Blepharoplasty is exploding in popularity and is probably the one cosmetic operation that produces the best results for the least amount of surgery.

The primary goal of aesthetic blepharoplasty is the attainment of a youthful, natural eyes.The surgeon cannot expect to correct any eyelid contour a patient dislikes which is not within the realistic scope of the operation.

The complete aesthetic blepharoplasty is designed to remove redundant eyelid skin, excess herniated orbital fat, hypertrophic orbicularis oculi muscleand surplus soft tissue.What one accomplishes with eyelid surgery is related to the probability of success versus the possibility of complications.The result should be mutually satisfactory for the patient and the surgeon.

Blepharoplasty is a series of discreet steps, each designed to eliminate a component of the overall pathology.The primary objectives of lower lid blepharoplasty are to diminish bags or bulk of the lower eyelid and to resolve accompanying wrinkles or skin folds.The traditional transcutaneous lower lid blepharoplasty is very effective in diminishing bags or bulk but its effectiveness in resolving wrinkles or skin folds of the lower eyelid often leaves much to be desired.It can also in result in scleral show or retraction of the lower lid, a risk estimated to be as high as 10%.The bags or bulges, often found to be hereditary can be removed via the transcutaneous or transconjunctival routes.The transcutaneous technique will bring about improvement, but complication risks are greater.The transconjunctival method is probably the better option in that it carries almost no risk and a greater chance of improvement.

Regardless of age or skin, the transconjunctival approach can be used alone, or with an associated procedure such as pinch removal of skin and/or muscle, or lateral canthal tightening, or peeling as EASY TCA® on the skin of the lower eyelid, or laser silk touch CO2 ultrapulse on the skin of the lower eyelid.

The ideal patient for this procedure is one whose primary problem is prominent lower lid bags.

The transconjunctival approach is best performed with the radiosurgical unit Ellman ®.

The lower eyelid is covered with skin and underlying orbicularis muscle which continues past the lower orbital rim into the face.Behind the orbicularis near the lid margin is the trasal plate.At the inferior border of the tarsus is the orbital septum anteriorly which continues down to attach the crest of the lower orbital rim.Just behind the septum are the lower orbital fat compartments.Also at the lower edge of the tarsus are the attachments of the retractors of the lower lid as well as the conjunctive of the lower lid.These layers are lossely adherent and continue posteriorly wrapping around the lower surface of the globe back towards the orbit.The fat lies in this space behind he orbital septum and in front and below the lower lid retractors.The inferior oblique courses from the medial aspect of the lower rim of the orbit back into this fat space moving posteriorly and laterally separating the medial from the central fat compartments before extending below the equator of the globe.

Local anesthesia for transconjunctival blepharoplasty is somewhat different from the other lower lid surgery.Injection must be made through the conjunctiva to numb that surface.Sensory nerves to the conjunctiva branch off deep in the orbit so that an injection under the skin will not numb the conjunctiva profundly.The local anesthetic solution is 1% or 2% xylocaine with 1:100’000 epinephrine with Wydase .The injection is made from the top of the patient’s head.The lower eyelid is tented forward and the globe is protected with the retractor.The injection is made through the conjunctiva after first feeling for the rim of the orbit and walking backward.The needle will fall into the fat pad compartments.Approximatively 1cc.of local is injected into the medial, central and lateral fat compartments.The Wydase allows the local to spread.Needless to say, care must be taken avoid inadvertently sticking the needle into the eyeball.

Converting from a side position to perform the lower lid blepharoplasty to one of standing at the head of the patient will take a little adjusting.Also,the act of making an incision through the conjunctiva is a mjor mental hurdle for most of us.The Ellman plate is placed over the globe and into the cul de sac.A retractor is used to retract the lower lid downward exposing cul de sac.Using an Ellman radiosurgical insulated needle tip ,plapate lower rim of the orbit, move slightly backward and make a small incision through the conjunctiva and lower lid retractors.The incision will be 3-4 mm deep, although it may appear deeper than that when one first performs the transconjuctival lower lid blepharoplasty.Once the incision is made, the knuckle of fat covered with septae will bulge.Once this knuckle of fat appears,enlarge the incision from lateral canthus to caruncle.Remember, the punctum extends inferiorly 2 mm before turning medially, therefore the incision must be made at least 4 mm, into the cul de sac from the punctum.

