You are in: eMedicine Specialties > Plastic Surgery > EYELIDS Blepharoplasty, Lower Lid TransconjunctivalArticle Last Updated: Oct 3, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: D Glynn Bolitho, MD, PhD, FACS, FRCSC, FCS(SA), Associate Clinical Professor, Department of Plastic Surgery, University of California at San Diego; Private Practice, LaJolla, California D Glynn Bolitho is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, California Society of Plastic Surgeons, and Royal College of Physicians and Surgeons of Canada Coauthor(s): Foad Nahai, MD, Professor, Department of Surgery, Emory University Editors: Neal R Reisman, MD, JD, Associate Chief, Department of Plastic Surgery, Clinical Associate Professor, St Luke's Episcopal Hospital, Baylor College of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: transconjunctival blepharoplasty, blepharoplasty, lower lid transconjunctival, transcutaneous blepharoplasty, lower lid malpositions, fat herniation, isolated fat herniation, orbital fat, inferior fornical conjunctiva, capsulopalpebral fascia, ectropion, round eye INTRODUCTIONSection 2 of 10
  The transconjunctival blepharoplasty is receiving increasing attention as an alternate technique to traditional transcutaneous blepharoplasty. Many of the lower lid malpositions appear to be obviated by the use of this technique (Silkiss, 1992; Zarem, 1993). Transcutaneous blepharoplasty has been associated with the round eye appearance, inferior scleral show, and frank ectropion, which is the invariable consequence of overgenerous skin resection. More conservative skin resection obviates some of these complications, particularly when a lower lid tightening procedure is added. These techniques include wedge excision, lateral canthoplasty or canthopexy, and periosteal flap fixation based on the lateral orbital margin. Transconjunctival blepharoplasty has been advocated to limit the incidence of these complications, particularly in patients with minimal skin laxity or predominant fat herniation who otherwise would not require skin excision. This article reports the authors' experience with consecutive transconjunctival blepharoplasty performed by the senior author (FN) and compares the results with those achieved using conventional transcutaneous blepharoplasty techniques. A total of 177 patients were operated on over a 34-month period with a mean follow-up time of 2.4 months (range 1-18 mo). This experience suggests that the transconjunctival approach is a safe, effective procedure with minimal complications and is useful in the younger patient with isolated fat excess as well as in the older patient with manifestations of mild-to-moderate skin redundancy. History of the ProcedureThis technique has been practiced in Europe for almost 70 years. The first description by Bourget in 1928 was followed by the account of Tessier in 1973 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 and early 1980s (Tomlinson, 1975; Baylis, 1989) but the landmark contribution by Zarem and Resnick (1991) propelled this procedure into more widespread acceptance. Although earlier studies focused on the young patient with isolated fat excess, these authors expanded the indications to include older patients with some degree of cutaneous redundancy. They reported excellent results and a reduced incidence of postoperative lower lid complications. The authors' experience with this technique has been highly favorable, with fewer complications and less apparent morbidity than with the transcutaneous approach. ClinicalHistory and physical examination Preoperative evaluation includes a thorough history and physical examination. Identify herniated fat pads and note the degree of skin laxity. Carefully assess lower lid tone in all patients. Test visual acuity and perform an unanesthetized Schirmer test in selected patients. As several authors have observed, fat pad herniation is best tested with the patient's eyes in an upward gaze (Soll, 1993). Evaluate lower lid laxity by elevating the central lid with the examining forefinger or thumb and by testing lid return using the lower lid snap test. A lax lower lid may be an indication for lateral canthopexy or wedge excision in some patients. INDICATIONSSection 3 of 10
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 (Zarem, 1991). Further experience with this technique has resulted in expansion of the indications for its use. 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. Lower lid blepharoplasty does not eradicate fine skin wrinkling regardless of which technique is used. This issue is better addressed with either chemical peels or laser resurfacing. Use of transconjunctival upper blepharoplasty may be reserved for the patient with a high tarsal crease with no central or lateral fat pad herniation and minimally redundant upper eyelid skin and for patients who present with residual fullness of the upper eyelid following prior blepharoplasty. RELEVANT ANATOMYSection 4 of 10
Inferior periorbital fat is contained posteriorly by the capsulopalpebral fascia and overlying conjunctiva of the posterior fornix (see Image 1). 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. Transconjunctival blepharoplasty permits access to the orbital fat by an incision through the inferior fornical conjunctiva and capsulopalpebral fascia without any disruption of the skin and muscle of the lower lid. This results in a reduction in the risk of ectropion and round eye syndrome, 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 (Januskiewicz, 1999). 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. CONTRAINDICATIONSSection 5 of 10
Contraindications for those procedure include patients with significant lower eyelid skin laxity, patients with overt festoon formation, and those who are elderly. TREATMENTSection 6 of 10
Intraoperative Details
COMPLICATIONSSection 7 of 10
Clinical series evaluation Of 177 consecutive patients, 75 underwent transconjunctival blepharoplasty and 102 underwent transcutaneous blepharoplasty. Mean follow-up time was 2.4 months with a range of 1-18 months. Patients were evaluated for evidence of infection, subconjunctival hematoma, scleral show and ectropion, granuloma, and dry eye or exposure problems. Rates of complication occurrence for the two groups were compared using a chi-squared test with Yate continuity correction. Of the transconjunctival cases, 67 patients underwent primary blepharoplasties (89%), and 8 (11%) underwent secondary procedures. Of the transcutaneous blepharoplasties, 89 patients (87%) underwent primary procedures, and 13 (13%) underwent secondary procedures. Nine patients underwent upper lid transconjunctival procedures. Complications were minimal in both groups although patients in whom a transconjunctival approach was used had a lower incidence (4 of 75 patients [5.3%]) than those in whom the transcutaneous approach was used (13 of 102 patients [12.7%]). This was skewed to some extent by the higher incidence of temporary exposure problems in the transcutaneous cases (4.9% vs 0%), all of which settled spontaneously. Of the remaining complications, the most conspicuous differences were the lower incidence of infection (0% vs 2%) and scleral show (0% vs 2%) in the patients undergoing transconjunctival blepharoplasty. The incidence of subconjunctival hemorrhage was similar in both groups of patients at just over 1% and was not statistically significant. One patient undergoing transconjunctival blepharoplasty (1.3%) developed a small granuloma in the suture line. This appears to be a rare complication, also reported by Soll et al (1993). In all patients, dry eye complications were transient and resolved completely within 3 months. Inadequate fat resection complicated 2 (2.7%) of the transconjunctival blepharoplasties, and revision was required in both patients. No complications occurred with the upper lid procedures. No transconjunctival complications have occurred in the 15 months since the procedures. FUTURE AND CONTROVERSIESSection 8 of 10
Conclusions The authors' experience, in addition to the reports of others, attests to the efficacy and safety of the transconjunctival approach when performed in carefully selected patients. Although some authors have not demonstrated different complication rates between these two approaches, the authors' impression from their data indicates fewer complications from the transconjunctival blepharoplasty provided patients were carefully selected. The authors agree with Baylis and colleagues (1989) 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. Patient selection remains an important factor. Good candidates are those 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. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Blepharoplasty, Lower Lid Transconjunctival excerpt Article Last Updated: Oct 3, 2006 | ||||||||||||||||||||||||||
