and postoperative edema.

A retrospective study by Undavia et al found that in 54 out of 66 patients (82%) undergoing retroseptal transconjunctival blepharoplasty, the retroseptal space could be accessed directly by positioning the conjunctival incision 0.5 mm posterior to the clinically visible fat’s most superior projection (with globe retropulsion and lower eyelid infraplacement accompanying the procedure).[9]

In the preseptal approach, the incision is made through the conjunctiva below the tarsus, and the plane of dissection is between the orbicularis muscle and the orbital septum. The fat pads are exposed well by either the retroseptal or the preseptal approach. Some surgeons close the transconjunctival incision with a 6-0 absorbable suture. The incision may be left reopposed without suturing.

The procedure can be performed with scalpel, scissors, or electrocautery. Electrocautery affords precision and simultaneous hemostasis, which is of utmost importance during blepharoplasty. Avoiding heme staining of the tissues permits the surgeon to identify specific anatomic landmarks and to complete the blepharoplasty precisely.

The use of the potassium-titanyl-phosphate (KTP) laser for this procedure has been described and advocated for transconjunctival blepharoplasty. The laser causes no bleeding—its main advantage—and can be used for incision and resection of the fat pads.

Postoperative Details

At the end of the procedure, the eye is thoroughly irrigated with balanced saline solution. A lubricating ointment may offer additional eye protection. Ice packs can be applied to the eyes to prevent excessive edema.

The patient should avoid heavy lifting and overactivity for at least a week postoperatively. Contacts should not be worn for at least a week. See the image below.

Postoperative photograph of the right eye. Postoperative photograph of the right eye.

Complications

Risks are inherent to eyelid surgeries. Potential complications common to any approach include bleeding, infection, corneal abrasion, and even diplopia or blindness. All of these complications have been reported in different series of patients following transconjunctival blepharoplasty.

A few other postoperative complications are possible. Because of the method of incision, conjunctival fornix shortening and transient entropion are possible, although no cicatrization of the fornix occurs, and shortening appears minimal. Resultant eyelid malposition is uncommon.

Eyelid elevation and entropion may occur since the retractors are typically not sewn back together. These problems are rare and almost always temporary. Even when the incision is sutured, the suturing is only of the conjunctiva and not the retractors. Healing in the sutured and nonsutured patient has reportedly been equal.

Pyogenic granuloma has been reported after transconjunctival blepharoplasty. Mechanisms include inflammatory reaction to a suture at the suture line or malposition of wound edges in nonsutured cases.

A study by Matsuda et al indicated that use of an epinephrine-containing local anesthetic during transconjunctival aponeurotic repair for blepharoptosis of the upper eyelid can lead to postsurgical eyelid droop. The investigators reported that by stimulating the Müller muscle during surgery, epinephrine can interfere with estimation of postsurgical eyelid height, which means that drooping may occur once the drug’s effects wear off.[8]

The most common complication after transconjunctival blepharoplasty is inadequate fat removal and consequent patient dissatisfaction. This type of complication may reflect the experience of the surgeon and can be rectified.

Outcome and Prognosis

Transconjunctival blepharoplasty allows the surgeon to offer a scar-free rejuvenation of the lower lid and has met with a high degree of patient satisfaction. The risk of complication from this procedure is low, although patients must be properly counseled preoperatively (as with any blepharoplasty). The adjunct use of other rejuvenation techniques supports the continued use of this approach in an expanded population of patients.

A study by Segal et al found that of 15 lower eyelids that underwent transconjunctival blepharoplasty, 11 showed a decreased postoperative margin reflex distance 2 (average follow-up time, 4.6 mo), while lower lid scleral show was eliminated in six out of seven eyes.[10]

Future and Controversies

Transconjunctival blepharoplasty has gained in popularity, and more than 60% of blepharoplasty patients are treated using this approach. Some surgeons may be committed to the transcutaneous approach for the older patient with skin laxity and redundancy, although the combination of additional techniques to address the skin at blepharoplasty is now more accepted.

The future of blepharoplasty lies not in the selection of the approach but in the decision to excise fat. Recent discussions have focused on fat preservation techniques in which fat is not excised. These techniques transfer fat over the inferior orbital rim and therefore provide a smoother transition from orbital eyelid contour to cheek contour. Fat repositioning can be accomplished through the transconjunctival approach.