The upper incised conjunctiva is retracted with a suture 6-0 ethilon.Position the retractor (Desmarres retractor for example) so that now it will retract the inferior incised conjunctiva and retractors.Tease the fat out of the central compartment until a cleft between the fat and the floor of the orbit can be distinguished.Now,expose all fat compartments.

The central and lateral fat compartments are really continuous but are separated by the arcuate expansion of the inferior oblique.This is a well defined discrete connective tissue structure.This ligament is grasped and cut laterally.The central fat suddenly becomes continuous with the lateral fat pad.The lateral fat compartment is thus more exposed and is found to be covered with more septae than the central compartment.The medial fat pad often attempts to hide.It takes tenacity to identify and expose it.The medial fat pad is more superior than the central fat pad.Persevere and identify the medial fat pad to maintain control of the operation.

At this point, a valley will appear between the medial and central fat pads.This valley houses the inferior oblique muscle which separates the medial and central fat compartments.The muscle can be identified by gentle blunt dissection in the valley, but sometimes fat may need to be excised before exposing the the inferior oblique muscle.Remember, identify the inferior oblique and be comfortable for the remainder of the operation.

The question is now,  »How much fat do I excise ? « .Pre operative evaluation (especially that last look in the sitting position prior to anesthesia) and pre operative photographs aid in that decision, for once the patient lies down, the contour of the eyelids and fat bulges may change entirely.Therefore, good photographs become valuable as a guide for fat extraction.In 50% of the patients,bulging in the lower lids is in the medial two-thirds of the eyelid only.

In 25% of cases,the prominence is medial and lateral and often appears separated by a valley analogous to the direction of the underlying arcuate expansion of the inferior oblique.25% present with prominence accross the entire lower lid.A rule of thumb is to aim for 80% correction for a slightly undercorrected eye appears more natural,overcorrection looks surgical.

The common problem with both the transcutaneous and transconjuctival approach is the possible residual fat left in the lateral compartment due to failure to adequately excise the fat.Once the landmarks of the lower lid have been identified,excision of the fat begins.One can begin laterally and proceed medially or medially and proceed laterally.Keeping the inferior oblique muscle in view facilitates the excision of the fat pads.Gentle pressure on the globe helps define the fat in each compartment.Excision can be with the radiosurgical cutting bovie current, or cross clamping with a hemostat or scissor excision.

Hemostasis is always the major concern in the lower lid blepharoplasty.Remember, unlike the upper lid where the vessels lie on the surface of the fat pad,the vessels in the lower fat pads go through the fat pad.The medial pad has vessels going through on the way to the orbicularis.The central vessels also transverse through the pad similar to the medial pad.In eyelid surgery,half a thimble of blodd coming from the eye looks like a liter from anywhere else.This is the one thing that stops surgeons from being comfortable with the blepharoplasty and that’s why we use the radiosurgical unit Ellman.Control of bleeding depends on exposure: Using the Desmarres retractor and applicator sticks, the bleeding points can be identified and controlled with the mono or bipolar radiosurgical unit.Once the fat pads have been excised and hemostasis controlled, the lower eyelid is pulled upinto an anatomic position.Gentle pressure on the globe will identify any residual bulges.This can be resected.Upward retraction will also relase any adhesions that may be pulling it down.

Closure of the conjunctiva is usually accomplished with one suture of 6-0 plain catgut.

In the post operative course, there is often less bruising and edema.Cold compresses are used for 2-3 days.Normal post operative blepharoplasty instructions apply.

In summary, the davantages of the transconjunctival lower lid blepharoplasty are:

-lack of scar

-lack of dissection of the orbicularis muscle

-relative bloodless approach to the fat pads and

-an excellent alternative approach for secondary blepharoplasty when performed for residual fat, most likely found in the lateral compartment.

The desadvantages are:

-early on ,exposure is more difficult

-cornea is at risk due to the cautery used

-the possibility of traction ectropion

-and over correction, which is extremily difficult to do.

Once mastered, the technique of transconjuctival lower lid blepharoplasty will become more familiar and comfortable with the procedure.its expanded applications become more obvious.The enhanced post operative appearance and reduced complications will make you wonder why you waited so long to learn the procedure.