Transconjunctival Approach Blepharoplasty Treatment & Management

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.

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.

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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.

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.

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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.

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]

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.